Posted by Tyler Chancey, GCFA on

Tyler Chancey is a seasoned cybersecurity professional currently serving as the Director of Cyber Security at Scarlett Cybersecurity Services, With a solid foundation in Computer Software Engineering from the University of Florida, Tyler holds a repertoire of certifications that underscore his expertise. These include the prestigious Microsoft 365 Certified: Enterprise Administrator Expert and Microsoft 365 Certified: Security Administrator Associate, showcasing his mastery in Microsoft's enterprise solutions. Tyler's commitment to comprehensive security is further evidenced by his CompTIA Security+ certification, demonstrating proficiency in core cybersecurity principles. Additionally, his GIAC Certified Forensic Analyst (GCFA) credential attests to his advanced skills in forensic analysis—an invaluable asset in today's complex cybersecurity landscape. Tyler's dedication to staying at the forefront of industry standards is evident in the active pursuit and maintenance of these certifications, making him a trusted authority in the field.

HIPAA in Cybersecurity

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law. It was established in 1996 to protect and secure the privacy of individuals’ health information. There are several entities under HIPAA including healthcare providers, health plans, and businesses associated with handling protected health information (PHI).

What is HIPAA in Cybersecurity?

HIPAA (Health Insurance Portability and Accountability Act) sets standards for protecting sensitive patient data. Compliance with HIPAA regulations is crucial to prevent healthcare cyber attacks, which can result in costly fines and damage to reputation. 

Cybersecurity is a critical aspect of HIPAA because healthcare organizations store and transmit PHI online in today's digital age, making them vulnerable to cyber-attacks. Cybersecurity breaches can result in the theft, destruction, or unauthorized access of PHI. 

According to the stats, there were 642 healthcare data breaches reported in 2020, which resulted in the exposure of over 30 million individuals' PHI. An IBM report states that the average cost of a healthcare data breach was $7.13 million in 2020. These stats showcase the significance of following HIPAA.

Not following HIPAA can lead to financial and reputational damage for healthcare organizations and harm to individuals. HIPAA requires covered entities to implement appropriate administrative, physical, and technical safeguards to protect PHI and prevent cyber security breaches. 

Now to understand HIPAA in cyber security, we need to have some understanding of HIPAA first. We have put together this comprehensive guide featuring everything there is to know about HIPAA in Cybersecurity, its history, purpose, rules, and regulations. Let’s dive in.

What is HIPAA?

HIPAA was signed into law under the presidency of President Bill Clinton in August 1996. There have been several updates and amendments to HIPAA. The three rules of HIPAA include HIPAA Privacy Rule, Security Rule, and Breach Notification Rule.

The Purpose of HIPAA

The main purpose of HIPAA is to protect the privacy and security of people’s health information. It allows people to access their own health information in a secure manner. The security rule under HIPAA sets the standards for safeguarding electronic PHI (ePHI). 

HIPAA features a security rule that includes healthcare cybersecurity solutions to avoid unauthorized access, use, or disclosure. It ensures the confidentiality, integrity, and availability of ePHI by limiting the use and disclosure of information to only authorized personnel. 

All the covered entities are bound to implement appropriate administrative, physical, and technical safeguards to protect PHI.

HIPAA’s Scope of Coverage

There are several entities that are covered under HIPAA. They include healthcare providers, and health plans along with the firms and businesses associated with them who handle PHI. As of March 2021, there are over 2.8 million registered HIPAA-covered entities in the United States. It shows how extensive is the scope of HIPAA’s coverage. 

In today’s age, the cybersecurity aspect of HIPAA holds great importance. There is a significant increase in healthcare data breaches, and the healthcare industry is one of the top targets for cyber attacks.

In fact, according to the 2020 Data Breach Investigations Report by Verizon, the healthcare industry was the only industry in which the majority of data breaches were caused by cyber attacks (51%).

All of the stats and reports we have mentioned show how crucial it is for healthcare organizations to protect PHI. The only way they can do that is by having strong cybersecurity measures and HIPAA compliance.

HIPAA Security Rule

All the set of standards and rules established to protect the confidentiality and integrity of ePHI comes under the HIPAA Security Rule. These standards are applied to all the covered entities in HIPAA as mentioned earlier.

We can divide the security rule of standards into three categories. There are administrative safeguards, physical safeguards, and technical safeguards. All entities, businesses, and firms have these departments. So, it’s imperative to have HIPAA compliance to ensure a secure and safe environment.

Each category consists of several standards that covered entities and business associates must implement to safeguard ePHI.

Administrative Safeguards 

Administrative safeguards refer to the policies and procedures to manage the selection, development, implementation, and maintenance of security measures to protect ePHI. This includes risk analysis and management, workforce security, contingency planning, and security training. 

For instance, the implementation of workforce security policies by a healthcare organization. These policies would include procedures for verifying the identity of employees and their level of access to ePHI. It also includes guidelines for creating strong passwords and regularly changing them. 

The organization may also conduct security awareness training to educate employees about the importance of safeguarding ePHI. Every employee should be familiar with the potential consequences of failing to comply with HIPAA regulations

An employee can easily become the weakest link in a company. They can be a reason for a security breach. Training each employee is required to help reduce the risk of unauthorized access to ePHI. You can also explore hiring a HIPAA Officer or HIPAA Compliance Consultant to assist with training and oversight.

Physical Safeguards

Physical safeguards are the measures to physically protect the ePHI that these businesses hold. This includes access controls, facility security, workstation use, and device and media controls. 

The installation of security cameras and access control systems at the entrances of healthcare facilities to prevent unauthorized access. Healthcare organizations may use biometric identification technology, such as fingerprint scanners or facial recognition, to control access to sensitive areas where ePHI is stored. 

The use of cable locks, security cages, and other physical security measures to secure computer systems, storage devices, and portable media is also an example of physical safeguards.

Technical Safeguards

Technical safeguards refer to the technology and healthcare cybersecurity measures that a covered entity or business associate implements to protect ePHI. The access controls, audit controls, integrity controls, transmission security, and encryption and decryption come under this umbrella.

Technical safeguards are an essential component of the HIPAA Security Rule as they aim to protect ePHI from unauthorized access, alteration, or destruction in electronic form. 

  • Access controls include mechanisms such as unique user IDs, passwords, and encryption to ensure that only authorized individuals can access ePHI. 
  • Audit controls help to record and examine activity related to ePHI to identify any security breaches. 
  • Integrity controls ensure that ePHI is not tampered with or destroyed accidentally or intentionally. These controls can include measures such as digital signatures, checksums, and hashing. 
  • Transmission security refers to the use of encryption and other security measures to ensure that ePHI is protected when it is transmitted over a network or the internet. 
  • Encryption and decryption refer to the process of converting ePHI into a secret code to prevent unauthorized access or theft of sensitive information. For example, a healthcare organization may use encrypted messaging systems to communicate sensitive patient information between physicians and staff. 

HIPAA in Cybersecurity

We have established that technology plays a huge role when it comes to storing and managing Electronic Health Records (EHRs) and patient data in the healthcare industry. It results in cybersecurity becoming a critical concern for healthcare organizations.

The healthcare industry needs to have strong cybersecurity measures including everything we mentioned in the technical safeguards. Cybersecurity is a subset of the HIPAA security rule. It’s one of the biggest aspects of it and without it, a healthcare industry can collapse in a matter of days.

If we neglect the importance of cybersecurity in HIPAA, a small breach can result in the exposure of sensitive patient information, reputational damage, financial loss, and patient harm. Let’s learn about cybersecurity threats in healthcare.

Cybersecurity Threats in Healthcare

There are various types of cybersecurity threats in healthcare, including malware attacks, ransomware attacks, phishing attacks, and insider threats. According to the HIPAA Journal, phishing attacks are the most common cause of data breaches in the healthcare industry.

Phishing is the type of situation that showcases the importance of educating employees about potential cyber risks. Not only this, but they should also have strong technical safeguards such as email filtering and spam detection.

In 2017, the WannaCry ransomware attack affected various industries including healthcare organizations worldwide. The attack impacted over 200,000 organizations in 150 countries, including the UK's National Health Service, resulting in canceled surgeries and appointments, delayed care, and financial losses.

HIPAA Privacy Rule

As the name suggests, the HIPAA privacy rule was established to protect the privacy of individually identifiable PHI. This rule sets the requirements for the use and disclosure of PHI, giving patients control over their personal health information. All the mentioned covered entities under HIPAA must comply with the privacy rules. 

The Privacy Rule establishes a set of standards that covered entities and their business associates must follow to protect the privacy of PHI. The standards include the following:

  • Limits on the use and disclosure of PHI: The Privacy Rule restricts the use and disclosure of PHI, except as permitted or required by law or with the patient’s authorization. 
  • Minimum necessary rule: HIPAA Privacy Rule requires covered entities to limit their use and disclosure of PHI to the minimum necessary to accomplish the intended purpose of the use or disclosure.
  • Individual rights: It gives individuals specific rights with respect to their health information, such as the right to access, request amendments to, and receive an accounting of disclosures of their PHI. 
  • Administrative requirements: It requires covered entities to implement administrative safeguards to protect the privacy of PHI, such as appointing a privacy officer and providing privacy training to employees.

Description of patient’s rights under HIPAA Privacy Rule

HIPAA gives patients several rights with respect to their PHI.

  • Right to access: Patients have the right to access their PHI and obtain a copy of their medical records. 
  • Right to request amendments: Patients have the right to request that their PHI be amended if they believe it is incorrect or incomplete. 
  • Right to an accounting of disclosures: Patients have the right to receive an accounting of disclosures of their PHI. 
  • Right to request restrictions: Patients have the right to request restrictions on the use and disclosure of their PHI.

Compliance Requirements for Privacy Rule

The Privacy Rule sets out several requirements for covered entities and business associates to ensure the privacy and security of individuals' health information. The Rule specifies limitations and conditions on the uses of PHI that may be made without a person's consent. It also mandates suitable protections to preserve the privacy of such information.

  • Designating a privacy HIPAA officer: Covered entities must designate an individual to be responsible for developing and implementing the entity's privacy policies and procedures. 
  • Conducting a risk assessment: Covered entities and business associates must conduct a risk assessment to identify potential vulnerabilities in their systems and procedures for protecting personal health information. 
  • Developing privacy policies and procedures: Covered entities and business associates must develop and implement policies and procedures to protect the privacy of personal health information, including procedures for responding to breaches of privacy. 
  • Providing training to workforce members: Covered entities and business associates must provide training to employees who have access to personal health information to ensure that they understand their obligations under the Privacy Rule.
  • Implementing safeguards: Covered entities and business associates must implement appropriate administrative, physical, and technical safeguards to protect personal health information. 
  • Reporting breaches: Covered entities must report breaches of personal health information to affected individuals, the Department of Health and Human Services, and in some cases, the media.

Failing to comply with the Privacy Rule can result in significant financial penalties. The Department of Health and Human Services Office for Civil Rights is responsible for enforcing the Privacy Rule and can impose fines of up to $1.5 million per violation

HIPAA enforcement and penalties are in place to ensure that organizations adhere to the regulations.

HIPAA Enforcement and Penalties

The Department of Health and Human Services (HHS) is responsible for enforcing HIPAA regulations. The HHS Office for Civil Rights (OCR) investigates complaints and reports of HIPAA violations. The OCR also conducts audits of covered entities and business associates to ensure compliance with HIPAA regulations.

The OCR is responsible for enforcing HIPAA regulations. It investigates complaints and reports of HIPAA violations and conducts audits of covered entities and business associates to ensure compliance with HIPAA regulations. The OCR has the authority to impose civil monetary penalties (CMPs) and other penalties for non-compliance

Monetary Penalties

The OCR may impose civil monetary penalties (CMPs) for HIPAA violations. The amount of the CMP depends on the severity of the violation and can range from $100 to $1.5 million per violation. The OCR may also enter into settlement agreements with covered entities or business associates for HIPAA violations. 

Criminal Penalties

In addition to CMPs, criminal penalties may also apply for HIPAA violations. The Department of Justice (DOJ) is responsible for prosecuting criminal violations of HIPAA. Criminal penalties can include fines and imprisonment. 

For example, if an individual knowingly obtains or discloses PHI in violation of HIPAA, they may be fined up to $50,000 and imprisoned for up to one year. If the offense is committed under false pretenses, the fine may be up to $100,000 and imprisonment up to five years. 

If the offense is committed with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm, the fine may be up to $250,000 and imprisonment up to ten years.

Now, if you are someone who runs an organization or a business, you need to be compliance with HIPAA and you need to have strong cybersecurity measures. Either, you can have your own IT team of experts to handle these HIPAA and cybersecurity complexities, or you can go for third party/outsourced cybersecurity.

Cybersecurity providers always have to ensure that their rules and regulations are direct with HIPAA when it comes to protecting PHI. Most the cybersecurity firms offer outsourced cybersecurity, and you as a business owner can totally avail of such services.

Final Thoughts

This comprehensive guide covers everything you need to know about HIPAA in cybersecurity, including its background, purpose, scope of coverage, and security rule. It emphasizes the significance of HIPAA compliance to ensure a secure and safe environment.

In conclusion, prioritizing cybersecurity and HIPAA compliance is critical to protect individual health information and maintain the trust of patients.

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