HIPAA Gap Analysis and a HIPAA Risk Analysis

HIPAA Gap Analysis
Learn about the HIPAA Gap Analysis

What is the difference between a HIPAA Gap Analysis and a HIPAA Risk Analysis?  Many organizations use these interchangeably, however, they are not correct in doing so.  Don’t make the same mistake. We can help you understand the difference.

Office of Civil Rights Requirements

The Office for Civil Rights clearly spelled out the steps and requirements for a HIPAA Security Risk Analysis.  As a result, it requires covered entities to conduct an accurate and thorough assessment. It must consider potential risks and vulnerabilities to the confidentiality, integrity and availability of electronic protected health information held by the organization.  Furthermore, entities must consider the potential risks, threats and vulnerabilities to all of the covered entities ePHI.  This includes all ePHI which is created received, maintained or transmitted, including the source or location of the ePHI

Understanding a HIPAA Gap Analysis

The HIPAA Rule does not require a HIPAA Gap Analysis.  The Gap Analysis is usually a limited evaluation of a covered entity or business associate’s organization to reveal whether there are certain policies, controls or safeguards required by the HIPAA.  As a result, it is important rules are in place and implemented. The HIPAA Gap analysis should begin with a review of all policies, procedures, processes, practices and systems. It must investigate all facilities that relate to privacy, uses and disclosures of PHI.

Gap Analysis Insufficient for HIPAA Rule

A Gap Analysis  does not satisfy the Security Risk Analysis requirement. It does not demonstrate an accurate and thorough analysis. In effect, it must consider all risks, threats  and vulnerabilities to all of the ePHI an entity creates, receives, maintains or transmits.  Consequently, the gap analysis is not equivalent to the risk analysis as it does not satisfy the rule as specified  by 45 C.F.R. §164.308(a)(ii)(A).  It is important to note that OCR expects a covered entity to document and implement all of the necessary regulations of the HIPAA Rule to obtain a Compliant rating.

Therefore, it is important to identify your covered entity’s needs and determine whether you require a Gap Analysis or Risk Analysis.  Assure that the vendor you engage is qualified to perform the specific type of analysis that you need. 

Reasonable Safeguards for PHI

Reasonable Safeguards for PHI
Reasonable Safeguards Are Important

Protecting  PHI

Reasonable Safeguards for PHI are precautions that a prudent person must take to prevent a disclosure of Protected Health Information.  To protect all forms of PHI: verbal, paper, and electronic, provides must apply these safeguards.  They help prevent unauthorized uses or disclosures of PHI.  In addition safeguards must be part of every privacy compliance plan.  Organizations must share this with all members of the organization.

Safeguards for Verbal PHI

Apply Reasonable Safeguards for PHI to all of your verbal disclosures of Protected Health Information. When you work with a patient, first determine who is with the patient before discussing PHI.  Secondly do not assume the patient permits disclosure of their PHI just because family or a friend is in the room with them. Ask who is with the patient and if the patient permits disclosure.  Finally you may ask the persons to leave the room providing the patient an opportunity to object.

Paper PHI

In addition, reasonable safeguards for PHI must apply to the use of all paper products to prevent these from reaching the wrong person.  Providers must dispose of all paper products that have PHI in a shredder once no longer used.  Personnel must make every effort to give the patients summary to the correct patient.  When a paper patient summary is given to a patient, every effort must be made to give it to the correct patient.

Electronic PHI

Password protect all computers in order to protect electronic PHI.  Employees must only use the computer medical accounts to which they are assigned.   One must consider the use of encryption of any email or texts that contains ePHI.

Use of Reasonable Safeguards for PHI Prevent Violations

In conclusion the use of reasonable safeguards may be the difference between an Office for Civil Rights finding of a privacy violation or a finding that an incidental disclosure occurred.   The latter is secondary to a permissible disclosure, and not a violation. Reasonable safeguards protect PHI and help prevent you from violating patient privacy.

For more information follow this link.

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