HIPPA Compliance

The HIPAA Security Rule requires appropriate Administrative, Physical, and Technical Safeguards to ensure the confidentiality, integrity, and security of protected health information (PHI).

Overview of the HIPAA Security Rule

The Security Rule is made up of three key parts:

1. Technical Safeguards

2. Physical Safeguards

3. Administrative Safeguards

All three parts include implementation specifications, which are either:

• Required – Must be implemented.

• Addressable – Must be implemented if it is reasonable and appropriate to do so; the decision must be documented.

Note: An addressable implementation specification is not optional. When in doubt, implement it, it is typically a best practice.

Technical Safeguards

Technical safeguards focus on the technology that protects PHI and controls access to it. The Security Rule does not mandate specific technologies; it is designed to be technology neutral.

Five Standards Under Technical Safeguards

1. Access Control

2. Audit Controls

3. Integrity

4. Authentication

5. Transmission Security

Physical Safeguards

The following are important implementation specifications under physical safeguards:

• Facility Access Controls – Contingency Operations (addressable):
  Establish (and implement as needed) procedures that allow facility access in support of restoration of lost data under the disaster recovery plan and emergency mode operations plan in the event of an emergency.

• Facility Access Controls – Facility Security Plan (addressable):
  Implement policies and procedures to safeguard the facility and the equipment therein from unauthorized physical access, tampering, and theft.

• Facility Access Controls – Access Control and Validation Procedures (addressable):
  Implement procedures to control and validate a person’s access to facilities based on their role or function, including visitor control, and control of access to software programs for testing and revision.

• Facility Access Controls – Maintenance Records (addressable):
  Implement policies and procedures to document repairs and modifications to the physical components of a facility which are related to security (e.g. hardware, walls, doors, and locks).

Workstation and Device Security

• Workstation Use (required):
  Implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access ePHI.

• Workstation Security (required):
  Implement physical safeguards for all workstations that access ePHI, to restrict access to authorized users.

Device and Media Controls

• Disposal (required):
  Implement policies and procedures to address the final disposition of ePHI, and/or the hardware or electronic media on which it is stored.

• Media Re-Use (required):
  Implement procedures for removal of ePHI from electronic media before the media are made available for re-use.

• Accountability (addressable):
  Maintain a record of the movements of hardware and electronic media and any person responsible therefore.

• Data Backup and Storage (addressable):
  Create a retrievable, exact copy of ePHI, when needed, before movement of equipment