Guide to HIPAA administrative safeguards
The Health Insurance Portability and Accountability Act (HIPAA) regulates American healthcare organizations. HIPAA guards patient privacy and secures health data. Covered Entities must put in place administrative safeguards to achieve these goals.
This article will explain what HIPAA administrative safeguards are and how they work. We will explain the nine core administrative safeguards. Readers will learn essential policies to achieve HIPAA compliance.
HIPAA security rule safeguards
The HIPAA Security Rule mandates safeguards to protect the confidentiality, integrity, and availability of electronic Protected Health Information (ePHI). These safeguards fall into three distinct categories, all working together to create a comprehensive security posture:
- Physical safeguards: These focus on securing the physical environment where ePHI is accessed, stored, or transmitted. Think tangible security measures like locks on doors to server rooms, policies controlling access to facilities, positioning workstations to prevent unauthorized viewing, procedures for securing mobile devices, and proper disposal of hardware containing ePHI. They protect against physical threats like theft, unauthorized access, or environmental hazards.
- Technical safeguards: This category involves the technology and related policies used to protect ePHI and control access to it. Examples include implementing access controls (like unique user IDs and passwords), encryption for data both at rest and in transit, audit controls to record activity in systems containing ePHI, mechanisms to authenticate users, and procedures for automatic logoff. Technical safeguards use technology to enforce data security policies.
- Administrative safeguards: These are the focus of this article and encompass the administrative actions, policies, and procedures designed to manage the selection, development, implementation, and maintenance of security measures protecting ePHI. They guide conduct, ensure workforce training, assign security responsibility, and mandate regular risk analysis and management. Administrative safeguards provide the framework and oversight for the entire security program.
All three types of safeguards are essential for compliance. Administrative safeguards, in particular, provide the crucial structure and oversight needed to effectively implement and manage both physical and technical security controls.
What are HIPAA administrative safeguards?
HIPAA administrative safeguards are policies, processes, or actions that contribute to the protection of electronic Protected Health Information (ePHI). Policies and procedures help Covered Entities:
- Select the correct security tools
- Manage secure access to ePHI
- Install controls to meet HIPAA rules
- Ensure continuity in managing HIPAA compliance
HIPAA administrative safeguards come in two categories. Regulations define policies and processes as “required” or “addressable”. Healthcare organizations must know how these standards differ.
Required standards
Covered Entities must apply these standards to the level demanded by HIPAA rules. Policies and procedures must follow every aspect of the required safeguards. There is little scope for flexibility.
Addressable standards
Covered Entities must consider addressable standards. But, organizations have much more freedom about how or whether they put in place policies. Security teams can decide to opt out of addressable standards. Organizations choosing this route must document why they have taken this decision
What is the purpose of HIPAA administrative safeguards?
Administrative measures form a significant part of the HIPAA Security Rule because they establish the essential framework for managing ePHI protection. While physical safeguards secure locations and technical safeguards protect data electronically, administrative safeguards ensure these measures are properly implemented, maintained, and adhered to through formal policies and procedures. They bridge the gap between technology/physical security and human action.
These policies document the organization's security approach as required by HIPAA. They demonstrate a conscious effort to understand regulatory obligations and implement controls that align with HIPAA standards, providing evidence of compliance efforts.
HIPAA administrative safeguards also guide healthcare organizations operationally. They provide a clear structure of policies and procedures for employees and Business Associates to follow when handling ePHI, acting as a foundation for building robust day-to-day security practices.
Furthermore, administrative measures cultivate a culture of security and compliance. By mandating training, enhancing security awareness, and defining consequences for violations, they help reduce the risk of accidental or intentional ePHI exposure caused by human error or negligence. Employees have clear guidelines and training materials derived from these policies.
HIPAA administrative safeguards standards
Under HIPAA rules, it is not enough to install technical safeguards. Covered Entities must document the controls they use. Policies and procedures achieve this aim. They act as a framework to protect ePHI.
HIPAA regulations specify nine core administrative safeguards. These safeguards include a degree of flexibility. Regulators do not expect every Covered Entity to apply the same approach. However, healthcare organizations must include every safeguard in their policies and procedures.
Security management process
The security management process deals with risk analysis and auditing. Compliant organizations must put in place policies to detect and handle security violations. Relevant addressable areas in this category include:
- Risk analysis
- Risk management
- Violation penalties
- Information system auditing
Assigned security responsibility
This set of implementation specifications deals with organization and accountability. Covered Entities must identify an individual with HIPAA security responsibility.
The assigned security professional develops security policies and procedures. They should:
- Encourage security awareness throughout the organization
- Ensure risk analysis is part of everyday security planning
- Put in place processes documented in HIPAA security policies
- Report to security managers about policy flaws or security gaps.
Organizations without an assigned security officer are in breach of the Security Rule. Allocating an individual with the required skills is crucial.
Workforce security
Workforce security deals with privileges management. These implementation specifications provide individuals with appropriate access to ePHI. They also deny access to individuals without a legitimate professional need.
Implementation standards to concentrate on in this area include:
- Assigning appropriate access privileges
- Managing employee clearance when staff need short-term access to ePHI
- Offboarding employees and removing privileges
Information access management
This set of implementation standards handles how organizations manage access to ePHI. This is not the same as workforce security. Information access involves segmenting networks and creating secure zones for ePHI.
The only required information access management issue involves healthcare clearinghouses. Policies must isolate healthcare clearinghouse functions to protect ePHI during data processing.
Authorizing access is also an addressable specification. And the same applies to establishing and modifying access settings. Covered Entities can install access controls that suit their business needs. But, security measures must meet the requirements for workforce access.
Security awareness and training
According to this implementation standard, all employees must undergo HIPAA compliance training. Addressable areas to focus on when building security awareness and training include:
- Providing security reminders, including the definition of Protected Health Information
- Avoiding malware and phishing attacks
- Monitoring log-ins
- Use of physical safeguards to protect PHI
- Secure password management
Security incident processes
Covered Entities should have processes and policies to address security incidents. This implementation standard applies the Breach Notification Rule. Healthcare organizations must have security incident procedures that:
- Report incidents according to HIPAA rules
- Launch incident response processes
Contingency planning
This implementation standard protects ePHI during security incidents or natural disasters. Covered Entities must create a contingency plan that applies when incidents occur. Required contingency plan components include:
- Scheduling secure data back-ups
- Creating and testing disaster recovery plans
- Emergency mode operation plans
Security incident procedures also include addressable policy areas that may be relevant. Addressable safeguards include:
- Revision and testing processes
- Application analysis
- Data integrity analysis
Evaluation
Covered Entities must assess how they protect ePHI. Testing and revision procedures should:
- Identify areas of concern and document any policy changes
- Respond to changes in the external environment that may compromise ePHI
- Take into account new HIPAA security regulations or security vulnerabilities
- Recommend technical safeguards to remedy those weaknesses.
Under the Security Rule, organizations must put in place evaluation policies. These policies should assess how the organization secures patient data. But Covered Entities can choose their evaluation strategy.
Some situations may need extensive data criticality analysis. Other organizations may focus on access management or tracking physical safeguards.
Business Associate contracts and other arrangements
This implementation standard covers Business Associates that receive, process, manage, or send ePHI. Covered Entities must sign security contracts with associates.
Business Associate contracts should demand that associates meet HIPAA security standards. Risk management officers should also assess associates to identify their security standards.
Who handles administrative safeguards in HIPAA?
Organizations that process, store, receive, or send ePHI must use administrative safeguards. This includes Covered Entities and Business Associates under the HIPAA Security Rule.
Policy officers manage policies and procedures within organizations. This individual should write and maintain policies. They are responsible for carrying out risk assessments. They encourage security awareness and manage training. Policy officers also track staff compliance. They ensure that penalties apply when employees violate HIPAA security safeguards.
On the regulatory side, the Department of Health and Human Services (HHS) maintains HIPAA rules. The Office for Civil Rights (OCR) investigates potential violations. The OCR may levy fines if administrative safeguards do not follow the HIPAA Security Rule. However, regulators generally provide compliance advice instead of applying financial penalties.
Disclaimer: This article is for informational purposes only and not legal advice. Use it at your own risk and consider consulting a licensed professional for legal matters. Content may not be up-to-date or applicable to your jurisdiction and is subject to change without notice.