This training on HIPAA compliance will teach the attendees how to examine their security policies, practices, and risk issues to find and fill any gaps in the documentation that is required by the HIPAA rules to show compliance, survive audits, and avoid enforcement action.

The prevention of health information privacy and security incidents and breaches depends on taking the proper steps to find issues and deal with them before they cause trouble. There is a need to make sure your policies and procedures are in place (using a HIPAA Gap Analysis), examine the systems and information flows that may be at risk (using HIPAA Risk Assessment), and plan out your overall organization-wide risk management activity (using HIPAA Risk Analysis).

The three terms, HIPAA Gap Analysis, HIPAA Risk Assessment, and HIPAA Risk Analysis often are used interchangeably, but the terms are anything but interchangeable, and all three must be part of an overall HIPAA privacy and security compliance and breach prevention program. This session will explain the differences between the terms and show how to use the analyses and assessments to find potential privacy, security, and breach issues and plan their remediation and mitigation.

A HIPAA Gap Analysis is typically an examination of an organization’s enterprise to assess whether certain controls or safeguards required by the Security Rule are implemented. It entails reviewing all of the requirements in the regulations and determining if the related safeguards are in place and properly implemented in policy and procedure.

A HIPAA Risk Assessment is an examination of each of the information systems involved with Protected Health Information, and their various information flows and connections, to discover potential risk issues and to determine the specific issues that should be addressed in safeguards in order to reduce risks to the confidentiality, integrity, or availability of PHI.

A HIPAA Risk Analysis is the overall evaluation of the risks on an organizational level, considering all the issues identified in the Gap Analysis and system Risk Assessments, and planning for the mitigation of risks over time to reduce the risks to a reasonable and appropriate level, based on the severity of the risks and the organization’s ability to mitigate them.

Using all three of these processes, Gap Analysis, Risk Assessment, and Risk Analysis, together is the key to putting the right information security program in place and protecting the organization from potentially catastrophic events.

The Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security and Breach Notification Rules require covered entities and their business associates to safeguard electronic protected health information (ePHI) through reasonable and appropriate security measures. One of these measures required by the Security Rule, is a risk analysis, which directs covered entities and business associates to conduct a thorough and accurate assessment the risks and vulnerabilities to ePHI (See 45 CFR § 164.308(a)(1)(ii)(A)). Conducting a risk analysis is the first step in identifying and implementing safeguards that ensure the confidentiality, integrity, and availability of ePHI. A Gap Analysis, to review conformance with the requirements of the HIPAA Rules, is a useful tool to identify whether certain standards and implementation specifications of the Security Rule have been met, and a Risk Assessment of each information handling process is essential to identifying and planning the mitigation of risks to the confidentiality, integrity, and availability of ePHI.

Organizations that have not performed the complete process of Risk Analysis, including Gap Analysis and Risk Assessments, are more likely to suffer incidents and breaches of ePHI, including those caused by inappropriate un-reviewed or uncontrolled internal access, and those caused by external factors, such as Ransomware incidents that can bring an organization to its knees. Even relatively simple processes, like ensuring that all portable devices holding ePHI are properly secured, if undiscovered, can lead to significant breaches and resulting penalties. These kinds of incidents have resulted in the need for notifications to patients and penalties in the millions of dollars for the affected organizations, and could likely have been prevented by performing and following through on a thorough Gap Analysis, Risk Assessment, and Risk Analysis process.

The costs of compliance through Gap Analysis, Risk Assessment, and Risk Analysis are far lower than the costs of not doing what’s required, and suffering the significant expense and consequences of incidents, breaches, and enforcement actions.