What Is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) is a U.S. law that was enacted in 1996. It sets national standards for protecting sensitive patient health information from being disclosed without the patient’s consent or knowledge.
HIPAA applies to healthcare warehouses, health plans, and certain healthcare providers, including doctors, hospitals, and other types of medical facilities. The law includes provisions for maintaining the security and privacy of protected health information (PHI), as well as standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and employers.
HIPAA is enforced by the U.S. Department of Health and Human Services (HHS), part of the Office for Civil Rights (OCR). The OCR is in charge of investigating complaints and enforcing HIPAA compliance. They have the authority to impose fines and penalties for non-compliance, as well as take legal action against entities that violate HIPAA regulations. Additionally, state attorneys general also have the authority to take enforcement action against HIPAA covered entities under certain circumstances.
HIPAA enforces many requirements related to IT and computing, and among these are detailed cybersecurity requirements. In this article we explain how your organization should adapt its cybersecurity program to meet HIPAA compliance requirements.
Risk Analysis and Management
HIPAA requires relevant organizations and individuals (covered entities) and their business partners to conduct risk analyses as part of their overall risk management process. The risk analysis is used to identify and assess potential vulnerabilities and risks to electronic protected health information (ePHI), focusing on maintaining its integrity, availability, and confidentiality. It is a critical step in implementing adequate technical, physical, and administrative protections to secure ePHI.
The risk analysis process should include:
- Identifying and documenting all systems and applications that contain or transmit ePHI.
- Identifying and assessing potential risks and vulnerabilities to ePHI, such as unauthorized access, disclosure, alteration, or destruction.
- Evaluating the likelihood of identified risks and their potential impact.
- Implementing appropriate safeguards to address identified risks and vulnerabilities, such as encryption, firewalls, and access controls.
- Regularly reviewing and updating the risk analysis and management plan to address new threats and changes to the organization.
One of the key measures organizations can take to implement HIPAA requirements for risk analysis is to scan source code for vulnerabilities. This can help identify risks and vulnerabilities in systems that access or generate ePHI.
Risk management is an ongoing process that requires organizations and their associates to continuously monitor and assess the effectiveness of their security efforts, and update them as necessary.
Securing Third-Party Applications
Third-party application security refers to the measures taken to protect sensitive medical information when it is processed, stored, or transmitted by third-party applications or software-as-a-service (SaaS) solutions.
To secure a third-party SaaS solution that accesses IP or data, you can implement the following measures:
- Evaluating the security features and practices of the vendor, such as their data encryption methods, access controls, and security certifications.
- Requiring the vendor to sign a Business Associate Agreement (BAA) that outlines their responsibility to protect the data and comply with HIPAA regulations.
- Regularly monitoring the vendor’s compliance with the BAA and HIPAA regulations.
- Implementing your own security measures, such as data backup and disaster recovery plans, to mitigate the risk of data loss or breaches.
Administrative protections are a set of policies and procedures that covered entities and business partners must implement to protect the ePHI they handle. These safeguards include measures to ensure the proper management and use of ePHI, as well as the implementation of security management procedures to prevent unauthorized access, disclosure, use, and destruction of ePHI.
Some examples of administrative safeguards include:
- Implementing and maintaining written policies and procedures to ensure compliance with the HIPAA regulations.
- Appointing a security official responsible for HIPAA compliance.
- Providing security awareness training for all workforce members.
- Implementing and regularly reviewing incident response and data breach notification procedures.
- Conducting regular risk analyses and risk management activities.
- Performing regular monitoring and testing of security controls and systems to ensure they are functioning as intended.
- Establishing and maintaining a security incident management process to detect, investigate and mitigate security incidents.
- Implementing and enforcing access controls to ePHI.
Administrative safeguards are the foundation for protecting ePHI and should be implemented in conjunction with technical and physical safeguards to have a comprehensive security plan.
Physical protections are security measures that organizations and associates must implement to protect all ePHI from physical threats such as unauthorized access, theft, or natural disaster.
Some examples of physical safeguards include:
- Controlling access to facilities that store ePHI, by using locked doors, security guards, or security cameras.
- Securing the workstations and devices that store or transmit ePHI, by using locks, security cables, or other physical security devices.
- Maintaining and monitoring an inventory of all the hardware and equipment that stores or transmits ePHI, including servers, mobile devices, desktop computers, and laptops.
- Establishing and maintaining an emergency response plan to protect ePHI during an emergency or natural disaster.
- Regularly inspecting and testing physical security measures to verify that they are functioning as intended.
- Implementing and maintaining an incident response plan that includes procedures to properly handle and document lost or stolen devices that contain ePHI.
Physical safeguards are important because they help prevent unsanctioned use of ePHI, and ensure the availability and integrity of ePHI during a physical emergency or disaster.
Access control is a critical component of HIPAA’s administrative safeguards. It refers to the process of granting or denying access to ePHI based on an individual’s role and need-to-know within an organization.
Access control measures are intended to ensure that only authorized individuals have access to the organization’s ePHI, and that they only access information that is needed to perform their job functions. Here are some examples of access controls:
- Authentication: Verifying the identity of an individual who wants to access ePHI. This can be done through means such as usernames and passwords, security tokens, or biometric identification.
- Authorization: Determining what an individual is authorized to do with ePHI after their identity has been verified. This includes granting access to specific information, applications, or systems that are required to perform their job functions.
- Auditing: Tracking and logging all access to ePHI, including the date, time, and user that accessed the information, and what actions were taken.
- Access control lists: Defining and maintaining a list of users who are authorized to access ePHI, and what level of access they are granted.
Access controls should be regularly reviewed and updated to ensure any new users or changes to roles and responsibilities are reflected in the access control list.
Policies and Processes
HIPAA requires organizations and their associates to implement a set of written policy and procedural commitments to ensure the integrity, availability, and confidentiality of ePHI. These procedures and policies should be designed for the specific needs and operations of the covered entity, and should be reviewed and updated regularly.
Examples of policies and processes that an organization might consider include:
- Security management process: A process that outlines how the organization will identify and manage risks to the privacy of ePHI.
- Incident response: Procedures for responding to, and reporting of, security incidents involving ePHI.
- Remote access: Procedures for securely accessing ePHI from remote locations, including the use of virtual private networks (VPNs) or other secure remote access methods.
- Business associate agreements: Procedures for entering into agreements with business associates, and ensuring that they comply with HIPAA regulations.
- Sanction policy: Procedures for disciplining workers who fail to comply with the HIPAA requirements.
However, having written policies and codified procedures is not enough. Covered organizations must ensure HIPAA policies and processes are reviewed and updated periodically, and that all members of the workforce understand them.
Best Practices for Maintaining HIPAA Cybersecurity Requirements
Identify Code Vulnerabilities
SAST stands for Static Application Security Testing. It is a type of testing that is used to identify vulnerabilities in the source code of a software application. SAST is important for HIPAA compliance because it can help organizations identify and fix potential security vulnerabilities in their systems before they are exploited by hackers.
SAST can be a useful tool for organizations to use as part of their risk assessment process and to ensure that their systems are secure and compliant with HIPAA requirements.
Secure Code Repositories
A secure code repository is a system or service that is used to manage and store source code in a secure and controlled manner. These systems provide a centralized location for developers to store and share code, and they typically include a number of features that are designed to help ensure the security and integrity of the code.
Secure code repositories provide a way to securely manage and store source code, which is a critical aspect of protecting sensitive patient health information (PHI). By using a secure code repository, covered entities can ensure that PHI is protected at every stage of the software development lifecycle.
Security monitoring is a critical component of maintaining HIPAA cybersecurity requirements, as it helps covered entities and business associates detect and respond to potential security threats and breaches of ePHI.
Here are some best practices for maintaining HIPAA cybersecurity requirements through security monitoring:
- Implement security monitoring software: Use security monitoring software to detect and alert organizations to potential security threats and breaches of ePHI, such as unauthorized access, use, disclosure, or destruction of ePHI.
- Use intrusion detection and prevention systems: Implement intrusion detection and prevention systems to detect and prevent unauthorized access to networks, systems, and applications that store or transmit ePHI.
- Monitor network traffic: Regularly monitor network traffic for unusual or suspicious activity, such as excessive login attempts, unauthorized access to ePHI, or other indicators of a security breach.
- Monitor logs and audit trails: Regularly review logs and audit trails to detect and respond to potential security threats and breaches of ePHI.
- Use security analytics: Use security analytics to detect patterns and anomalies in data that may indicate a potential security breach.
- Regularly test: Regularly conduct penetration testing, vulnerability assessments, and security audits to identify potential security vulnerabilities and weaknesses.
Implementing a Security Policy
A security policy is a set of rules and guidelines that outline the organization’s approach to protecting ePHI from unauthorized access, use, disclosure, and destruction. Here are some best practices for implementing a security policy:
- Tailor the policy to the organization: A security policy should be tailored to the specific needs and operations of the organization. It should take into account the organization’s size, complexity, and technical infrastructure.
- Involve all stakeholders: Involve all stakeholders in the development of the security policy, including management, IT, legal, and compliance personnel.
- Assess risks: Assess risks and vulnerabilities to ePHI and include them in the security policy.
- Include incident response: Include incident response procedures in the security policy that cover all types of security incidents and breaches.
- Include regular review and update: Include a provision for regularly reviewing and updating the security policy to ensure it remains current and effective in protecting ePHI.
- Communicate the policy: Communicate the security policy to all workforce members, business associates, and any other parties who are bound by the policy.
HIPAA Compliance with Tabnine
Tabnine’s secure AI assistant for code is highly relevant for organizations operating under HIPAA. Healthcare organizations must ensure that their coding practices are compliant with the law. By running Tabnine on a private network, organizations can have complete control over their data and ensure that they meet the stringent security requirements of HIPAA. This is particularly important when dealing with patient health information, which must be kept confidential at all times. Tabnine’s ability to run locally, on self-hosted servers, in a VPC, or completely offline, provides an added layer of security that can help healthcare organizations protect sensitive patient data and maintain compliance with HIPAA regulations.
About Tabnine AI for Enterprise
Tabnine is an AI assistant tool used by over 1 million developers from thousands of companies worldwide. Tabnine Enterprise has been built to help software engineering teams write high-quality code faster and more efficiently, accelerating the entire SDLC. Designed for use in enterprise software development environments, Tabnine Enterprise offers a range of features and benefits, including the highest security and compliance standards and features, as well as support for a variety of programming languages and IDEs.