What is HIPAA

HIPAA, or the Health Insurance Portability and Accountability Act of 1996, is an important federal law in the U.S. that protects sensitive patient health information from being disclosed without the patient's consent or knowledge. Ultimately, HIPAA was created to protect the privacy of your medical records and other personal health information. HIPAA sets the national standards for the protection of health information, managed by healthcare providers, health plans, and healthcare clearinghouses (and their business associates).

You can think of HIPAA as the ultimate protector of your medical secrets. Prior to HIPAA, there were no standardized policies about who could see your health information, how it could be used, and how securely it needed to be stored. HIPAA changed that by providing a framework to ensure that patient information is treated with care, confidentiality, and integrity.

HIPAA and its Impact

HIPAA is very comprehensive, but the two rules that have the most overall impact on organizations are as follows:

• The HIPAA Privacy Rule: This part of HIPAA establishes national standards for protecting individuals' Protected Health Information (PHI). The Privacy Rule gives patients significant rights regarding their health information, including the right to examine and obtain a copy of their health records, and the right to request amendments. It also defines how and when PHI may be used or disclosed. For example, HIPAA tells a doctor when they are allowed to discuss your information with another specialist, or to share your health information with an insurance company.

• The HIPAA Security Rule: This rule specifically addresses the security of Electronic Protected Health Information (ePHI). It requires covered entities and their business associates to implement administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of ePHI. This is where IT and cybersecurity controls are critical and can address everything from access controls and encryption to audit logs and disaster recovery.

Who does HIPAA apply to

HIPAA is not just for hospitals but also encompasses:

• Covered Entities: These are health plans, healthcare clearinghouses, and healthcare providers who transmit health information in electronic forms in relation to transactions that HHS has adopted standards for.

• Business Associates: These are people or organizations that perform functions or activities on behalf of a covered entity that involves the use or disclosure of PHI (e.g., billing companies, IT service providers, cloud storage providers, law firms that deal with healthcare data). If you are touching health data on behalf of a covered entity, HIPAA applies to you!

Why HIPAA Compliance is Critical for Security and Trust

HIPAA compliance is not just following a rule; it is a framework to support patient trust, dignify ethical obligations, and protect extremely sensitive data in an ever-expanding digital world in healthcare. Non-compliance can lead to serious ramifications.

The importance of having effective HIPAA compliance can be summarized in the following ways:

• Protects Patient Privacy: Simply put, HIPAA protects the privacy of personal health information. The locus of control is with the patient, ensuring that the patient decides who accesses their data and for what purpose. When feelings of trust are established with healthcare entities as a result of a satisfactory standard of privacy, this will, ultimately, yield trust in the healthcare system.

• Protects Data Breaches: The Security Rule defines the fact that organizations shall maintain safeguards against unauthorized access, use, and/or disclosure of ePHI. With this function mandated, organizations must ensure strong cybersecurity risk mitigations are in place, which would limit the extent of costly and harmful data breaches.

• Inherent Security Mandate: Organizations and their partners in the healthcare ecosystem that manage ePHI have an implicit mandate to ensure robust IT security in any regulated function in accordance with accepted cybersecurity standards. For example, Identity and Access Management (IAM), Privileged Access Management (PAM), encryption, audit logging, and identification of Least Privilege Access (LPA) and Separation of Duties (SoD) should obviously be observed when considering unauthorized access and integrity of data.

• Accountability: HIPAA clearly assigns the accountability to covered entities and business associates for their PHI protection. If a breach requires action to remediate the breach, then covered entities and business associates are assigned to rectify the breach.

• Financial Penalties: The financial penalties for violating HIPAA regulations can range from thousands to millions of dollars based on the categories in which the violations occur. In addition to the financial penalty, there are the ensuing lawsuits and at a minimum, the financial impact of the negative publicity. Organizations typically evaluate the outcomes of regulation violations to look at the overall business impact of information security breaches.

• Builds or Retains Confidence: In an increasingly data-crazed world, commitment to a regulation such as HIPAA, evidences a responsibility to protect patient information that is paramount for maintaining any level of patient confidence and dependence.

• Finally, HIPAA supports fostering a culture of security: Ongoing compliance efforts to uphold the statute of HIPAA should encourage healthcare organizations and their respective partners to promote embedding privacy and security as foundational aspects in their culture, policies, and training.

• Manage Risks: HIPAA requires organizations to assess and manage risks associated with ePHI. Compliance to HIPAA requirements facilitates organizations to apply comprehensive risk management strategies specifically tailored to sensitive matters about health data.

ReShield understands the great complexities and obligations associated with HIPAA compliance. Our identity security technologies create the applicable foundational controls for organizations and their business associates to meet the requirements for the stringent Privacy Rule and Security Rule specifically with respect to ePHI. ReShield's Identity and Access Management (IAM), Privileged Access Management (PAM), Identity Governance and Administration (IGA), and Identity Security Posture Management (ISPM) capabilities will help healthcare organizations and their respective business associates enforce policies that promote Least Privilege Access (LPA), the establishment of Separation of Duties (SoD), securing all users irrespective of whether the identity is human or machine on sensitive health data, and getting full audit trails to ensure patient privacy.