Provider SRAs: Strengthening Patient Data Security and Ensuring HIPAA Compliance 

After a breach, the first question organizations often ask is: “May I review your security risk assessment?”

Following a data breach, conducting breach assessments and regular risk evaluations is essential. This helps security leaders stay informed about vulnerabilities and proactively address security gaps and threats. Provider SRAs protect patient data, ensure HIPAA compliance, and strengthen your organization’s cybersecurity posture against growing threats.

What Are Provider SRAs And Why Do They Matter?

Healthcare providers across the United States have the incredible opportunity – and responsibility – to help deliver improved patient outcomes, and ultimately elevate public health. Although healthcare professionals touch lives every day, they are also subject to some of the most stringent regulatory hurdles in the country. They handle highly sensitive protected health information (PHI), so they must follow strict organizational security measures and best practices to securely store patient data.

To safeguard sensitive data from malicious threats or accidental breaches, the HIPAA Security Rule requires healthcare organizations and other critical businesses to perform comprehensive risk assessments. These evaluations ensure that both their digital and physical environments are secure and compliant with regulatory standards.

Failing to dedicate sufficient time and resources to securing patient data can leave your organization vulnerable to audits and potential fines from the Office for Civil Rights (OCR). Prioritizing data security is just as crucial as developing effective care strategies to protect both your patients and your organization.

There is good news – there are best practices and insights available to help you and other healthcare providers operate with high confidence in your security, privacy, and HIPAA compliance practices.

How Often Should You Update Provider SRAs?

Despite the fact that there is no one-size-fits-all approach to properly managing your organizational risk, government regulators such as HHS and the Office for Civil Rights believe that quality risk analysis is the first step in remaining compliant with government laws to protect patient information.

According to the U.S. Department of Health and Human Services, “All e-PHI created, received, maintained or transmitted by an organization is subject to the Security Rule,” meaning that physicians must use appropriate administrative, physical, and technical safeguards to ensure the confidentiality, integrity and security of this information.

Healthcare providers should guide every annual Security Risk Assessment with a set of essential questions. In ClearDATA’s capacity as a healthcare cloud security company, we have observed clients that review their SRAs quarterly, annually, or even with years’ gap SRAs. It’s important to remember that even though there is no single approach that can best serve every healthcare provider. We typically recommend that healthcare providers review their SRAs at least every 6-12 months.

In addition to reviewing your organization’s SRA based on a pre-determined amount of time, many healthcare providers benefit from reviewing their SRA in response to operational changes and/or security incidents. Of course, it’s advisable to review your SRA before a negative incident occurs; but reviewing your existing tactics, techniques, and procedures after a cyber incident can be a valuable step in your team’s debrief to ensure no repeat security failures.

What Systems Should Be Included in your Provider SRAs?

As part of your SRA, do you include all information systems containing, process, and/or transmitting ePHI? It is vital to include all relevant information systems to ensure your data is fully protected. You can’t safeguard what you don’t know is being transmitted.

All healthcare providers should maintain a complete and accurate PHI inventory of every known and officially managed IT asset in your organization – establishing optimal security controls. Healthcare providers can record and update IT asset inventories using a well-designed, digitally stored spreadsheet.

What Documentation Is Essential for Effective Provider SRAs?

What goes into your SRA documentation? We recommend including possible threats and vulnerabilities, along with their assigned impact and probability ratings. Based on these ratings, organizations can determine potential severity of risks and prioritize healthcare risk management accordingly.

For example, some choose to establish a data classification policy that categorizes data as: Sensitive, Internal Use, or Public Use. Once you have determined these classifications, you can organize data accordingly. Organizational policies should cover all user interactions with sensitive data. They must clearly define the consequences of losing or compromising data. Policies should cover all user interactions with sensitive data and explicitly state the penalties for any loss or compromise. After all, human error is one of the leading causes of cybersecurity events. Effective IT asset management is essential for maintaining strong cyber hygiene across all organizational assets, including medical devices. Optimize your medical device management and strengthen cybersecurity with proper IT asset tracking.

Boosting Provider SRAs with Strong Leadership

After establishing your security policies and reviewing existing data, identify the teams or individuals responsible for developing and implementing information security policies and procedures. In many cases, the CIO or CISO assumes this responsibility, serving as the security officer and being named directly in policy documents.

As organizations grow, employees may interact less across the organization and may not know who is responsible for the security of the data they use every day. ClearDATA recommends healthcare providers take the time to introduce the CIO or CISO – and their responsibilities as the security officer – to the organization as a whole.

Why Regular Provider SRAs Are Critical for Patient Data Security

Security Risk Assessments are a critical best practice – and a HIPAA regulatory requirement – for healthcare providers.  If you have read about the early questions for your organization’s SRA, we can help.

In the meantime, check out our next blog, “Comprehensive Guide to Provider Security Risk Assessments (SRAs) in Healthcare.”

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