To restate the obvious, hospitals operate in a risky environment. They face a variety of risks and a blanket of government regulations. You have to admire the Chief Compliance Officer at a hospital. They learn to live with these risks.
In response to our new Internet age, the government has prioritized protection of privacy and consumer data.
In the healthcare industry, this is not a new development. The industry has been subject to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), including the Security Rule for nearly 20 years, and in the last few years has faced additional obligations under the HITECH Act. Data security and privacy obligations were increased with the electronic health records grant program and “meaningful use” requirements and audits.
The regulatory regime surrounding data privacy and security in the healthcare sector is enough to make your head spin. For CCOs in the hospital industry, there is no such thing as a “risk assessment.” They live with the changing risks every day.
The HIPAA Security Rule sets standards for the protection of electronic personal health information (“ePHI”) from unauthorized disclosure. Hospitals and other service providers are required to adopt administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of ePHI.
The Department of Health and Human Services has mandated that hospitals (and other service providers) conduct a risk assessment for evaluating data security. HHS has not defined what type of risk assessment or how such a risk assessment should be conducted.
When it comes to data security, hospitals face external and internal risks. External hacking incidents are rare. Theft and unauthorized disclosures are the primary risks. Administrative and physical protections often are the best way to minimize such risks. Technological protections against a hacking incident may be needed but often are a lower priority solution.
One thing is clear – a minimal risk assessment is unlikely to pass muster. Hospitals are under stress now since they are being audited for compliance with the “meaningful use” requirements. As these audit results become known in the industry, hospitals are likely to learn – bit-by-bit – how they stand.
In my view this is much ado about nothing, or simply marketing hysteria created by information security specialists seeking engagements with hospitals. Compliance professionals know how to conduct risk assessments, evaluate the results, and build a risk response strategy.
It is incumbent on CCOs to do their job, as they usually do, and work with professionals to conduct a risk assessment and develop a list of required actions to reduce the risks. Often the issue is not how to conduct the risk assessment but securing the resources to conduct the risk assessment and implement the solutions.
In this process, we return to an important strategy which is to document each and every step taken. The risk assessment and the steps taken to reduce risk should all be documented.
For hospitals, HIPAA security requirements are nothing new. HIPAA has been on the books for years and there is no excuse for failing to comply. It is true that enforcement of HIPAA has increased dramatically but again that is not an excuse for failing to comply.
HHS’ Office of Civil Rights has transformed its mission from reactive enforcement to proactive enforcement. OCR has announced a number of penalties over $1 million against healthcare organizations for violation of HIPAA’s Security Rule.
Hospitals fear a security breach. Given the sensitivity of the information they manage, a breach can have catastrophic consequences from both enforcement and a reputational perspective.