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No matter the size of your practice, compliance with the HIPAA Security Rule is a serious undertaking. In order to fix a problem, you must first know it exists. That’s why the Risk Analysis and Risk Management implementation specifications are the foundation of your security compliance efforts. We touched on risk management in Part 2 of our HIPAA series, but in the next two articles we’ll be digging into the Risk Analysis and Risk Management implementation specifications more thoroughly with tips and tools to help you through the process.

The importance of performing a thorough risk analysis and coming up with a risk management strategy cannot be overstated. Throughout this article there will be links to resources to help you decide how best to perform your risk analysis. If you’ve never performed a risk analysis, we strongly suggest going over those resources first.

What is a Security Risk Analysis?

While much of this article presents an outline of how to conduct a Security Risk Analysis (SRA), it first helps to understand what an SRA is. Identifying that a problem exists—or could exist—is crucial to fixing it, preventing it, or making it as safe as possible. That is the purpose of the SRA.

An SRA is ultimately a process that allows you to analyze the way your company approaches risk and see how all areas of your business or organization—from policies and procedures to technical implementation—influence each other. It creates lists of threats, vulnerabilities, and threat events which could impact not only your organization, but your patients, customers, or vendors as well. Once you understand the risk in your daily business functions, finding a solution to keep them secure and operational is much easier.

Threat: the potential for a person or thing to trigger or exploit a vulnerability.

Vulnerability: a flaw or weakness in the system security procedures, design, implementation, or internal controls that could be accidentally triggered or intentionally exploited and result in a security breach or a violation of the system’s security policy

Threat Event: how a particular threat could trigger or exploit a specific vulnerability

(NIST 800-30)

The SRA process is complicated and can require a substantial investment of time and effort to complete, depending on the size and scope of your business. But when it’s finished, the SRA will provide you with a blueprint for the future. It identifies areas that are protected, areas that could use some fixing, and areas that are desperately unprotected. This allows you to prioritize your needs and create a risk management strategy specific to your environment. And when going through your HIPAA Security Rule compliance, there’s no better tool than an SRA.

Why Do You Need an SRA?

For HIPAA, you must conduct a targeted SRA. §164.308(a)(1)(ii)(A) requires an “accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information. . . .” The key to this is the specification of electronic protected health information (ePHI).

Since the Security Rule only deals with ePHI (where the Privacy Rule handles all PHI), the SRA only needs to focus on the ways in which ePHI is created, received, maintained, or transmitted. Including or performing a second SRA to include all PHI and the ways it could be improperly handled or disclosed would be best practice to assess your policies and procedures regarding non-electronic PHI, but it’s not required under HIPAA.

It’s important to remember that ePHI involves far more than an electronic health or medical record system.  It includes all types of electronic media hardware that can create, receive, maintain, or transfer ePHI, as well as software such as appointment calendars or billing databases.

While it can only help your organization to conduct a business-wide risk analysis, the targeted scope of ePHI under HIPAA narrows what you need to assess. Don’t narrow your field too much, though. The cost of insufficient or non-existent SRAs and risk management plans can lead to data breaches and serious fines.

According to the Office of the National Coordinator (ONC) for Health Information Technology, simply filling out a checklist is not enough to complete an SRA or count as proper documentation of one under HIPAA. You can learn more about common misconceptions about the SRA at the ONC’s website.

Guides and Tools to Help You Conduct an SRA

While no tool can replace a thorough and accurate SRA, there are plenty to assist you during the process. The ONC recently released an updated version of its SRA Tool that you can download to help identify areas that may need improvement. They also have video tutorials like the one below and interactive games to test your knowledge of both privacy and security requirements.

ONC’s overview of the Security Risk Analysis

There are also numerous guides to help you better understand the process of risk analysis and management. Besides what we’ve mentioned in previous articles (the Department of Health and Human Services’ (HHS) HIPAA Security Series, and NIST’s Introductory Resource Guide—Appendix E), both the ONC and the HHS have overviews of the process.

For detailed explanations of the risk analysis and management process, NIST published two separate guides: SP 800-39 Managing Information Security Risk and SP 800-30 Guide for Conducting Risk Assessments. These are not specifically geared to HIPAA’s SRA, but the level of information provided is far more complete than many of the HIPAA-specific guides. We recommend that you read SP 800-39 before SP 800-30. While SP 800-30 offers greater detail about specific parts of the risk analysis process (especially in the appendices), SP 800-39 is more reader friendly and a good foundation for SP 800-30.

How to Conduct an SRA

Like all parts of HIPAA, scalability and flexibility are at the core of the SRA. A two-dentist practice isn’t going to need the same kind of SRA as a large nursing facility, so HIPAA doesn’t dictate the exact steps to conducting an SRA. However, all thorough and accurate SRAs will go through similar steps and feature key information, no matter the format you choose. As always for HIPAA, document each step for the final SRA report.

Note: While going through the steps, it’s important to remember to look at risk from an organizational perspective (business-wide policies and procedures or budgets), a business function perspective (billing or patient care), and an informational systems perspective (settings on specific technology or hardware purchases). Another way to look at this would be administrative, physical, and technical lenses to match up with the HIPAA safeguards (though, if you prefer HIPAA terminology, keep in mind that physical isn’t perfectly analogous to business function.)

Step 1: Gather a Team

An SRA shouldn’t be performed by one person. Business owners or senior leadership should work together with management and IT experts during the SRA process. Not everyone sees risk the same way, and having a knowledgeable team ensures that your SRA will identify risk from all necessary perspectives.

Step 2: Determine the Scope

In this case, HIPAA has defined the scope for you in §164.308(a)(1)(ii)(A): “the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information” wherever it is created, received, maintained, or transmitted.

If it holds, accesses, or transmits ePHI, it is part of the SRA. For some businesses this will be a lot to cover, while others may only reference a few systems. And while the scope could be increased to include all PHI, it shouldn’t be reduced.

Step 3: Create a Risk Analysis Framework

A risk analysis framework isn’t required for an SRA, but it’s a useful tool to maintain consistency and avoid ambiguity between those preparing the SRA, those implementing it, and those conducting future SRAs. Since few people see risk the same way, the framework creates a clear set of assumptions, constraints, risk tolerances, and priorities/tradeoffs that will determine how your business manages risk.

Many of these terms appear in later steps, but they’re not used in the same way. In the framework you explain how to identify and respond to the risk factors, while later you use the framework to actually identify and respond to the risk. The framework puts everyone on the same page so that each person knows what to look for, how to judge the risk, and how to manage that risk appropriately.

The framework should also dictate the methodology you use to conduct this and future SRAs. This can be qualitative (high, medium, low), quantitative (numerical quantities), or a mix of both. Not all risk can be numerically quantified (# of individuals affected vs lost reputation—the first can be counted, the second cannot), so a qualitative or mixed approach can be more useful.

If you choose to skip the framework step, much of this information will still need to be explained in later steps to satisfy documentation requirements, and you won’t have it readily available for subsequent SRAs.

Step 4: Gather Data

In order to determine the risk to ePHI, you must first determine where it is stored, received, maintained, and transmitted. And while this encompasses a great deal more than physical hardware, having a record of the physical hardware and its movements is a part of the Physical Safeguards (§164.310(d)(2)(iii)—Accountability). This is especially important as more and more healthcare settings utilize portable electronic media, such as tablets or laptops.

Think of the flow of ePHI. Where does it begin in your business? Do you create it or receive it? Follow it from its starting point to endpoint and document what systems each piece of ePHI interacts with. Depending on your business, this could be only a few pieces of software and hardware or it could be most systems in the office. Either way, you need a complete list in order to conduct a HIPAA-compliant SRA.

Step 5: Identify and Document Potential Threats and Vulnerabilities.

This could be considered one step or two, depending on how you decide to conduct your SRA. It may be simpler to identify potential threats and vulnerabilities separately, but you may find that as you identify a threat, you also identify the vulnerability it could exploit and vice versa. It is up to your team to decide the best method.

If you’ve already created a framework, you’re ready to identify threats and vulnerabilities. If not, take some time to decide what you’re going to consider a threat or vulnerability, how you’ll identify them, and what sources are valuable to work from during the process.

Sources of information could include past SRAs, business security reports or testing, known breaches of similar institutions (Breach Level Index, OCR Breach Report), the security community’s public lists and advisories (National Vulnerability Database, National Checklist Repository), information from vendors, and your managed services provider or IT staff.

As always, remember to document everything.

Threats: One important thing to note when starting your list of potential threats is that you are not required to list all potential threats. You must list all reasonably anticipated threats to ePHI. Having valuable sources of threat information is important, because you don’t want to waste time or resources on a threat that will never affect you, such as a hurricane if you’re nowhere near the ocean.

At this point you’re not looking at whether or not you’ve already mitigated the risk of such threats affecting ePHI. You’re only considering if it is a reasonably anticipated threat. And threats aren’t just about whether someone steals your data for misuse, but whether you can verify the integrity of your ePHI and have it available when you need it.

Vulnerabilities: When dealing with ePHI, it’s easy to think of vulnerabilities as technical problems. Non-technical vulnerabilities cannot be overlooked, and could even be the root problem to other perceived vulnerabilities. A lack of policies and procedures on how to securely set up new hardware or a budget that doesn’t meet the demand of current threats could lead to a number of technical vulnerabilities through misconfiguration of security settings or poor hardware purchasing. This is why a team is important for looking at both the big picture and the small details.

Step 6: Assessing Security Measures

Now that you have a complete list of threats and vulnerabilities, it’s time to see what security measures you already have in place to protect ePHI. Small- to medium-sized business have a greater degree of control over their environment, which is an advantage in mitigating risk. Like vulnerabilities, security measures can be both technical and non-technical, and should be looked at from all perspectives. When documenting, also identify that all technical security measures are not only there but also configured and utilized correctly.

Step 7: Determining Risk

In order to determine risk, it’s time to put the threats and vulnerabilities together to create a list of possible threat events. This is not a strictly one-to-one pairing. A single threat might affect multiple vulnerabilities, and a single vulnerability might be affected by multiple threats. (For more guidance on threat events, see Appendix E of SP 800-30.)

For each threat event, you must determine the likelihood of it occurring and the impact it would have on ePHI and your business if it did. Likelihood is the probability that a threat event will occur.

Below are examples (both qualitative and quantitative) of how you could determine likelihood and impact. Depending on your business’s risk tolerance, you might add more levels beyond high, medium, and low.

The impact of a threat event can be felt across different levels. The most obvious is the direct breach to ePHI’s confidentiality, integrity, and availability, but impact can also be felt in the loss of revenue from a damaged reputation, the cost of fixing the effects of the threat event, time and effort spent dealing with regulatory audits, and other intangible results. Below is an example of how you might measure impact.

Level of Risk

Accurate assessments of the above are vital to determining the overall level of risk posed by a threat event because risk is a combination of likelihood and impact. For example, if the impact is high but the likelihood is low, then the overall risk would be low. The clearer the definitions in the framework of what constitutes the levels of likelihood and impact, the more accurate and consistent your evaluations of threat will be. Threat matrices (such as those in Appendix I of SP 800-30) can be used for both qualitative and quantitative methodologies.

Step 8: Document and Manage Risk

If you’ve kept up with your documentation, the final SRA report should be simple to put together. Appendix K of SP 800-30 offers a base template for writing an SRA report, but you should tailor it to your business’ needs. In general, it should include all the lists you’ve made, as well as the reasons for your determinations and how you plan to use this information.

The final task of an SRA is to develop a risk management plan. HIPAA understands that risk cannot be wholly eliminated, but it should be reduced to reasonable and acceptable levels. Conducting an SRA and implementing a risk management plan become the foundation for implementing the rest of the Security Rule’s safeguards. In the next installment of our HIPAA series, we’ll look at how to use your SRA to create a risk management plan.

If you’d like the IT experts at Anderson Technologies to be a part of your risk analysis team, contact us today at 314.394.3001 or by email at info@andersontech.com.

Even if you’ve never worked in the healthcare industry, you’ve probably heard of HIPAA. An appointment to get your teeth cleaned comes complete with a slew of forms that include your rights according to HIPAA.

But can you explain what HIPAA is and why that form is necessary? We often sign and date and move on, knowing it relates vaguely to what our care provider can do with our private health information.

HIPAA includes a lot more than you may realize, and if you work with Protected Health Information (PHI), especially electronic Protected Health Information (ePHI), understanding HIPAA is crucial. This article is the first in a series discussing what HIPAA is, understanding the Privacy and Security Rules, and analyzing HIPAA compliance standards.

What Does HIPAA Stand for?

If you’re not exceptionally familiar with this acronym, you may think it stands for the Health Information Privacy and Accountability Act. That seems reasonable given how the everyday person is exposed to it. In fact, it stands for the Health Insurance Portability and Accountability Act.

That doesn’t sound so familiar, does it? HIPAA was enacted in 1996 not with the intent to protect people’s privacy, but instead to regulate and simplify the health insurance industry. According to the official HIPAA language, the objective of this government regulation is:

To amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes.

Essentially, Congress wanted to make health insurance cheaper and simpler by reducing administrative costs and creating a standard method that everyone related to the health insurance industry could adopt. So where does all this privacy and security regulation come into play? The requirement “to simplify the administration of health insurance” triggered everything.

In the Administrative Simplification section of HIPAA, the Act requires that the rights of individuals relating to the use and disclosure of their health information be clearly explained and that standards are set for the electronic exchange of health information. These two subsections, privacy and safeguards, would later be addressed in what is now referred to as the Privacy Rule and the Security Rule.

The Privacy Rule

The Privacy Rule went into effect in 2000 and has been amended several times. It lays out the standards and guidelines for how PHI in all forms—verbal, physical, or electronic—can be used and disclosed. The Privacy Rule is the reason you know the acronym HIPAA at all.

Thanks to the Privacy Rule, health care providers, insurance companies, and their business partners must follow the same rules regarding health information. Individuals have the same right to access and the same expectation of privacy from all entities according to the guidelines in the Privacy Rule. PHI can include:

• identifiable personal information,
• any medical or mental health condition diagnosed during the lifetime of the individual,
• any treatment or procedure performed in the lifetime of the individual,
• payment information relating to health care,
• and any identifiable or medical information that the individual wants restricted.

The Privacy Rule is also the reason you must sign that form stating you understand your rights according to HIPAA. Being informed that you have the right to privacy is part of your legal rights. There are exceptions to these rules, such as life-threatening emergencies, court orders, and release of information authorizations, but all are directly addressed and specified within the rule.

Ultimately, the HIPAA Privacy Rule sets the standard for each patient’s right to privacy regarding their PHI. Thanks to the Privacy Rule, PHI is automatically considered confidential in almost all circumstances, and it also explains under what circumstances PHI may be shared.

The Security Rule

The Security Rule is a little different. It first went into effect in 2003 and, unlike the Privacy Rule, relates only to ePHI. The Security Rule established the safeguard standards everyone dealing with ePHI must follow to be HIPAA compliant. Compliance means all ePHI is stored, processed, and transferred in a way that ensures patient privacy. While it doesn’t dictate specific implementation steps, since each company’s use and needs around ePHI is different, anyone dealing with ePHI must address each specification.

HIPAA began as a way to simplify health insurance procedures and make those handling health information more accountable to every citizen’s rights about their private health information, and its effects have been far-reaching. For anyone dealing with PHI, the requirements can appear daunting at first, but with a trusted IT partner, HIPAA compliance means any and all health information will be safe in your hands.

Look for our next HIPAA article, which will discuss the Security Rule in more detail. Until then, you can contact Anderson Technologies’ expert consultants for help navigating HIPAA compliance by calling 314.394.3001 or emailing info@andersontech.com.

Sure, e-commerce sites are convenient, but more and more frequently they are teeming with cyber threats that could compromise your financial information, identity, or even your business. Here’s what you can do to protect yourself.

Online sales in the U.S. are projected to reach $523 billion by 2020, according to a report by Forrester Research. In fact, many Americans are buying more online than in-store, and retailers aren’t the only ones taking notice. Criminals see the e-commerce boom as an opportunity for payment fraud, identity theft, and other cyber crimes.

Of every $100 spent online, $4.79 is at risk of a fraud attack, according to The Global Fraud Index, a PYMNTS and Forter collaboration. It’s important to remember cyber criminals don’t just acquire data by targeting you personally. They hack businesses in hopes of infiltrating their databases to steal customer information. If you’ve created an account with a website that is compromised, your information is at risk, even if you haven’t shopped there in months!

Most retailers take precautions to provide their customers with safer online shopping experiences, but the onus is also on the individual. These tips will help you identify secure e-commerce sites, protect your personal information, and at least mitigate the damage should you fall victim to a cyber criminal’s attack.

1. Only Shop at Sites with “HTTPS” URLs at Checkout

HTTPS stands for Hypertext Transfer Protocol Secure and indicates that the business has an SSL (Secure Sockets Layer) certificate. This certificate requires the vendor go through a validation process. Once installed SSL and TLS (Transport Layer Security) are used to secure sensitive online transactions—such as credit card purchases, financial data transfers, account logins, and other browsing activities requiring a heightened level of security. The data you share with a site’s web servers is encrypted in transit, and thus much harder for hackers to exploit.

2. Assess the Site’s Legitimacy

Before sharing any personal information, research the site’s return policy, social media presence, and online reviews. Check that it has a Privacy Policy, Terms of Use, and detailed contact information. If anything seems suspicious, leave the site immediately.

3. Create a Separate Email for Online Shopping

Do not provide e-commerce sites with your personal or business email address. Instead, create an account you use solely for online shopping. You can set up your accounts so all emails forward into a single inbox, but limit how often you hand out your primary email addresses.

4. Create Unique Logins and Passwords for Every Vendor

Password management is an important component of safer online shopping yet it is often overlooked. Should a cyber criminal gain access to one of your accounts, you want the damage to end there. Do not use the same login and password for everything. Create complicated passwords that cannot be easily guessed. Password management applications, such as LastPass, are invaluable tools to help automate this.

5. Use a Dedicated Credit Card for Online Shopping

Most credit card companies offer some fraud guarantees and will work with you if your information is stolen. Additionally, consider using PayPal, which goes to great lengths to keep its customers secure.

6. Do Not Save Your Payment Information

Sure, you’ll add a few seconds to future checkouts, but it is worth it? Should a criminal infiltrate an e-commerce platform at least you won’t be giving them your credit card number on a silver platter. Also, refrain from saving passwords on your browser and clear your history routinely.

7. Delete Accounts You No Longer Use

Remember, even if you haven’t visited the e-retailer in months, your information could still be obtained by a criminal who hacks the site. By removing accounts from sites you no longer frequent, you’ll help keep your personal information safe.

8. Be Wary of Promotional Emails

Cyber criminals use email as a means of spreading malware and launching spear phishing scams. If you receive an email from a retailer that looks too good to be true, visit the site directly to confirm the information is valid. Always verify the email address of the sender. If everything seems above-board, hover over the link before clicking it, which will allow you to review the URL. Be sure to do so carefully, as crooks often use domain names that look similar to reputable sites.

E-commerce is a part of life, but we can’t take our cyber security for granted. No business owner wants to encourage personal purchases on the job, but it is worth sharing best practices for safer online shopping to help keep your employees, and your business, secure.

Anderson Technologies is a St. Louis IT consulting company that helps small businesses educate their employees about effective cyber security practices. For more information on our cyber security training services, email info@andersontech.com or call 314.394.3001 and check out our free eBook, An Employee’s Guide to Preventing Business Cyber Crime.