Few would argue the idea that achieving HIPAA (Health Insurance Portability and Accountability Act) compliance is a complicated undertaking. Even so, the process, at least from an IT prospective, can be broken down into five main steps.
Step 1: Evaluate the requirements and develop a plan of action
The first step to achieving HIPAA compliance for the IT department is to evaluate the requirements for your organization. The requirements that are most relevant to healthcare IT are primarily contained in Part 164 – Security and Privacy.
As the organization works to understand the HIPAA requirements for IT, it is important to begin developing a plan of action. HIPAA outlines security and privacy objectives that must be met, but it leaves it up to the individual organizations to figure out how to go about meeting these objectives.
Step 2: Document your policies
Your plan of action in response to the HIPAA requirements can start out as something informal, but eventually you are going to need to formalize your plan by creating some ridged policies and procedures. In fact, HIPAA requirement 164.530 (i)(1) states:
Standard: Policies and Procedures. A covered entity must implement policies and procedures with respect to protected health information that are designed to comply with the standards, implementations, specifications, or other requirements of this subpart and subpart D of this part.
You will notice in the excerpt above that HIPAA makes a distinction between policies and procedures. Policies can best be thought of as a set of rules designed with the intent of achieving HIPAA compliance. Procedures are standardized tasks that adhere to the policies that you set.
As you begin creating and documenting your policies, remember to keep them reasonable. Remember, the government does not judge you on how good your policies are (so long as they meet the minimum requirements), but rather on how well your organization adheres to the policies. The simpler the policies, the easier it will be to comply with them.
Step 3: Use procedures to comply with your policies
Put your policies into practice. Having documented policies alone will not achieve HIPAA compliance. Your organization must adhere to the policies that have been put into place. This is where procedures come into play.
Procedures are simply task-oriented sets of standardized actions designed to help the organization adhere to the established policies. The procedures should be constructed in a way that allows them to be repeatable. This ensures that anyone who follows the procedures will be adhering to the organization’s standard processes.
Step 4: Put into place tracking mechanisms
As you have probably already figured out, achieving HIPAA compliance means creating many different policies and at least as many procedures. For every standardized procedure that you create, you will also need a tracking mechanism.
A tracking mechanism should provide evidence that you are meeting the regulatory requirements. It should be a direct reflection of how well the organization is following the procedures that have been established. For example, suppose that you develop a formal procedure for allowing the helpdesk to reset user passwords. You might create a SharePoint workflow that allows a user to submit a request to the helpdesk and that also allows the helpdesk to respond back to the user with the new password. Assuming that a logging mechanism is integrated into the workflow, the logs can be compared against the Windows audit logs to prove that all password reset requests did indeed adhere to the organization’s policies.
Step 5: Audit yourself
The last step in the process is to audit yourself. It is reasonable to expect a HIPAA audit sooner or later. Because these audits can result in some very stiff penalties being imposed for non-compliance, it is a good idea to seek out any deficiencies for yourself through internal audits. These audits can be performed by a qualified employee or by a third-party HIPAA compliance firm.
Achieving HIPAA compliance is a long and drawn-out process. The best way to make this process manageable is to break it down into a series of simplified steps such as the ones that are outlined here.