In today’s world, the protection of personal information is more important than ever. For the healthcare industry, this is particularly crucial as it deals with sensitive patient information on a daily basis. To ensure the privacy and security of this information, the Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996. HIPAA contains several regulations, including the protection of Protected Health Information (PHI), which is defined as any information that can be used to identify a patient. This blog will delve into the importance of HIPAA PHI and the requirements to get compliant.
- 1 What Is PHI HIPAA?
- 2 What Does Include PHI Under HIPAA?
- 3 Requirements For Organizations To Secure PHI With HIPAA Compliance
- 4 What To Do After HIPAA Violations And Data Breach Of PHI?
- 5 Conclusion
What Is PHI HIPAA?
PHI stands for Protected Health Information, which refers to any individually identifiable health information that is created, received, stored, or transmitted by a covered entity or business associate. It is related to a patient’s past, present, or future physical or mental health condition, or the provision of healthcare services.
HIPAA, which stands for the Health Insurance Portability and Accountability Act, is a federal law since 1996 to protect the privacy and security of individuals’ medical information, including PHI. HIPAA PHI regulations require covered entities to provide patients with access to their own medical information and to notify them in the event of a breach of their PHI.
What Does Include PHI Under HIPAA?
Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) refers to individually identifiable health information that is created, received, maintained, or transmitted by a covered entity or business associate in relation to the provision of healthcare services.
PHI includes any information, whether oral or recorded in any form or medium, that relates to the past, present, or future physical or mental health or condition of an individual, as well as any healthcare services provided to that individual. Examples of PHI include:
- Patient name, address, and social security number
- Medical diagnoses and treatment information
- Laboratory test results
- Prescription and medication information
- Radiology images
- Billing and payment information
- Health insurance information
Under HIPAA, PHI also includes any information that is useful to identify an individual in combination with any of the above information. This means that any information that could be used to identify a patient, such as a name or date of birth, would be considered PHI.
It is important to note that PHI is protected by the HIPAA Privacy Rule and the HIPAA Security Rule, and covered entities and business associates must ensure that they are in compliance with these rules to safeguard the confidentiality, integrity, and availability of PHI.
Requirements For Organizations To Secure PHI With HIPAA Compliance
To ensure compliance with the HIPAA Security Rule, organizations should implement the following requirements:
- Conduct a risk analysis: Firstly, organizations should identify and assess potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI. This includes risks from natural disasters, system failures, and unauthorized access to ePHI.
- Implement safeguards: Organizations should implement reasonable and appropriate administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of ePHI. This includes policies and procedures for workforce training, access control, and disaster recovery.
- Develop and implement a security management process: Organizations should develop and implement policies and procedures to ensure the security of ePHI. This includes regular risk assessments, implementation of security measures to mitigate risks, and ongoing monitoring of security processes.
- Designate a security officer: Organizations should designate a security officer who is responsible for developing and implementing security policies and procedures, and ensuring compliance with HIPAA Security Rule requirements.
- Train workforce members: Organizations should provide training to workforce members on HIPAA Security Rule requirements and policies and procedures for safeguarding ePHI. This includes initial training for new employees and periodic refresher training.
- Maintain documentation: Organizations should maintain documentation of policies, procedures, and other documentation related to HIPAA Security Rule compliance. This includes risk assessments, security management processes, training, and incident response plans.
Above all, by implementing these requirements, organizations can ensure that they are in compliance with the HIPAA Security Rule and are adequately protecting ePHI from potential threats and vulnerabilities.
What To Do After HIPAA Violations And Data Breach Of PHI?
There are several steps to mitigate the potential harm and ensure compliance with HIPAA regulations. These steps include:
Contain The Breach And Investigate
The first step is to contain the breach and limit further access to or disclosure of the PHI. This may involve shutting down affected systems, removing affected hardware or media, or disabling affected user accounts. The covered entity or business associate should conduct a thorough investigation to determine the cause and extent of the breach. This includes the purpose of accessing the PHI by the person.
Notify Affected Individuals
If the breach involves unsecured PHI and affects 500 or more individuals, the covered entity or business associate must notify affected individuals without unreasonable delay, and no later than 60 days after the discovery of the breach. The notification should include a description of the breach, the type of PHI involved, and steps the affected individuals can take to protect themselves.
Notify The Secretary Of HHS
If the breach involves 500 or more individuals, the covered entity or business associate must also notify the Secretary of the Department of Health and Human Services (HHS) without unreasonable delay, and no later than 60 days after the discovery of the breach. If the breach involves fewer than 500 individuals, the covered entity or business associate must keep a log of the breach and report it to the Secretary of HHS within 60 days of the end of the calendar year.
The covered entity or business associate should take steps to mitigate the potential harm to affected individuals, such as offering credit monitoring or identity theft protection services.
Review And Revise Policies And Procedures
The covered entity or business associate should review and revise its policies and procedures for safeguarding PHI to ensure that similar breaches do not occur in the future.
Document The Incident
The covered entity or business associate should document the incident, including the actions taken to contain and investigate the breach and retain this documentation for at least six years.
Overall, by following these steps, covered entities and business associates can help to minimize the potential harm of a HIPAA violation or data breach involving PHI and ensure compliance with HIPAA regulations.
In conclusion, protected health information (PHI) is any individually identifiable health information. It needs to keep held or shared by a covered entity or business associate in relation to the provision of healthcare services. If a HIPAA violation or data breach involving PHI occurs, covered entities and business associates should take steps to contain the breach, conduct an investigation, notify affected individuals and the Secretary of HHS if required, mitigate harm, review and revise policies and procedures, and document the incident. If you are looking to implement any of the Infosec compliance frameworks such as SOC 2 compliance, HIPAA, ISO 27001, and GDPR compliance, Impanix can help. Book a Free consultation call with our experts or email us at [email protected] for inquiries.