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Free EditionThe Health Insurance Portability and Accountability Act (HIPAA) is a regulatory policy for all organizations that store, process, or transmit protected health information (PHI). While HIPAA mandates that all organizations safeguard their data, it doesn't suggest any measures or specific measures to do so. But, your organization still needs to adhere to HIPAA in order to protect your data and avoid financial penalties.
Any entity that stores, processes, or transmits PHI must comply with HIPAA's requirements and ensure the security and privacy of the information. These entities are categorized into:
HIPAA requires entities to put certain requirements in place to safeguard PHI and ensure the integrity, availability, and confidentiality of patient information. HIPAA's requirements are broadly put into two rules, the Privacy Rule and Security Rule.
The Privacy Rule outlines specific guidelines to safeguard patients' medical data and establishes criteria for the proper utilization and disclosure of PHI without patient consent. This rule also grants individuals the rights to obtain their rights and suggest corrections if required. This rule emphasises on patient consent and how covered entities must obtain proper consent before using their health information. This rule and its requirements can be found in 45 Code of Federal Regulations (CFR) Part 160 and Subparts A and E of Part 164.
The Security Rule aims to safeguard PHI handled by covered entities by implementing specific administrative, physical, and technical security measures. These safeguards guarantee the confidentiality and security of PHI while ensuring that the entities are taking the necessary steps to prevent cyberthreats, unauthorized physical access, and data breaches.
ADManager Plus is an identity governance and administration (IGA) solution which offers various capabilities to not just manage and secure identities, but also to meet the requirements of various compliance mandates such as the PCI DSS, SOX, and more. The following table illustrates how it can help you meet HIPAA requirements.
| Section | Description | How ADManager Plus helps |
|---|---|---|
| 45 CFR 164.308 (a)(1)(i) | Implement policies and procedures to prevent, detect, contain, and correct security violations. | Keep an eye on the risk factors in your environment, assess their impact, and take on-the-fly actions to mitigate them effectively. Get a detailed risk assessment report to find the security risks your organization is exposed to, find areas that require attention, and learn about remediation measures |
| 45 CFR 164.308 (a)(1)(ii)(A) | Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity or business associate. | |
| 45 CFR 164.308 (a)(1)(ii)(B) | Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with 45 CFR 164.306(a). | |
| 45 CFR 164.308 (a)(3)(i) | Implement policies and procedures to ensure that all members of its workforce have appropriate access to electronic protected health information, as provided under paragraph (a)(4) of this section, and to prevent those workforce members who do not have access under paragraph (a)(4) of this section from obtaining access to electronic protected health information. | Automate access certification campaigns and ensure that access rights are regularly reviewed and that users only have the privileges they need to perform their duties. |
| 45 CFR 164.308 (a)(3)(ii)(A) | Implement procedures for the authorization and/or supervision of workforce members who work with electronic protected health information or in locations where it might be accessed. | Optimize task execution and control delegation of tasks with mulit-level approval workflows. Use different workflow agents, namely requesters, reviewers, approvers, and executors, and customize and automate the workflow process. |
| 45 CFR 164.308 (a)(3)(ii)(B) | Implement procedures to determine that the access of a workforce member to electronic protected health information is appropriate. | Automate access certification campaigns and ensure that access rights are regularly reviewed and that users only have the privileges they need to perform their duties. |
| 45 CFR 164.308 (a)(4)(ii)(C) | Implement policies and procedures that, based upon the covered entity's or the business associate's access authorization policies, establish, document, review, and modify a user's right of access to a workstation, transaction, program, or process. | |
| 45 CFR 164.308 (a)(5)(ii)(C) | Procedures for monitoring log-in attempts and reporting discrepancies. | Generate comprehensive reports on failed login attempts and have them mailed to stakeholders. |
| 45 CFR 164.308 (a)(5)(ii)(D) | Procedures for creating, changing, and safeguarding passwords. | Generate detailed password reports and gain insights into users with expired passwords, soon-to-expire passwords, changed passwords, and unchanged passwords. Configure password complexity policies with factors such as minimum and maximum length, case sensitivity, and more to ensure that, during user creation, the passwords created are strong and secure. |
| 45 CFR 164.308 (a)(6)(ii) | Identify and respond to suspected or known security incidents; mitigate, to the extent practicable, the harmful effects of security incidents that are known to the covered entity or business associate; and document security incidents and their outcomes. | Identify potential vulnerabilities and mitigate them with an identity risk assessment report. |
| 45 CFR 164.308 (a)(7)(ii)(A) | Establish and implement procedures to create and maintain retrievable exact copies of electronic protected health information. | Automate incremental or complete backups of your AD, Azure AD, Microsoft 365, Google Workspace, and Exchange environment to restore affected data in case of any disaster. |
| 45 CFR 164.308 (a)(7)(ii)(B) | Establish (and implement as needed) procedures to restore any loss of data. | Easily restore incremental or complete backups of your environment in case of any disaster. |
| 45 CFR 164.312 (a)(1) | Implement technical policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons or software programs that have been granted access rights as specified in ยง 164.308(a)(4). | Allow access to electronic information systems only to those with access rights by periodically reviewing users' access rights and certifying them. |
| 45 CFR 160.310(a) | A covered entity or business associate must keep such records and submit such compliance reports, in such time and manner and containing such information, as the Secretary may determine to be necessary to enable the Secretary to ascertain whether the covered entity or business associate has complied or is complying with the applicable administrative simplification provisions. | Meet compliance requirements with an automated reporting system that helps fetch the data required for audit compliance and makes that data exportable. Easily export these reports into various formats like HTML, CSV, PDF, and XLS. |
Protecting ePHI and ensuring patient data integrity and confidentiality is the ultimate outcome of complying with HIPAA requirements and involves a lot of processes and preparatory steps. Here's a checklist that you can follow to prep your organization for HIPAA compliance:
Regularly review users' access to patient data and strip off any excessive rights with access certification campaigns.
Generate comprehensive reports on users' login attempts, passwords, and more, and manage them on-the-fly.
Meet audit requirements swiftly by exporting reports in formats such as PDF, CSV, XLSX, and more.
Schedule and automatically generate HIPAA compliance reports at a desired time and have them mailed to audit committee members instantly.
Implement policies such as role-based access control, the principle of least privilege, and more to safeguard patient data.
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