A Security Risk Assessment is Mandatory for Your Practice or Organization.

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What is a Security Risk Analysis?

2016 Update

The HIPAA requirement for a risk analysis has been in place since 2003.  With changes to various programs, including Meaningful Use and ICD-10, enforcement of this requirement has started in force for all organizations who create, store, or exchange patient records.  2016 will bring an increase in audits and enforcement activities from various government organizations, some funded by the penalties and fines an audit may produce.   If your organization has not started this process, you may be vulnerable to fines that begin at $10,000 per occurrence.

In 2014 audits expanded to Home Health Care organizations, Nursing Homes, Dentist, and Physical Therapy Organizations with a medical component. 

A security Risk Analysis can save you or your organization thousands of dollars in fines and penalties, as well as preserving your business reputation, in the event of an audit.  CMS and the ONC recognize one credential, the AHIMA Certified in Healthcare Privacy and Security, as the professionals qualified to perform the Security Risk Analysis. Brothers and Associates LLC is a nationally recognized organization conducting Risk Analysis using the NIST format to help your organization meet the compliance requirements of HIPAA. 

To schedule your risk analysis call us today at 502 517 6943.

Risk Analysis Requirements under the Security Rule

The Security Management Process standard in the Security Rule requires organizations to “[i]mplement policies and procedures to prevent, detect, contain, and correct security violations.” (45 C.F.R. § 164.308(a)(1).) Risk analysis is one of four required implementation specifications that provide instructions to implement the Security Management Process standard. Section 164.308(a)(1)(ii)(A) states:

RISK ANALYSIS (Required).

Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the [organization].

Scope of the Analysis

The scope of risk analysis that the Security Rule encompasses includes the potential risks and vulnerabilities to the confidentiality, availability and integrity of all e-PHI that an organization creates, receives, maintains, or transmits. (45 C.F.R. § 164.306(a).) This includes e-PHI in all forms of electronic media, such as hard drives, floppy disks, CDs, DVDs, smart cards or other storage devices, personal digital assistants, transmission media, or portable electronic media. Electronic media includes a single workstation as well as complex networks connected between multiple locations. Thus, an organization’s risk analysis should take into account all of its e-PHI, regardless of the particular electronic medium in which it is created, received, maintained or transmitted or the source or location of its e-PHI.

Data Collection

An organization must identify where the e-PHI is stored, received, maintained or transmitted. An organization could gather relevant data by: reviewing past and/or existing projects; performing interviews; reviewing documentation; or using other data gathering techniques. The data on e-PHI gathered using these methods must be documented. (See 45 C.F.R. §§ 164.308(a)(1)(ii)(A) and 64.316(b)(1).)

Identify and Document Potential Threats and Vulnerabilities

Organizations must identify and document reasonably anticipated threats to e-PHI. (See 45 C.F.R. §§ 164.306(a)(2) and 164.316(b)(1)(ii).) Organizations may identify different threats that are unique to the circumstances of their environment. Organizations must also identify and document vulnerabilities which, if triggered or exploited by a threat, would create a risk of inappropriate access to or disclosure of e-PHI. (See 45 C.F.R. §§ 164.308(a)(1)(ii)(A) and 164.316(b)(1)(ii).)

Assess Current Security Measures

Organizations should assess and document the security measures an entity uses to safeguard e-PHI, whether security measures required by the Security Rule are already in place, and if current security measures are configured and used properly. (See 45 C.F.R.§§ 164.306(b)(1), 164.308(a)(1)(ii)(A), and 164.316(b)(1).) The security measures implemented to reduce risk will vary among organizations. For example, small organizations tend to have more control within their environment. Small organizations tend to have fewer variables (i.e. fewer workforce members and information systems) to consider when making decisions regarding how to safeguard ePHI. As a result, the appropriate security measures that reduce the likelihood of risk to Posted July 14, 2010 Page 6 the confidentiality, availability and integrity of e-PHI in a small organization may differ from those that are appropriate in large organizations.

Determine the Likelihood of Threat Occurrence

The Security Rule requires organizations to take into account the probability of potential risks to e-PHI. (See 45 C.F.R. § 164.306(b)(2)(iv).) The results of this assessment, combined with the initial list of threats, will influence the determination of which threats the Rule requires protection against because they are “reasonably anticipated.” The output of this part should be documentation of all threat and vulnerability combinations with associated likelihood estimates that may impact the confidentiality, availability and integrity of e-PHI of an organization. (See 45 C.F.R. §§ 164.306(b)(2)(iv), 164.308(a)(1)(ii)(A), and 164.316(b)(1)(ii).)

Determine the Potential Impact of Threat Occurrence

The Rule also requires consideration of the “criticality,” or impact, of potential risks to confidentiality, integrity, and availability of e-PHI. (See 45 C.F.R. § 164.306(b)(2)(iv).) An organization must assess the magnitude of the potential impact resulting from a threat triggering or exploiting a specific vulnerability. An entity may use either a qualitative or quantitative method or a combination of the two methods to measure the impact on the organization.

The output of this process should be documentation of all potential impacts associated with the occurrence of threats triggering or exploiting vulnerabilities that affect the confidentiality, availability and integrity of e-PHI within an organization. (See 45 C.F.R.§§ 164.306(a)(2), 164.308(a)(1)(ii)(A), and 164.316(b)(1)(ii).)

Determine the Level of Risk

Organizations should assign risk levels for all threat and vulnerability combinations identified during the risk analysis. The level of risk could be determined, for example, by analyzing the values assigned to the likelihood of threat occurrence and resulting impact of threat occurrence. The risk level determination might be performed by assigning a risk level based on the average of the assigned likelihood and impact levels.

The output should be documentation of the assigned risk levels and a list of corrective actions to be performed to mitigate each risk level. (See 45 C.F.R. §§ 164.306(a)(2), 164.308(a)(1)(ii)(A), and 164.316(b)(1).)

Finalize Documentation

For more information on methods smaller entities might employ to achieve compliance with the Security Rule, see #7 in the Center for Medicare and Medicaid Services’ (CMS) Security Series papers, titled “Implementation for the Small Provider.” Available at http://www hhs.gov/ocr/privacy/hipaa/administrative/securityrule/smallprovider.pdf.

The Security Rule requires the risk analysis to be documented but does not require a specific format. (See 45 C.F.R. § 164.316(b)(1).) The risk analysis documentation is a direct input to the risk management process.

Periodic Review and Updates to the Risk Assessment

The risk analysis process should be ongoing. In order for an entity to update and document its security measures “as needed,” which the Rule requires, it should conduct continuous risk analysis to identify when updates are needed. (45 C.F.R. §§ 164.306(e) and 164.316(b)(2)(iii).) The Security Rule does not specify how frequently to perform risk analysis as part of a comprehensive risk management process. The frequency of performance will vary among covered entities. Some covered entities may perform these processes annually or as needed (e.g., bi-annual or every 3 years) depending on circumstances of their environment.

A truly integrated risk analysis and management process is performed as new technologies and business operations are planned, thus reducing the effort required to address risks identified after implementation. For example, if the covered entity has experienced a security incident, has had change in ownership, turnover in key staff or management, is planning to incorporate new technology to make operations more efficient, the potential risk should be analyzed to ensure the e-PHI is reasonably and appropriately protected. If it is determined that existing security measures are not sufficient to protect against the risks associated with the evolving threats or vulnerabilities, a changing business environment, or the introduction of new technology, then the entity must determine if additional security measures are needed. Performing the risk analysis and adjusting risk management processes to address risks in a timely manner will allow the covered entity to reduce the associated risks to reasonable and appropriate levels.

In Summary

Risk analysis is the first step in an organization’s Security Rule compliance efforts. Risk analysis is an ongoing process that should provide the organization with a detailed understanding of the risks to the confidentiality, integrity, and availability of e-PHI.

Resources

The Security Series papers available on the Office for Civil Rights (OCR) website, http://www.hhs.gov/ocr/hipaa, contain a more detailed discussion of tools and methods available for risk analysis and risk management.