What Are the Three Safeguards for Protecting ePHI?

It’s no secret that the proliferation of Electronic Protected Health Information (ePHI), coupled with the healthcare industry’s increasing ePHI sharing demands, has made HIPAA compliance much more difficult for organizations. ePHI is on laptops, smartphones, removable drives and tablets — spread across multiple locations and sprawling healthcare complexes and beyond. It’s a true challenge managing all of this ePHI at scale. Your business is at an increased risk of ePHI breaches and HIPAA violations, which is why it’s so important to understand the ins and outs of HIPAA’s regulations.

Although HIPAA is updated over time, several rules make up the bulk of HIPAA requirements. While the Privacy Rule is important, the Security Rule is the most applicable when it comes to protecting ePHI. Added to HIPAA in 2003, the Security Rule requires organizations to protect ePHI in three important respects — administrative, technical, and physical — and you’ll need safeguards in place for all three to stay compliant.

Let’s look at the three safeguards under the Security Rule and learn what they mean for your organization.

Administrative Safeguards

The first layer of ePHI protection should come from your administrative policies and practices. This safeguard largely governs how you manage your staff and employees, as well as how they handle ePHI in their daily workflow.

According to HIPAA, your organization can stay compliant by following these administrative safeguards:

  • Security Officer: You need an employee to serve as your HIPAA Security Officer. This person is in charge of all things HIPAA in your business. At a minimum, they should guide annual risk analyses, manage employee HIPAA compliance, and conduct training.
  • Risk analysis: HIPAA requires businesses to conduct an annual risk analysis. During the analysis, you should look at the potential for attacks targeting ePHI, rank them, and create a mitigation plan. It isn’t enough to be aware of the problems — HIPAA requires you to come up with fixes that are “reasonable and appropriate” to solve the issue. You also need to document your risk analyses and store them for at least six years for audit purposes.
  • Access management: ePHI shouldn’t be available to everyone in your organization. You need administrative safeguards in place that grant access to ePHI on an as-needed basis. Ensure your processes only grant role-based access to ePHI and then revoke it once access is no longer needed.
  • Training: HIPAA requires you to train and supervise employees who access ePHI. Your Security Officer needs to provide security awareness training at least once a year on your HIPAA policies. It’s also a good idea to have employees sign a document at the end of the training acknowledging that they completed the training.

Technical Safeguards

Technical safeguards refer to your IT setup and infrastructure. Although HIPAA made these requirements pretty vague, they give organizations a framework to secure ePHI, which includes:

  • Access control: Again, your systems should only allow authorized users to access ePHI. From a technical perspective, that means you need user verification and automatic time-outs in place.
  • Audits: Your network needs to automatically log every instance that your team accesses ePHI, whether it be via hardware or software.
  • Integrity controls: Technical safeguards need to prevent your team (or malicious parties) from changing, exfiltrating, or improperly deleting ePHI.
  • Transmission security: This is one of the most important requirements under the Security Rule. HIPAA requires you to secure ePHI while it’s in transmission, which means you need end-to-end encryption. Encryption scrambles sensitive data to protect it from attackers and ensures ePHI stays concealed even if it’s intercepted.

Physical Safeguards

The final safeguard under the Security Rule is physical safeguards. While it’s critical to lock down your ePHI digitally, you need to protect it in the real world, too. Physical safeguards prevent unauthorized access to ePHI via your building, devices, or hardware. This includes safeguards like:

  • Storing ePHI in a separate location with keycard access
  • Installing cameras and additional locks
  • Hiring a security guard
  • Properly wiping hardware of ePHI before disposal
  • Locking all workstations and tablets with strong passwords
  • Remotely wiping lost or stolen devices

Situational PHI Awareness is the Key to Protecting ePHI

The HIPAA Security Rule applies to both covered entities as well as their Business Associates. Everyone needs to follow HIPAA’s administrative, technical, and physical safeguards to lock down ePHI, but these safeguards don’t dictate how, exactly, providers can comply.

HIPAA is supposed to be flexible enough that organizations can implement its guidelines as they see fit. That’s designed to minimize the burden on healthcare providers, but the vague guidelines can be a burden in and of themselves. As a healthcare organization, it’s up to you to stay compliant, protect ePHI, and avoid penalties. While these three HIPAA safeguards are an important part of the Security Rule, you’re still required to follow every HIPAA guideline.

In order to adequately protect ePHI, you must have awareness of where it’s located, how it’s used, and how it’s moved within and outside of your organization. Today, healthcare providers must be able to share ePHI to improve productivity, streamline workflows, and improve patient care and satisfaction — but they must be able to do so securely.

Tausight is a situational ePHI awareness platform providing visibility into both structured and unstructured ePHI in real-time and across all endpoints and servers in your healthcare ecosystem. Contact us today to learn how Tausight can help you gain the visibility you need to protect ePHI.

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David Ting

Founder and CTO, Tausight

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