Case Analysis HIPAA Compliance
Memo HIPAA Compliance
Medical institutions are obligated to be Health Insurance Portability and Accountability Act (HIPAA) compliant to ensure that measures and regulations are adopted to uphold health records’ privacy and security (Findlaw, n.d.). The medical institution holds confidential and sensitive information that needs to be protected to e ensure that it does not land on the malicious or third parties. Exposure or loss of health information results in irredeemable losses, thus leaving the victims vulnerable. The HIPAA for medical institutions is implemented at administrative, technical, and physical levels (Findlaw, 2020). In this case, the small hospital-acquired in Alba needs to be HIPAA compliant. The current operations at the hospital are done manually except for the insurance billing. The hospital needs to adopt different recommendations to be HIPAA security compliance.
Risk Analysis and Management
The hospital will be required to perform risk analysis administrative safeguards as part of the security management process. The hospital’s risk analysis will be vital in determining the appropriate and reasonable security measures to be adopted. The risk analysis as a Security Rule is implemented through a process. In this case, evaluating the likelihood and impact of a risk occurring the e-PHI (Drolet et al., 2020). Consequently, the medical institution adopts the relevant security solutions to counter and address the identified e-PHI risks in the organizational operations.
Furthermore, the medical institution needs to document the security solutions adopted to counter the different risks. Additionally, the Security Rule takes the maintenance of continuous, reasonable, and relevant security protections (Findlaw, 2020.). Therefore, risk analysis needs to be an ongoing process that involves reviewing e-PHI and detecting security incidences.
The small hospital needs to incorporate different administrative safeguards as outlined Security rule in adherence to the HIPAA. Therefore, the hospital needs to have a security management process that takes security measures to reduce risks and vulnerabilities to appropriate and reasonable levels (Drolet et al., 2020). The e-PHI is exposed to a wide range of risks that must be countered through technological advancement and innovations. For instance, the hospital can have anti-intrusion software.
The hospital should have security personnel to oversee the secure and safe running of the e-PHI. The security personnel needs to be designated across the system to implement and develop security policies and procedures suited for the hospital system (Findlaw, n.d.). The hospital should also have clear and efficient Information Access Management to ensure that access to information is aligned to the Privacy Rule Standard. The standards limits use and access to PHI to the minimum necessary to ensure that health information is not exposed to malicious parties (Findlaw, 2020). The Security Rule provides entities with policies and procedures required in authorizing access to e-PHI when such access is relevant based on the user or recipient role.
The hospital needs to enhance workforce training and management to ensure that workers can operate the e-PHI while observing the security policies and procedures. The hospital is operating under an e-PHI needs to offer relevant authorization and supervision for its workforce. The hospital needs to train its workforce on security policies and procedures to uphold its administrative operations (Findlaw, 2020). The hospital needs to perform a security evaluation regularly. The periodic assessment evaluates the adherence to Security Rule and security policies and procedures, thus ensuring that the organization’s security and safety are upheld.
The hospital needs to adopt a strong access and control system to regulate and limit physical access to the facility while ensuring authorized access is allowed. Physical control is a vital element as it protects the e-PHI infrastructure from interference (FFindlaw, 2020). For instance, CCTV can be installed and connected to controls rooms to enhance physical access control. The hospital needs to have a workstation and device security to ensure that people accessing the facilities are vetted or certified to access and use the system. The hospital needs to implement policies and procedures to specify effective use and access to electronic media and workstations. The hospital needs to have policies and procedures to ensure safe transfer, disposal, removal, and re-use of electronic media.
The hospital needs to have technical safeguards aligned to achieving the HIPAA goals and objectives. In this regard, the hospital needs to have elaborate and effective access control to regulate access to the information system. The hospital needs to adopt technical policies and procedures that ensure that only authorized persons can access the e-PHI (Findlaw, 2020). For instance, the hospital can introduce sensors and CCTV cameras to detect intrusion or movement around critical infrastructure.
The hospital needs to audit its system to ensure that they operate securely in meeting its goals and objectives. The hospital e-PHI must have the capability to implement hardware, software, and procedural mechanisms to record and examine access and other information systems’ operations. The recording of operations and transactions in the e-PHI system enables the facility to track operations. Thus, security and safety issues can be detected and addressed in time before they cause significant damages (Findlaw, n.d.). The e-PHI needs to have proper integrity controls to ensure that the system is not destroyed or compromised by malicious or external parties. The hospital needs to adopt policies and procedures to ensure that e-PHI is not improperly destroyed or altered. The integrity controls ensure that the system is always subjected to the right use, and any inappropriate use is detected and rejected.
The hospital needs to adopt transmission security to ensure that health information and records are shared within secure and safe provisions. The transmission security in a covered entity implements security measures that protect against unauthorized access to the e-PHI being transmitted over an electronic network (Drolet et al., 2020.). It is vital to note that a hospital will be required to share medical information with users and other stakeholders, such as health insurance companies. Therefore, the transmission of information is subjected to end-end protection.
The adherence to HIPAA in the new hospital will require a substantial transformation to ensure that its comprehensive security and safety and operations under the e-PHI are upheld. The administrative, physical, and technical safeguard ensures that the hospital is sufficiently covered. The comprehensive security recommendations for the hospital ensure that confidentiality, integrity, and availability of e-PHI is observed, threats to the system are reasonably identified and countered, protection against impermissible disclosures are made, and compliance by the workforce is upheld. The security and safety measures adopted are preventive to ensure that the hospital will not suffer the negative consequences of losing sensitive and confidential medical records.
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Findlaw (2020). Can I Sue for a HIPAA Violation. Retrieved from: https://healthcare.findlaw.com/patient-rights/can-i-sue-for-a-hipaa-violation-.html
Findlaw (2020). The New HIPAA Privacy Rule: What Is It and Who Should Care? Retrieved from: https://corporate.findlaw.com/law-library/the-new-hipaa-privacy-rule-what-is-it-and-who-should-care.html
Drolet, B. C., Marwaha, J. S., Hyatt, B., Blazar, P. E., & Lifchez, S. D. (2017). Electronic communication of protected health information: privacy, security, and HIPAA compliance. The Journal of hand surgery, 42(6), 411-416.