Tips to Prepare for Healthcare Security Risk Assessment

Most healthcare practices wouldn’t dream of forgoing malpractice insurance. It’s a necessity to keep a practice safe. And yet, many practices take a very risky stance when it comes to healthcare security, especially as it relates to data security and HIPAA compliance.

While not exactly an insurance policy, one way your practice can protect itself from security weaknesses and vulnerabilities is through a healthcare security risk assessment that ensures you’re not taking unnecessary risks while staying HIPAA compliant. 

Quick Links

• Understanding Healthcare Security Threats
• Understanding HIPAA Security Requirements
• How a Healthcare Security Assessment Can Keep Your Practice Safe
• Top Tips to Prepare for Healthcare Security Risk Assessment

Understanding Healthcare Security Threats

With the onslaught of threats and their ability to evolve quickly, as well as the widely reported impacts of healthcare cyber attacks, it’s crucial for healthcare organizations to protect sensitive patient data and maintain trust. However, it’s not just cyber attacks that pose a threat, healthcare organizations must also be aware of insider threats and physical security breaches.

Of course, cyber attacks, such as ransomware, phishing, and malware, are among the most significant threats to healthcare organizations. Ransomware attacks, as we saw with Change Healthcare, can cripple hospital operations by encrypting critical data and demanding a ransom for its release.

Similarly, malware can infiltrate systems through various vectors, compromising patient data and disrupting services. Given the sensitive nature of healthcare data, these cyber threats can have severe repercussions, including financial losses, legal liabilities, and reputational damage.

In contrast, phishing attacks often target employees, tricking them into disclosing sensitive information or clicking on malicious links, or disclosing  passwords which provide access into networks or vulnerable applications. From there, hackers are free to access or download data or install malware or ransomware that can have long lasting repercussions.

Insider threats from employees, contractors, or other insiders who have access to sensitive information are also a serious concern. Intentional actions, such as data theft for financial gain or espionage, can be quite costly. In fact, in 2024, one healthcare organization settled a suit, from insider actions, for $4.5 million dollars.

Unintentional actions, such as accidental data breaches due to negligence, are also a serious concern. Healthcare organizations must implement robust access controls, continuous monitoring, and employee training programs to mitigate these risks. Establishing a culture of security awareness is essential to prevent insider threats and ensure all staff members understand their role in protecting patient data.

Finally, physical security breaches, in the form of unauthorized access to facilities or equipment, can lead to the theft of medical records, as well as prescription drugs, or medical devices. Ensuring physical security involves measures such as access control systems, surveillance cameras, and security personnel. Moreover, integrating physical security protocols with cybersecurity measures can provide a comprehensive approach to protecting healthcare environments.

Understanding HIPAA Security Requirements

HIPAA sets the standard for protecting sensitive patient data. Part of a HIPAA security risk assessment includes understanding HIPAA security requirements, especially as they pertain to ePHI. These requirements are outlined in the HIPAA Security Rule, which provides a comprehensive framework for safeguarding ePHI against various threats and vulnerabilities.

The HIPAA Security Rule applies to all covered entities, including healthcare providers, health plans, and healthcare clearinghouses, as well as their business associates.

The rule mandates the implementation of administrative, physical, and technical safeguards to protect ePHI. These safeguards are designed to address a wide range of healthcare security risks, from cyberattacks to unauthorized access by employees. So, let’s take a closer look at those requirements.

HIPAA Compliant Administrative Safeguards

1. Security Management Processes: Policies and procedures to prevent, detect, contain, and correct security violations.
2. Clearly Assigned Security Responsibility: Designate a security official responsible for developing and implementing security policies and procedures.
3. Information Access Controls: Implement policies and procedures for authorizing and limiting access to ePHI.
4. Security Awareness and Training: Provide training to all workforce members on security policies and procedures.
5. Security Response Procedures: Establish procedures for addressing security incidents and mitigating their effects.
6. Contingency Plans: Develop and implement a contingency plan for responding to emergencies or other occurrences that damage systems containing ePHI. This should include regular cloud backups as well as other business continuity strategies.
7. Evaluation and Audits: Perform periodic evaluations to ensure compliance with security policies and procedures.
8. Business Associate Agreements (BAA): Ensure business associates comply with HIPAA security requirements through proper contracts and agreements.

Physical Safeguards for HIPAA Security

1. Facility Access Controls: Implement policies and procedures to limit physical access to facilities while ensuring authorized access.
2. Workstation Use: Implement policies and procedures governing the proper use of workstations to protect ePHI.
3. Workstation Security: Ensure physical safeguards for workstations to restrict unauthorized access.
4. Device and Media Controls: Implement policies for the disposal, reuse, and removal of hardware and electronic media containing ePHI.

Technical Safeguards for HIPAA Security

1. Access Control: Implement technical policies and procedures to allow access only to those persons or software programs that have been granted access rights.
2. Audit Controls: Implement hardware, software, and procedural mechanisms to record and examine access and other activity in information systems.
3. Data Integrity: Implement policies and procedures to protect ePHI from improper alteration or destruction.
4. Entity Authentication: Implement procedures to verify that a person or entity seeking access to ePHI is who they claim to be.
5. Transmission Security: Implement technical security measures to guard against unauthorized access to ePHI transmitted over electronic networks, such as encrypted HIPAA compliant email.

While some of these safeguards certainly overlap, for many healthcare organizations, especially those with limited teams or strained resources, the essential task of staying HIPAA compliant when it comes to security can be overwhelming.

How a Healthcare Security Assessment Can Keep Your Practice Safe

One of the primary advantages of a comprehensive healthcare security assessment is that it can help identify and mitigate potential vulnerabilities within your practice. Regular security assessments can ensure compliance with regulatory requirements but also help practices enact proactive measures to safeguard sensitive information.

Another key benefit of a healthcare security assessment is that it helps your team develop a robust incident response plan. In the event of a security breach or cyberattack, having a well-defined plan can significantly reduce the impact and recovery time. An assessment can help identify potential threat vectors and recommend measures to enhance detection and response capabilities, minimizing disruption to patient care and maintaining trust.

Finally, a security assessment fosters a culture of security within your practice. When you involve your entire staff in the assessment process and provide targeted training based on identified risks, you can cultivate a vigilant workforce, knowledgeable about security best practices. 

Top Tips to Prepare for Healthcare Security Risk Assessment

Preparing for a healthcare security risk assessment is essential for identifying and mitigating potential security vulnerabilities in your practice. You’ll want to prepare your staff and practice for risk assessment through careful consideration of how your practice conducts regular day-in, day-out business operations. This is the only way to get true insight into how to improve your HIPAA security health. 

1. Conduct a Preliminary Security Review

Before the formal assessment begins, conduct a preliminary review of your current security measures. Evaluate your administrative, physical, and technical safeguards to identify any obvious gaps or weaknesses. This initial review will provide a baseline understanding of your security posture and help you prioritize areas that require immediate attention. It also enables you to gather and organize relevant documentation, such as security policies, incident response plans, and access control lists, which will be crucial during the assessment.

2. Assemble a Dedicated Team

As one might guess, given the amount of work involved, security isn’t a one person show. Assembling a dedicated team is critical for a successful security risk assessment. This team should include key stakeholders from various departments. For larger organizations, this team might include IT, compliance, legal, and clinical staff. Smaller organizations may need to cast people in dual roles to complete tasks but, at a bare minimum, should designate a project leader. This person will be needed to coordinate the assessment activities, facilitate communication, and ensure all necessary resources are available.

3. Educate and Train Staff on HIPAA Security

Educating and training staff is vital for fostering a culture of security awareness and readiness. All staff should understand the importance of the upcoming assessment and their role in the process. Provide targeted training sessions that cover security best practices, incident reporting procedures, and the significance of compliance with regulations like HIPAA. Well-informed staff members are more likely to adhere to security protocols and contribute valuable insights during the assessment.

4. Perform a Thorough Tech Inventory

A thorough inventory of all hardware, software, and data assets is essential for an accurate risk assessment. Identify and document all devices, applications, and databases that store or process electronic protected health information (ePHI). This inventory should include details about the asset's location, access controls, and any known vulnerabilities. Additionally, it should include detailed information about patches and security updates where applicable.

A comprehensive inventory ensures no critical assets are overlooked during the assessment and helps in evaluating the effectiveness of your existing security measures.

5. Review and Update Security Policies and Procedures

Reviewing and updating your security policies and procedures is a crucial step in preparing for a risk assessment. Ensure your policies are up-to-date, comprehensive, and aligned with current regulatory requirements and industry best practices. Pay particular attention to areas such as data encryption, access controls, incident response, and employee training. Clear, well-documented policies provide a solid foundation for the assessment and demonstrate your commitment to maintaining robust security measures.

Preparing for a healthcare security risk assessment with these steps ensures a thorough, effective evaluation of your security posture. One of the strongest moves you can make to improve security in your healthcare practice is to have a good idea of your current security posture and a clear, proactive plan to improve any weaknesses or vulnerabilities.

Whether you’re looking for a healthcare security risk assessment that evaluates your existing security and HIPAA compliance or you’re looking for a healthcare workflow platform that enhances your security stance, reach out to the iCoreConnect team or book a demo. We focus on healthcare security and workflow enhancements so you can focus on patient care.