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HIPAA Compliance Security Checklist 2024 [Updated]



What is HIPAA Rule?

The Health Insurance Portability and Accountability Act (HIPAA) requires all healthcare companies to effectively comply with the administrative, technical and physical safeguards necessary to protect the privacy of customer information and maintain data integrity of employees, customers, and shareholders.

To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, included Administrative Simplification provisions that required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security.

In the case of HIPAA (Health Insurance Portability and Accountability Act), it is important, of course, not to lose the information on the patient. But, and just as important, you have to keep this information secret. Therefore, it is necessary to closely monitor who can read the data when backup and restore procedures, and of course who can ask the IT department to restore the data.

Not all data protection schemes impose this level of access security. But in an environment governed by HIPAA, access security must be the priority of any data protection, backup, and recovery solution.

It is, therefore, necessary to translate the various HIPAA requirements for administrative, physical and technical protection into actions related to storage. This ranges from the kind of written policies and procedures applied to network storage, to physical data encryption capabilities at the storage server level.

The regulation includes two basic rules: the security rule and the confidentiality rule. The details and obligations of these rules are defined below.

In this article you will know more about:

Hipaa Requirements & Privacy Policy

The HIPAA Privacy Rule governs the use, disclosure and requires covered entities and BAs to adequately protect an individual’s PHI. The privacy rule also grants patients rights to their health information, including the right to request corrections, review and obtain a copy of their health records.

Despite the intentionally vague HIPAA requirements, every Covered Entity and Business Associate that has access to PHI must ensure the technical, physical and administrative safeguards are in place and adhered to, that they comply with the HIPAA Privacy Rule in order to protect the integrity of PHI, and that – should a breach of PHI occur – they follow the procedure in the HIPAA Breach Notification Rule.

All risk assessments, HIPAA-related policies and reasons why addressable safeguards have not been implemented must be chronicled in case a breach of PHI occurs and an investigation takes place to establish how the breach happened. Each of the HIPAA requirements is explained in further detail below. Business unsure of their obligation to comply with the HIPAA requirements should seek professional advice.

Helpful Resources:

Safety rule

The HIPAA security rule primarily governs personal information protection (ePHI) by setting standards to protect this electronic information created, received, used or retained by a covered entity. The security rule identifies three specific safeguards – administrative, physical and technical – to ensure data security and regulatory compliance.

Storage

HIPAA requirements affect storage strategies throughout the equipment lifecycle, from the moment of introduction into the network to the way the equipment is used, in order to protect the confidentiality of the data stored on this material. One of HIPAA’s top concerns with storage management is to protect stored data from unauthorized access. Everything else is secondary because if the first condition is not fulfilled, the business can be continued. This mission of protection of the stored data clearly concerns the administrators. They must make sure to erase the traces that a file leaves in the computer.

Temporary files, copies of files on client computers, backup tapes removed, or any other trace of old data, must be erased. It is not enough to delete all files, but also information such as file references, all random data items on disk, and ACLs. Although data protection against unauthorized access is always in the mind of the administrator, the HIPAA requirements greatly complicate current storage practices.

Even file deletion is no longer as simple, and storage strategies and procedures must embody this reality. Quite simply, the requirements of HIPAA change the mindset for storage management and affect all networked computing activities. Given the modern medical environment, this means that storage management rules and procedures apply horizontally across various vertical applications.

Who must comply with HIPAA?

All civil and military health care plans, medical compensation offices and medical providers who perform certain financial and administrative transactions electronically must comply with HIPAA. Military treatment centers, suppliers, regional contractors, subcontractors and other related companies fall into these categories.

There are two HIPAA clauses that relate specifically to the privacy and security of your protected health information (PHI), the Privacy Rule and the Security Rule.

Who does it apply to?

Healthcare providers and organizations

Business partners (BA) and BA subcontractors of health care entities (as defined by Health Information Technology for Economic and Clinical Health (HITECH))

What data is protected?

Protected health information is “individually identifiable health information” according to the definition of:

Any information, including demographic information, collected from an individual that is created or received by a health care entity or a BA.

Any information that may be reasonably used to identify an individual that relates to the past, present or future health or physical or mental condition of that individual.

Any information that relates to the provision of medical care to that person

Any information related to past, present or future payment for the provision of medical care to that person.

How Does Privacy Rule Protects you?

The HIPAA Privacy Rule allows medical staff to use and disclose your protected health information for your treatment, payment and health care operations without written authorization. Most additional uses and disclosures require your permission. Under the Privacy Rule, you have the right to:

  1. Receive a copy of the Notice of Privacy Practices of the Military Medical System

  2. Request access to PHI

  3. Request correction of PHI

  4. Request a summary of all PHI disclosures

  5. Request restriction on the use and disclosure of PHI

  6. File a complaint regarding privacy violations

HIPAA Compliance Security Rule

The HIPAA Security Rule specifies a set of business processes and technical requirements that providers, medical plans and compensation offices must follow to ensure the security of private medical information. The Safety Rule is oriented to three areas:

1.         Technical Safeguards

2.         Physical Safeguards

3.         Administrative Safeguards

Here’s how to know who you can trust with your personal data, and what the HIPAA Act and the Privacy and Security Rules mean to you.

  • Privacy and security regulations

The HIPAA law, privacy and security regulations have been in effect to protect your private health care data since 1996. As technology has changed and information has become more accessible, they have also been reviewed due to our Changing environment and advances in technology over the years. All of these regulations have been put in place to help keep your private information secure.

 The Health Insurance Portability and Responsibility Law (HIPAA) and the HIPAA Privacy Rule set the standard to protect sensitive patient data by creating standards for electronic exchange, and the privacy and security of medical information patient for those in the health industry.

As part of HIPAA, the Administrative Simplification Rules were designed to protect patient confidentiality, while allowing medically necessary information to be shared while respecting patient’s right to privacy. Most health providers, health organizations and government health plans that use, store,

 The main purpose of HIPAA was to help people maintain health insurance coverage: rules of administrative simplification and control of administrative costs. With so much information changing hands between healthcare providers and health insurers and in many other parts of the world health services.

The HIPAA Act seemed to simplify the handling of sensitive patient documentation and information in the healthcare industry, while protecting the confidentiality of patients’ medical information.

HIPAA Compliance Checklist 2024

HIPAA Privacy Notice and Compliance Requirements

Patient safety and confidentiality are top priorities for services provided by the server. Take a look below to see some of the ways we work to protect your privacy.

1. Technical safeguards

These are technical mechanisms and processes designed to protect, control and monitor access to information.

Data encryption (being transmitted) – Industry standard 256-bit AES encryption is used at all points where patient information is transmitted between a user and servers. This includes complete encryption of information shared by providers and patients, as well as encrypted transmission of downloaded/loaded documents and images.

  • HIPAA compliant web hosting

Server uses an enterprise hosting solution that provides all the tools necessary to maintain HIPAA-compliant security measures and patient privacy. Due to the encryption standards used by server, our hosting solution has no access to confidential patient information.

  • Data encryption (at rest)

All patient data and billing information is stored in encrypted database tables using the 256-bit AES standard. All documents and images uploaded by a patient or provider are also stored in encrypted form. Full disk encryption is in place for all hard drives that store patient information and website operating data using SHA-512 encryption standards.

  • Audio/video encryption

The audio and video of all telemedicine sessions are transmitted over an encrypted public internet channel using standard cryptographic primitives. Audio and video streams are decoded as received by a participating provider or patient.

  • Distributed Servers

Multiple servers are used to manage specific tasks, such as web hosting, data storage, and video session management. Each server is uniquely configured with separate access information, software decryption keys, permissions, and backups. Access to systems containing sensitive information is limited to an internal network structure with authentication procedures.

  • HIPAA compliant business standards

In accordance with HIPAA guidelines and regulations, providers of telemedicine software solutions are required to maintain HIPAA-compliant business and security practices. In addition, health care providers are required to sign a partnership agreement with their telemedicine software provider. Server maintains the HIPAA standards and concludes a mutual BAA with each server subscriber.

2. Physical safeguards

These are processes that protect physical equipment and related buildings, from natural and environmental hazards, as well as from physical intrusions.

Access controls – Procedures are in place to provide in-depth visibility into API calls, including who, what, and from whom users are accessing the servers. The procedures also include warranties to prevent unauthorized physical access, alteration, and theft by using activity logs and alert notifications.

Patient information is not stored, printed, copied, disclosed or processed excessively by any means other than those intended for that purpose.

  • Using the workstation

All IT devices installed and configured to limit ePHI access to authorized users only. ePHI is only stored, revised, created, updated or deleted using computer peripherals that meet the security requirements for this type of device. Before leaving a computer device unattended, users must log off or lock or secure the device or applications.

This practice prevents unauthorized users from accessing ePHI or any component of the system. The computer peripherals are located and oriented so that the non-displayed information cannot be viewed by unauthorized persons.

  • Procedures for mobile devices

When stored on portable or mobile computing devices (laptops, smartphones, tablets, etc.) or on removable electronic storage media (USB sticks, etc.), ePHI is encrypted. The original (source) or single copy of PHI is not stored on portable computing devices.

3. Administrative safeguards

These are practices designed to control the security measures and conduct of personnel who access, view, process and distribute protected medical information electronically.

  1. The server records and maintains an inventory of the computer components of the telemedicine service.

  2. The systems have sufficient capacity to ensure continuous availability in the event of a security incident.

  3. Systems ensure that malware protection is deployed and updated.

  4. All privileged user actions are saved. Any modification of these logs by a system user, privileged or final must be detectable. Log records are periodically reviewed by authorized server administrative personnel.

  5. Information about important security-related events is logged, including event types such as connection failure, system failures, access rights changes, and event attributes such as the date, time, user ID, file name and IP address, where technically possible.

  6. Log records are kept for at least 6 months and made available to the covered entity upon request.

  7. Backups are maintained to ensure continuity and delivery expectations.

  8. A vulnerability management process is in place to prioritize and resolve security vulnerabilities based on the nature/severity of the vulnerability.

  9. A patch management process is in place to ensure that patches are applied quickly.

  • Employee training

Training is introduced to raise awareness of policies and procedures governing access to ePHI and how to identify malware attacks and malware. Staff with access to ePHI must regularly complete appropriate HIPAA data privacy training.

  • Emergency plan

Server has implemented a Business Continuity Plan (BCP) to respond to system failures or other emergencies that could damage the system or make the system or ePHI unavailable (for example, a natural disaster, fire, vandalism , a software failure, a virus, an operator error). ).

To reduce the risk of data loss or corruption, Server maintains accurate and recoverable copies of ePHI and other data necessary for the operation of the system. Backups contain enough information to restore the information system to a recent, operational, and accurate state. Business continuity incidents that impact service delivery for the covered entity are recorded,

  • Contingency test plan

Server regularly conducts a Business Impact Analysis and Risk Assessment (BIA / RA) to identify and mitigate potential threats and threats to ePHI information. The emergency plan is tested regularly and when significant changes are made to the plan to demonstrate that it will be effective and that staff members will understand their respective roles and responsibilities for recovery.

If the tests reveal that the emergency plan is ineffective in an emergency or otherwise, server will revise the plan accordingly.

  • Restriction of access by third parties

The server ensures that unauthorized parent organizations and contractors do not access ePHI, and that business partner agreements are signed with business partners who will have access to ePHI. Disclosure of ePHI information to a third party, such as a third-party subcontractor, is only permitted with the prior written consent of health care providers and for the sole purpose identified in contractual agreements with health care providers.

Third-party contractors are limited to the only necessary access, use, retention and disclosure of ePHIs required to fulfill contractual obligations. Third party contractors must receive clear instructions on security measures to protect ePHI.

  • Security Incident Report

Server isolates and contains the incidents and associated logged data before they become a violation. Server has a documented security incident management process for detecting and resolving incidents.

Server reports confirmed security incidents or weaknesses involving ePHI or services for patients and providers as soon as possible or otherwise agreed.

Server must cooperate fully with the covered entities to deal with these incidents. Cooperation may include providing access to computerized factual data for forensic assessment.

  • Confidentiality rule

Appropriate safeguards are in place to protect the confidentiality of personal health information. Information added to the system by patients can only be accessed by assigned providers and authorized administrative staff.

Patients have rights to their health information; including the right to obtain a copy of their medical records – or to review them – and the possibility of requesting corrections if necessary.

Is Your Site HIPAA Compliant?

Download >> HIPAA compliance checklist 2019 >> HERE

HIPAA violation notification rule

Offense notifications are made without unreasonable delay and no later than 60 days after discovery of the offense. If a violation of the unsecured protected health information occurs at or through server, it will notify the covered entity after the discovery of the breach. Infringement notifications must include the following information:

  • The nature of the ePHI involved, including the types of personal identifiers exposed.

  • The unauthorized person who used the ePHI or to whom the disclosure was made (if known).

  • If the ePHI has actually been acquired or viewed (if known).

  • The extent to which the risk of harm has been mitigated.

How to know if your personal health information and information is safe?

Everyone is concerned about protecting your privacy with the huge amount of information and personal data stored electronically today, What the health care provider is doing to protect your health care information.

Health plans, health care compensation chambers, health service providers that transmit health information have standards that they must respect. You do not have to follow these rules.

Is HIPAA the only law that protects patient confidentiality and health records?

No, HIPAA is a federal law, there are many other individual laws that work to protect your individual privacy and the handling of the data contained in your medical records. These laws and rules vary from state to state.

HIPAA is the basic standard and each state can add it and have its own additional standards.

How does HIPAA and the privacy rule protect my personal data?

The HIPAA law focuses on simplifying the health care system and ensuring patient safety. Title IV is a safeguard that guarantees the protection of the privacy of your medical information. Together with the federal guarantee of your privacy, the HIPAA law aims to reduce fraudulent activity and improved data systems. When all the necessary requirements to comply are fully met:

  • HIPAA Rules for Compliance by Health Care Providers

  • HIPAA Privacy Rule – Protection of the type of data communicated

  • HIPAA Security Rule – Protection of databases and data for security

HIPAA Compliance Rule – Indicates the procedures for application and procedures for hearings and penalties. People when there has been a violation of protected health information

Who does the HIPAA privacy rule apply to?

The privacy rule, as well as all administrative simplification rules, apply to health plans, health care centers and any health care provider that transmits health Information electronically in relation to transactions for which the Secretary HHS has adopted standards under HIPAA (the “covered entities”).

 Examples of people or companies that HIPAA does not apply to:

  • Direct consumer genetic testing (DTC) companies

  • state agencies, such as child protection services

  • law enforcement agencies

  • life insurance companies

  • schools

  • your employer

What is the purpose of the HIPAA security rule?

The HIPAA safety rule refers to the compliance requirements of health service providers. For a service provider to be HIPAA compliant, they must comply with the conditions established by the HIPAA Security Rule.

This includes requirements and guidelines for appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity and security of Protected Health Information (PHI).

The health information protected under the confidentiality rule includes any information that may be transmitted or retained by one of the entities covered by the HIPAA Act along with individually identifiable health information identifications.

The individually identifiable health information includes any information that can identify the patient as an individual, such as name, address, date of birth, Social Security number.

It also includes in the present, past or future any information related to the physical or mental health of the patients, the provision of medical care to the individual or information about payment for the provision of health care to the patient.

What is unidentified health information?

There are no restrictions on identified health information, identified health information is information that cannot be linked to an individual since it has been stripped of all the individualized information that could identify the individual and therefore has no identifying characteristics and does not It provides no risk.

 Some health care providers have adopted measures such as the control of access to offices with medical files through electronic key card systems and only allow employees limited access to the minimum amount of information needed.

In addition, the use of special services to make secure electronic transactions is also being used by many medical facilities and insurance providers. If you have concerns about what your doctor or health care provider is doing to comply with HIPAA, ask them what steps they have taken to ensure their privacy.

Remember that if they are compatible with HIPAA, they had a long list of things to do to be considered compatible with HIPAA. Privacy laws and data protection of sensitive patients are taken very seriously. It is very likely that they follow these rules very strictly because it is the law.

If your health insurance comes from a small self-administered health organization, they may not have to comply with HIPAA Regulations. It is important to check with them to see if they are complying, and if not, what steps they are taking on their own to ensure their privacy.

Are there any privacy exceptions to the HIPAA law?

HIPAAs privacy exceptions give health care providers and others who are required to follow an exception in HIPAA in some areas where they do not have to follow the rules described by the act and the rules. You must be informed about the three most common HIPAA privacy exceptions so you can be aware of what medical information or data about you can be legally disclosed and are not covered under HIPAA protection.

How to Make Your WordPress Site HIPAA Compliant?

As a healthcare provider, a HIPAA compliance security checklist is a must. If you have a medical website built with WordPress, you are probably wondering if it should (and can) be compatible with HIPAA. In fact, it does not focus on website compliance, which makes the HIPAA website requirements a little vague.

 In this respect, there is another important concept to touch: ePHI. This acronym, which stands for “protected electronic health information”refers to any information in digital form that can be used to identify a patient. HIPAA has the same privacy requirements for all types of PHI transmission, physical or otherwise, making it an essential element of HIPAA compliance.

 In this spirit, the application of protection measures that meet HIPAA’s requirements for confidentiality, integrity and availability of ePHI is becoming essential. Any associated website must deploy administrative, physical, technical and security measures to ensure that the confidentiality of protected health information is always guaranteed.

It should be noted that an essential element of any effective HIPAA compliance program is a contract of association. If an organization handles, uses, distributes or accesses protected health information (PHI), it is considered a BBA under the HIPAA regulations.

Although there is no simple way to make WordPress site HIPAA compliant, there are some steps that can and should be done.

  • Start by analyzing the potential risks

Depending on the activities and purpose of the website, the risks may vary a bit, so it is impossible to have a universal risk analysis that is appropriate for all cases. Website owners should be aware of common cyber-attacks and try to identify any situations in which the ePHI will be processed.

  • Choose an appropriate hosting service

Unless you are hosting your website yourself, it is important to choose the right hosting service. Making a HIPAA-compliant WordPress site worth nothing if the hosting service is weak and fragile to attack.

It then becomes important to opt for a HIPAA-compliant hosting service, which should offer a powerful firewall, encrypted VPN connection, so that no one can sniff your traffic. And offer off-site backups so that data is never lost, among other important and useful security features.

  • Explore the plugins

One of the most powerful features of the WordPress platform is the ability to enhance it with the help of plugins. Achieving HIPAA compliance is also easy if you choose the right plugins.

A good example of this is HIPAA FORMS, a WordPress plugin that allows your website to have HIPAA compliant web forms. It uses regular form plugins, such as Caldera Forms or Gravity Forms, and adds a layer of security. It includes a signature field where users can sign by dragging their mouse or with their finger on the touch screens.

 During submission, it encrypts the data and sends it to the HIPAA FORMS service API. It then stores the data in a HIPAA compliant storage solution. Keep in mind that this plugin requires a paid license.

The options for WordPress plugins are endless. You will find many WordPress security plugins from which to choose.

  • Deep study of each plugin

Plugins are a marvel of WordPress but are also one of its weak points in terms of security. According to research, plugin vulnerabilities accounted for more than half of the known attack entry points.

 To avoid this, make sure to always get plugins from official sources. Also always keep them up to date. The same goes for the main WordPress platform because it is also prone to security issues.

  • Store ePHI outside of WordPress

Most websites are built on WordPress, making these sites a target for cybercriminals. WordPress is not really the safest platform, so avoid storing ePHI data.

 Talk to your hosting provider to make sure you get the best wordpress security solution here. With the right host, you can get external hosting locations and ensure that all data is stored and retrieved safely encrypted.

  • Use all common safety tips

Security is a common topic on the Web. Users can follow many WordPress security tips, but very few follow them.

The common security rules that a HIPAA compliant Web site should follow are:

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WP Hacked Help accompanies you after the launch of your website to maintain or evolve according to HIPAA standards. We offer a security maintenance package of $70 for HIPPA websites. Our team of qualified developers is also responsible for making the necessary updates and check the overall functioning of your site.


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