The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule is a regulation developed by the United States Department of Health and Human Services (HHS) to protect the privacy and security of specific medical information. This rule establishes security standards for the protection of protected health information that is in electronic format. Below is a summary of the critical elements of the HIPAA Security Rule, including who is covered, what information is protected, and what safeguards must be in place to ensure adequate protection of electronically protected health information.
Background:
Before the implementation of HIPAA, there was no generally accepted set of security standards or general requirements to protect health information in the healthcare industry. However, with the advancement of technologies, the industry began to move away from paper processes and rely more on electronic information systems. This created the need to establish security standards to protect electronic health information.
Scope of the Security Rule:
The Security Rule applies to health plans, health care intermediaries, and any health care provider that transmits health information electronically in connection with a transaction for which the Secretary of HHS has adopted standards under HIPAA. In addition, it also applies to commercial associates of these entities. The rule states that these entities must implement reasonable and appropriate administrative, technical, and physical safeguards to protect electronically protected health information.
Protected Information:
The Security Rule applies to electronically protected health information (e-PHI). This includes any individually identifiable health information that a covered entity creates, receives, maintains, or transmits in electronic format. The rule does not apply to protected health information transmitted orally or in writing.
General requirements:
- The Security Rule establishes general requirements covered entities must meet to protect electronically protected health information. These requirements include:
- Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit.
- Identify and protect against reasonably anticipated threats to the security or integrity of information.
- Protect against unauthorized use or disclosure of information.
- Ensure your staff meets safety requirements.
Risk Analysis and Management:
The Security Rule requires covered entities to perform a risk analysis as part of their security management processes. Risk analysis helps determine what security measures are reasonable and appropriate for a particular entity. This process includes assessing the likelihood and impact of potential risks, implementing appropriate security measures, documenting chosen security measures, and maintaining ongoing security protections.
Administrative Safeguards:The Security Rule establishes several administrative safeguards that covered entities must implement. These include:
Security Management Process: Covered entities must identify and analyze potential risks and implement appropriate security measures.
Security personnel must designate a security officer responsible for developing and implementing security policies and procedures.
Information Access Management: They must establish policies and procedures to authorize access to e-PHI following the “minimum necessary” principle.
The HIPAA Security Rule establishes essential standards for protecting electronically protected health information. Covered entities must implement administrative, technical, and physical safeguards to ensure information confidentiality, integrity, and availability. Risk analysis, management, and administrative safeguards are fundamental to successfully implementing the Security Rule.
It is important to note that this article is only a summary and is not a substitute for thoroughly reading and understanding the HIPAA Security Rule. Entities regulated by HIPAA must comply with all applicable requirements and should not rely solely on this summary as a source of legal information. You should review the whole rule and obtain legal advice to ensure proper compliance with HIPAA and the protection of electronically protected health information.
