What healthcare organizations need to know about HIPAA audit trail requirements

What healthcare organizations need to know about HIPAA audit trail requirements

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federally enforced set of rules and requirements to protect patient data. Healthcare providers, administrative staff, and other business associates must abide by these rules. Any entity that has access to patient information is also covered under the HIPAA Security Rule and must comply.

Whether your healthcare practice in Phoenix, Scottsdale, or Tempe is using healthcare mobile apps to automate doctor consultations or dealing with authorities about disclosing COVID-19-related information, it must observe HIPAA’s compliance regulations all the time.

The key to an effective compliance program is to follow HIPAA audit trail requirements.

What are HIPAA audit trail requirements?

Audit trails are essential in ensuring all activities within a healthcare system, such as accessing and modifying data, are well-documented. Insights obtained from a healthcare audit and user activity monitoring programs play a crucial role in boosting your healthcare practice’s data protection initiatives. These insights also help make HIPAA regulatory compliance a lot less challenging.

Related reading: Get an electronic medical record (EMR) audit to answer these 3 questions

HIPAA requires audit trails to meticulously track all data in every IT system that interacts with any piece of healthcare information. Meeting this requirement involves carefully looking into the following aspects:

Log compliance

Does your healthcare organization store, transmit, and handle data in a way that complies with industry standards? The key to answering this question can be found in your organization’s log compliance records. Keeping an organized record of system logs is instrumental in ensuring data integrity. This is why logs must be audited and why audit logs, in turn, must also be compiled and assessed.

Furthermore, HIPAA requires risk analysis of systems that are in any way linked to patient data. Most organizations do this by conducting penetration tests, vulnerability scans, and other similar protocols.

There are requirements, too, for monitoring login attempts on systems containing sensitive data. This encompasses activities that contain protected information — even if the purpose of logging in is not to access protected health information (PHI). Healthcare providers must also identify any unusual activity in the systems, which can be done by searching through activity logs and incident reports.

Security of data at rest

Data at rest is as vulnerable as data in transit. This is why HIPAA enforces rules to keep data at rest secure. And while encryption is the most widely used security protocol, the HIPAA Security Rule §164.312(b) actually doesn’t specify which tools to use to protect data. Encryption is not even mandatory under the Security Rule.

But while the Security Rule isn’t clear on encryption protocols, regulations regarding HIPAA logging are fairly stringent. Take this particular rule, for instance: “Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.”

This essentially states that a provider must use mechanisms that will carefully track activity in any computer system capable of accessing electronic PHI. That includes servers, specific electronic medical record (EMR) systems, or any personal device with PHI access.

Are HIPAA audits required?

HIPAA audits are mandatory to protect people’s medical data. In fact, it is the Health and Human Services Office for Civil Rights (OCR) that enforces HIPAA privacy and security rules and conducts audits for healthcare operations and associated businesses handling medical data.

However, healthcare organizations find it challenging to comply with HIPAA requirements. In fact, in 2019, 34.9 million Americans, or roughly 10% of the US population, had their PHI compromised, easily due to said challenges. This is why healthcare providers require the help of healthcare IT experts to ensure their IT infrastructure and data security strategies are designed to remain compliant.

How to prepare for a HIPAA audit

This HIPAA audit checklist ought to keep your practice compliant.

✓ Educate employees

Compliance training must cover every aspect of HIPAA compliance. Providers must make this training mandatory for all staff — especially those who don’t have extensive knowledge of compliance matters — and make training a priority. Note that the OCR has policies that involve testing healthcare staff about their HIPAA compliance knowledge, so a knowledgeable workforce will be valuable in keeping an entire organization compliant.

✓ Create a risk management and risk analysis plan

A risk management and risk analysis plan is key to addressing security risks that may violate HIPAA rules. This necessitates keeping a highly organized documentation of all security-related information, including files about breach response and notification, IT security measures, and physical security.

✓ Appoint a security and privacy chief

Crucial to the role of a security and privacy chief is reviewing and assessing relationships with third-party associates. This officer, a role required by the HIPAA, will lead the organization in making sure that there are safeguards firmly in place for every dealing with business partners involving healthcare information. This officer will also conduct relevant duties such as reporting breaches and reviewing the organization’s existing safety measures.

✓ Adjust policies if necessary

Determine whether your policies are working. Do so by asking staff about their challenges in following security guidelines. Based on their answers, tweak policies in a way that staff can more easily follow.

Make sure to set realistic timelines for adjusting rules and regulations. The OCR looks into how an organization handles problems, what policies are in place, and how they're implemented.

✓ Think like the OCR — do a HIPAA self-audit

Is your organization prepared for an actual audit? Are all your compliance bases covered? If not, do an internal audit and identify issues before the OCR conducts an actual audit on your organization. Ideally, you will partner with compliance specialists who know how an actual audit goes, how to solve privacy and security problems, and how to prepare your organization for the OCR’s actual audit.

Healthcare businesses know that complying with HIPAA is an industry requirement. Unfortunately, many aren’t experts in navigating the maze of HIPAA compliance guidelines, much less maintaining organized audit trails. Get in touch with Solution Partner’s team of healthcare IT professionals to get started on your practice’s risk analysis and risk management processes today. Call us at 623-584-6993.

1 Comment

  1. nice artical thanks for sharing.


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