The Health Insurance Portability and Accountability Act (HIPAA) requires healthcare providers to be good stewards of patient information. Protected health information (PHI) is governed by HIPAA, which requires healthcare providers to follow stringent data protection regulations.
PHI compliance is mandatory for all healthcare organizations in the United States as well as other organizations that are considered HIPAA covered entities or business associates. But what steps can businesses take to stay PHI compliant? Check out this guide to learn the basics of PHI compliance, as well as six tips to help you achieve it.
What Is PHI Compliance?
PHI is a type of sensitive data that all healthcare organizations are required to protect. There are serious penalties for disclosing PHI in any unauthorized way — even if you experience a ransomware attack or accidental data breach. More importantly, stolen PHI can hinder patient safety by delaying healthcare delivery or resulting in improper treatments. For instance, if a provider cannot access a patient’s health record, they may prescribe a medication that’s contraindicated due to their health history or other current medications.
Organizations must follow PHI compliance if:
- They’re a covered entity.
- They’re the business associate of a covered entity.
- They handle healthcare-related information that can tie back to a specific person or be used to identify a person.
Covered entities include healthcare providers, health plans, pharmacies, and other organizations that create, maintain, and transmit PHI as part of their business. But any vendor of a covered entity must also plan for PHI compliance if they handle patient data. This usually includes business associates that handle:
- Medical devices
- Data cloud storage
In some cases, employers may need to follow PHI compliance. This generally applies if you offer self-insured health coverage or an EAP.
6 Tips To Ensure PHI Compliance
If your organization handles PHI, HIPAA requires you to protect it. However, HIPAA standards are intentionally vague, which can make it a challenge to understand PHI compliance. While HIPAA is complex, these six tips can help your organization ensure PHI compliance.
1. Follow the Three Safeguards
First and foremost, make sure your organization follows HIPAA’s three safeguards. These are requirements from HIPAA that say all healthcare organizations have to take “reasonable steps” to protect PHI. Follow HIPAA’s administrative, technical, and physical safeguards to ensure PHI compliance.
2. Implement Multi-layered Security
You need more than just a firewall to protect PHI. Work with your IT team to implement several layers of security around your infrastructure, which should include:
- Spam filters
- Phishing detection
HIPAA also requires you to encrypt data both during transmission and while it’s at rest — that means you should never handle unencrypted PHI. Be sure to implement encryption in your emails and portable devices, which are particularly vulnerable to cyber attacks.
3. Track and Monitor Your PHI
You can’t protect PHI if you don’t know where it is. It’s easier to spot PHI if you’re a small organization, but if you’re a large hospital, it’s nearly impossible to find and protect all your data.
Solutions like Tausight make PHI compliance much easier by detecting PHI in personal emails, shadow IT apps, unsecured cloud applications and storage, mobile telehealth, and other often overlooked areas. Tausight also analyzes PHI activity and risk for continuous validation of cyber preparedness. Should a data breach occur, an immutable, off-site audit trail enables faster recovery.
4. Follow the Minimum Necessary Rule
HIPAA’s Minimum Necessary Rule prevents healthcare providers from sharing all of a patient’s sensitive data if it isn’t absolutely necessary. This minimizes liability by only sharing the patient data you need to do your job. After all, do you need to know a patient’s Social Security number to check their blood pressure?
Ensure your systems follow the Minimum Necessary Rule. This means only granting employees access to PHI if it’s critical to their job. Only grant ePHI and PHI access on an as-needed basis and revoke access once it’s no longer needed.
5. Institute a HIPAA Privacy Officer
HIPAA requires every covered entity to have a Privacy Officer. This is a designated professional at your business who helps you stay on top of HIPAA requirements and implement the appropriate security measures to comply. This can be an additional duty given to an employee in HR, but it’s a good idea to hire a full-time HIPAA Privacy Officer if you process a lot of PHI.
6. Train Your Team
HIPAA requires that you train all employees who have access to PHI, including your managers. Employees must be trained during onboarding and then once a year following that. Your training needs to cover both PHI compliance rules as well as cybersecurity best practices.
However, annual training is just the minimum: you’re free to train as often as you’d like to improve adherence, and you should do so to ensure that PHI compliance remains top of mind among your workforce. HIPAA also requires you to retrain your team if there’s a major change to the Act, so keep your ear to the ground for legislative updates.
Situational PHI Compliance is the Key to PHI Compliance
Every healthcare organization needs to take PHI compliance seriously so they can minimize the risk of breaches and cyberattacks that can hinder patient safety and lead to HIPAA violations. While these six best practices will help you achieve PHI compliance, you can’t protect PHI if you aren’t aware it exists. And with the ever-expanding security perimeter for today’s healthcare organizations, gaining visibility into PHI is crucial.
Tausight’s Situational ePHI Awareness solution offers continuous validation of cyber preparedness through 24/7 telemetry and reporting on PHI activity. Tausight detects and monitors PHI as it’s created, stored, accessed, moved, and copied across all endpoints throughout the healthcare continuum. Contact Tausight today to learn how you can gain visibility into PHI throughout your healthcare ecosystem and ensure PHI compliance.