HIPAA and IT Audits

HIPAA and IT Audits

Overview of the HIPAA Security and Privacy Rules

The HIPAA Security Rule provides guidelines on how healthcare organizations can protect the confidentiality, integrity, accessibility, and availability of electronic protected health information (ePHI) (Centers for Medicare & Medicaid Services (CMS) and Medicare Learning Network (MLN), 2021). The HIPAA security rule requires that all health care organizations develop and adopt security policies that protect ePHI. The rule also requires that health care organizations continuously analyze security risks and threats that exist within the ever-changing operation environment and put in place the required safeguards and solutions to such threats.

The HIPAA Privacy Rule provides guidelines for covered entities, and associates must follow these guidelines when sharing medical records and other identifiable personal information (Centers for Medicare & Medicaid Services (CMS) and Medicare Learning Network (MLN), 2021). The Privacy Rule grants patients the right to examine and obtain copies of their medical records and requests corrections on the records. Patients also are granted control over their health records and what can be disclosed and used by health providers (Centers for Medicare & Medicaid Services (CMS) and Medicare Learning Network (MLN), 2021). Although the Privacy Rule grants patients control over their health information, healthcare professionals are allowed to report incidents involving minors to child services and related authorities without the consent of the child’s guardian.

Incidents and Breaches Occurring based on Reported Incidents

The healthcare industry has seen the adoption of various health technologies to improve the quality of care and the efficiency of care delivery. However, such developments have made the healthcare industry become a top target of external and internal cyberattacks resulting in data breaches (Seh et al., 2020). Breaches and incidents are a threat to patients and the organization’s data and information and have negative impacts on the business.

Reported incidents include health care workers who post photos with clients. Other reported incidents leading to breaches include outdated software and malware planted in the system that provides backdoor access to the system’s information. Nurses have also been reported to secretly share patient information or be involved in unauthorized exposures of medical records. All of these incidents violate the HIPAA security and privacy rules.

Technical Controls and The Non-technical Controls Mitigate the Identified Risks and Vulnerabilities

Organizations can mitigate the identified risks, and vulnerabilities by putting in place technical and non-technical control in health information management. The technical control includes having an off-site backup data storage to protect against data loss due to the poorly protected security systems of user errors. Another control is making sure that there are timely updates of the software used across the organization. According to (Skierka, 2018), timely software security updates are essential in ensuring the security and safety of connected healthcare systems. In addition, multiple-step verification methods can be applied to control user access by effectively recognizing and differentiating between valid and invalid access requests.

The non-technical approaches that can mitigate against internal threats include limiting access privileges to medical records and educating the staff on personal and system’s security measures. In addition, user training improves employee awareness and their capacity to detect and prevent security threats such as phishing attempts (Patil & Arra, 2022).

Organizational Network Architecture for Compliance with HIPAA Regulations

The HIPAA requirements for network architecture include physical computing systems, wireless local access networks (LANs), and physical and server storage systems. One major requirement for HIPAA network architecture security is ensuring that the architecture has proper security measures in place to protect against internal and external security threats. The HIPAA regulations require that the organization be in control of systems and network access, monitor user activity, provide encrypted storage of ePHI, data backup outside the network architecture, and physical security of the network systems to avoid tampering.

Similarities and Differences between a Hospital and Other Organizations in Regard to HIPAA Compliance

Hospitals and other organizations handle identifiable client information and must comply with the set regulations on privacy and security. Both are similar in that they focus on protecting their client information from breaches and access by unauthorized individuals. Data breaches have serious repercussions for both an organization and its clients. For example, leaked payment information can expose the clients’ bank accounts to hackers leading to financial losses. Additionally, such breaches can expose an organization’s trade secrets to competitors leading to stiff competition and loss of business.

On the other hand, there are differences in HIPAA compliance requirements between hospitals and other organizations. The differences are related to the levels of patient health information hospitals and other organizations handle and store. Hospitals are involved in the direct care of patients in the primary, acute, and tertiary care settings. They directly collect health information and other identifiable patient information from the patients. In addition, they collect and store medical records from the patients. Therefore, hospitals are required to meet more strict regulations on the privacy and safety of health information.

IT Audit Steps in IT Audit Plan to Ensure Compliance with HIPAA Rules and Regulations

IT audit for HIPAA compliance to rules and regulations steps include:

Hiring a privacy officer to manage systems and network implementation to ensure adherence to existing regulations.

Assessing related risks in the adoption of electronic information systems.

Setting clear usage policies and procedures.

Conducting employee training on the systems and HIPAA regulations.

Continuously monitor, audit, and update the systems.

References

Centers for Medicare & Medicaid Services (CMS) and Medicare Learning Network (MLN). (2021, May). HIPAA Basics for Providers: Privacy, Security, & Breach Notification Rules. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf

Seh, A. H., Zarour, M., Alenezi, M., Sarkar, A. K., Agrawal, A., Kumar, R., & Khan, R. A. (2020). Healthcare Data Breaches: Insights and Implications. Healthcare 2020, Vol. 8, Page 133, 8(2), 133. https://doi.org/10.3390/HEALTHCARE8020133

Patil, K., & Arra, S. R. (2022, February). Detection of Phishing and User Awareness Training in Information Security: A Systematic Literature Review. In 2022 2nd International Conference on Innovative Practices in Technology and Management (ICIPTM) (Vol. 2, pp. 780-786). IEEE. https://doi.org/10.1109/ICIPTM54933.2022.9753912

Skierka, I. M. (2018). The governance of safety and security risks in connected healthcare. IET Conference Publications, 2018(CP740). https://doi.org/10.1049/CP.2018.0002Noncompliance with HIPAA regulations can result in significant fines and negative publicity. To help ensure that your organization remains in compliance with HIPAA regulations, you have been asked to write a 3–5 page paper in which you:

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

Create an overview of the HIPAA security and privacy rules.
Analyze the major types of incidents and breaches that occur based on the cases reported.
Analyze the technical controls and the nontechnical controls that are needed to mitigate the identified risks and vulnerabilities.

Analyze and describe the network architecture that is needed within an organization, including a medium-sized hospital, in order to comply with HIPAA regulations.
Analyze how a hospital is similar to and different from other organizations in regard to HIPAA compliance.
List the IT audit steps that must be included in the organization’s overall IT audit plan to ensure compliance with HIPAA rules and regulations.

Noncompliance with HIPAA regulations can result in significant fines and negative publicity. To help ensure that your organization remains in compliance with HIPAA regulations, you have been asked to write a 3–5 page paper in which you:

Create an overview of the HIPAA security and privacy rules.
Analyze the major types of incidents and breaches that occur based on the cases reported.
Analyze the technical controls and the nontechnical controls that are needed to mitigate the identified risks and vulnerabilities.
Analyze and describe the network architecture that is needed within an organization, including a medium-sized hospital, in order to comply with HIPAA regulations.
Analyze how a hospital is similar to and different from other organizations in regard to HIPAA compliance.
List the IT audit steps that must be included in the organization’s overall IT audit plan to ensure compliance with HIPAA rules and regulations.