Ready for a Gap Analysis?
Is your organization keeping up with the challenging world of HIPAA compliance? Are you concerned over weaknesses in your HIPAA compliance program or the non-existence of a program? Most importantly have you considered a HIPAA Gap Analysis to assess the program for risk areas in order to identify and correct problems? Now may be the time to take this important step.
Key Features of a HIPAA Gap Analysis
A HIPAA gap analysis is a focused review and analysis of a covered entity or business associates’ organization to determine its compliance with the HIPAA Privacy, Security Rules as amended by the Health Information Technology for Economic and Clinical Health Act [HITECH] (collectively the “HIPAA Rules”). As a result, it will review the overall flow of protected health information (PHI) created, accessed, used and disclosed within the organization. The gap analysis looks at all forms of PHI in the organization. This includes the information systems hardware and software systems that create, use, maintain, store and transmit PHI. Finally, the gap analysis reviews any existing policies, procedures and the safeguards that are in place to protect the information, and the policies that give individuals’ rights over their PHI.
A Good Starting Point
First of all, a gap analysis is a good starting point for beginning a HIPAA compliance program or in improving an existing compliance program. It is a useful and information filled tool, however, it will not take the place of a Security Risk Analysis (SRA). In comparison, the SRA is an in-depth examination of the administrative, physical and technical safeguards for electronic PHI (ePHI) required by the Security Rule. Therefore, information collected in the gap analysis will assist the organization in the completion of the SRA.
Administrative Safeguard Analysis
Initially, the gap analysis begins with a review of items required by the HIPAA Rules as identified in the individual Privacy, Security and HITECH Rules. Next, data reviewed in a HIPAA Gap Analysis includes the policies the covered entity or business associates must implement that ensure individuals’ rights over their PHI. This would include the right to access PHI, to request an amendment to PHI or an accounting of disclosures, to request a restriction, and make a privacy complaint, and others. In addition, under review are the policies and procedures used to safeguard PHI in all formats whether verbal, paper or electronic. These include administrative requirements such as policies, business associate agreements, named privacy and security officials, training on the policies that affect employees’ job duties, a complaint process, and breach reporting.
Physical Safeguard Analysis
In addition a gap analysis includes a review of physical safeguards which protect information systems and related equipment and facilities from hazards and intrusions. The analysis examines physical safeguards that protect paper PHI maintained in the regular course of business and also verbal PHI used and disclosed within the organization. In order to perform a thorough analysis of the physical safeguards gap analysis requires an onsite review.
Technical Safeguard Analysis
Finally, the gap analysis reviews technical safeguards that protect ePHI by applying mechanisms to protect the confidentiality, integrity and availability of the data. These safeguards control access to PHI and assure the information is true and accurate. They ensure PHI is available for those authorized to use the information to perform their job functions.
How It Can Help You
Above all the focus is to identify deficiencies and risk areas that exist between the policies and/or protections currently in place. It will look at the existing compliance program and the HIPAA Rules requirements. The analysis reviews the gaps identified and highlights necessary remediation to cure the deficiencies, reduce risk, and bring the program into compliance. This will give the entity the opportunity to determine how best to approach taking the necessary steps to bring itself into compliance.
Most importantly, the gap analysis will give covered entities and business associates an overall snapshot of their compliance efforts. Secondly, it will help them discover areas where they are non-compliant with HIPAA Rules or which put them at risk. Additionally, it will give the organization a roadmap to compliance. Finally, this will give the privacy officer the information needed to move forward with any necessary revisions to the program.
Our organization has had years of experience assisting clients with HIPAA compliance programs whether starting a program from the beginning or recommending revisions. We can help you understand the gaps that might exist in your program and how they can affect your organization. This will give you the opportunity to eliminate flaws or deal with issues that may put your company at financial and reputational risk. Most important, we have the knowledge and expertise to help you with this important project.
Cost of HIPAA Gap Analysis begins at $500
In conclusion, we are ready to help you deal with your HIPAA concerns. We will provide your organization with a gap analysis to define the state of your HIPAA compliance program and ensure compliance with the HIPAA Rules. In conclusion, we are available to discuss your needs and start on your gap analysis today.