How to be HIPAA Compliant Using Scalefusion MDM

  • September 15, 2022

USD 1.5 million. That’s the penalty applicable to healthcare organizations that violate the Health Insurance Portability and Accountability Act (HIPAA). Today, several healthcare organizations and associated businesses are at risk of being non-compliant due to the mismanagement of mobile devices at work.

MDM for HIPAA Compliance
MDM for HIPAA Compliance

Organizations may fall out of compliance because healthcare staff use their personal devices at work or download unauthorized apps that may compromise patient data. Every mobile device operation prone to compromise healthcare information can lead to a HIPAA violation, resulting in financial losses. Fortunately, businesses have the option to work with device management specialists to help stay HIPAA compliant.

What is HIPAA Compliance?

HIPAA compliance involves fulfilling the requirements of the Health Insurance Portability and Accountability Act of 1996, its subsequent amendments, and any related legislation such as the HITECH Act. The primary goal of HIPAA is to:

  • Protect and handle Protected Health Information (PHI). 
  • Facilitate the transfer of healthcare records to provide continued healthcare.
  • Reduce fraud within the healthcare system.
  • Create standardized information on electronic billing and healthcare information.

HIPPA rules apply to every type of Covered Entity–healthcare providers, health plans, or healthcare clearinghouses–and Business Associate that creates, maintains, or transmits PHI data. A Business Associate is a person or a company that provides service to a Covered Entity when the service, function, or activity includes access to PHI data.

Business Associates include IT companies, lawyers, accountants, billing companies, cloud storage services, email encryption services, and more.

HIPAA compliance can only occur when a Covered Entity or Business Associate implements the necessary controls and protections for any relevant PHI data. Healthcare companies that have access to PHI must ensure the physical, technical, and administrative rules are in place and followed.

Healthcare companies should be aware of the following rules to implement the requirements of HIPAA compliance.

1. HIPAA Privacy Rule – The rule sets standards for an individual’s right to understand and control how their health information is used. The goal of the Privacy Rule is to ensure an individual’s health information is protected while allowing the flow of health information needed to provide and promote high-quality healthcare

2. HIPAA Security Rule – While the Privacy Rule safeguards PHI, the Security Rule protects a subset of information covered under the Privacy Rule. This subset safeguards all identifiable information created, transmitted, received, or maintained in an electronic format. This is also known as electronic protected health information or ePHI.

3. HIPAA Breach Notification Rule – It is a set of standards that Covered Entities or Business Associates must follow in the event of a breach containing PHI or ePHI. The rule requires entities to notify the Department of Health and Human Services and issue a notice to the media if the breach affects more than 500 patients.

4. HIPAA Omnibus Rule – The rule is an addition to HIPAA regulation that mandates Business Associates to be HIPAA compliant, outlining the rules surrounding agreements. The agreements must be executed between a Business Associate and Covered Entity–or between two Business Associates–before any PHI or ePHI is shared.

The Need for HIPAA Compliance

Put simply, HIPAA exists to protect patient’s rights. HIPAA prohibits companies or healthcare facilities from disclosing healthcare information without the patient’s consent. Being HIPAA compliant ensures that healthcare providers, health plans, healthcare clearing houses, and Business Associates have safeguards in place to protect sensitive personal and health information.

How to Become HIPAA Compliant

The Department of Human Health Services (HHS) and the Inspector General (OIG) released a brief guide on how to create a compliance program. It is called “The Seven Fundamental Elements of an Effective Compliance Program.’’

  • Implementing written policies, procedures, and standards of conduct.
  • Designating a compliance officer and compliance committee.
  • Conducting effective training and education.
  • Developing effective lines of communication.
  • Conducting internal monitoring and auditing.
  • Enforcing standards through well-publicized disciplinary guidelines.
  • Responding promptly to detected offenses and undertaking corrective action.

Given the recommended tips, organizations should create an effective HIPAA compliance plan to ensure all safeguards are in place. The steps below should be followed by companies to demonstrate they are capable of handling and protecting PHI.

Step 1 – Choose a Privacy Officer and Security Officer. The Privacy Officer will be responsible for overseeing the development, implementation, maintenance, and adherence to privacy policies regarding the safe use and handling of PHI. The Security Officer will control the ongoing management of information security policies and procedures.

Step 2 Conduct risk assessment and implement security management policies. Review and document daily operations for identifying vulnerabilities. Check all assets – mobile devices, computers, and paper records. Implement necessary security measures to ensure all PHI is secure when data is being used, stored, or distributed.

Step 3 – Develop and implement policies and procedures and make them accessible to the staff. Utilize the policies and procedures to mitigate HIPAA risks. In an ideal world, organizations could be compliant every day of the year. But lapses do occur which can be spotted by internal auditors or regulators. If a violation takes place, put a process in place to conduct a root cause analysis and remediation.

Step 4 – Conduct workforce awareness and training programs on HIPAA regulations and the organization’s compliance plan. Healthcare providers should communicate HIPAA regulations with patients too.

Step 5 –  Monitor, audit, and update facility security measures on an ongoing basis. Maintaining compliance is all about having safeguards, both physical and digital.

HIPAA Compliance Checklist for 2022

There are several specifications under HIPAA, but it is recommended to not dive directly into the details. Instead, spend time understanding the big picture before drilling down into the specifics. The checklist is not a comprehensive compliance guide, but a pragmatic approach for healthcare businesses to understand their HIPAA priorities and readiness.

Audits

  • Have you conducted the following six audits?
  • Security Risk Assessment 
  • Privacy Standards Audits 
  • HITECH Subtitle D Privacy Audit
  • Security Standards Audit
  • Asset and Device Audit
  • Physical Site Audit

Documenting Gaps

  • Have you identified gaps in the above audits?
  • Privacy Standards Audits

Remediation Plans

  • Have you created remediation plans to address the gaps found in all six audits?
  • Are these remediation plans fully documented in writing?
  • Do you update and review these plans annually?
  • Are these plans retained in your record for six years?

Employee Awareness & Training

  • Have all staff members undergone annual HIPAA training?
  • Do you have documentation of their training?
  • Is there a dedicated staff member designated as the HIPPA Compliance Officer?

Employee Awareness and Training

  • Have all staff members undergone annual HIPAA training?
  • Do you have documentation of their training?
  • Is there a dedicated staff member designated as the HIPPA Compliance Officer?

Policies and Procedures

  • Do you have the policies and procedures relevant to the annual HIPAA privacy, security, and breach notification rules?
  • Have all staff members read and legally attested to the policies and procedures?
  • Do you have documentation of their legal attestation?
  • Do you have documentation of annual reviews of your policies and procedures?

Vendors and Business Associates

  • Have you identified all your vendors and business associates?
  • Do you have all Business Associate Agreements in place with all business associates?
  • Have you performed due diligence on your business associates to assess their business compliance?
  • Are you tracking and reviewing your Business Associate Agreements annually?
  • Do you have Confidentiality Agreements with non-business associate vendors?

Data Breaches

  •  Have you identified all your vendors and business associates?
  • Do you have all Business Associate Agreements in place with all business associates?
  • Have you performed due diligence on your business associates to assess their business compliance?
  • Are you tracking and reviewing your Business Associate Agreements annually?
  • Do you have Confidentiality Agreements with non-business associate vendors?

Breaches

  • Do you have a defined process for incidents and breaches?
  • Do you have the ability to track and manage the investigations of all incidents?
  • Are you able to provide reporting of minor or meaningful breaches or incidents?
  • Does your staff have the ability to anonymously report an incident?

HIPAA Security Rules

The growth of cost control programs in the healthcare industry is pushing organizations to reap the benefits of mobile devices, helping keep costs to a minimum. BYOD policies allow physicians, nurses, and other healthcare workers to bring personal devices to work. Few organizations choose to supply company-owned devices to maintain control and protect their networks.

However, HIPAA-covered entities or business associates that choose to use mobile devices in their organizations need to implement HIPAA mobile device policy to protect patient data. Mobile devices bring convenience, but they also come with several risks. Without adequate controls, mobile devices can be compromised and the ePHI stored on them exposed.

MDM and HIPAA Compliance

Organizations are responsible and accountable for developing mobile device procedures and policies that protect patient health information. To manage mobile devices in a healthcare setting, organizations need to build a risk management strategy that includes implementing device safeguards to reduce risks. The strategy should also include regular maintenance of mobile devices.

A critical point to consider when developing mobile device policies and procedures for HIPAA compliance is a mobile device management solution for managing BYOD policies, setting restrictions on usage, and security configuration.

How does Scalefusion MDM help with HIPAA Compliance?

With Scalefusion, healthcare organizations can achieve security controls to manage staff’s personal devices, without compromising privacy.

1. Encryption to protect ePHI – HIPAA rules instruct that devices must “Implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network.” Encryption helps when patient data is transmitted between Covered Entities and Business Associates. Using Scalefusion, admins can enforce encryption on storage media used on mobile devices.

2. Device-level protection with passcode policies and remote device lock – Deploying passwords is the first line of defense when it comes to device security. With Scalefusion, organizations can set strong password policies that define the length and complexity of passwords. Admins can remotely lock devices if they are lost or stolen. They can also remotely wipe any patient data present on such devices.

3. Configure VPN settings to secure network connectivity Admins can remotely configure VPN settings to allow secure access to corporate networks. Controls can be set to prevent users from connecting to Public Wi-Fi networks. Admins can push policies to ensure users stay connected to corporate networks when accessed remotely.

4. Control app usage – The usage of unregulated mobile apps is a major security risk. Scalefusion’s mobile application management distributes only permitted apps and ensures those apps are kept up to date with security updates. Organizations can also push their in-house apps made for their staff.

5. Device sharing for shift workers – Scalefusion helps organizations manage costs by enabling device sharing between healthcare professionals. Admins can set up multiple profiles with dynamic policies. The profiles automatically change on the shared devices based on a particular time or geographical location as scheduled. This also ensures that when the devices used within the physical boundaries of a healthcare space are moved out, access to work apps and data can be blocked.

6. BYOD management – The familiarity and convenience of using personal devices at work improve the productivity and workflows of healthcare staff. However, BYOD limits the control in managing sensitive data, increasing the chances of leaks or misuse to occur. Using Scalefusion MDM, companies can create two separate profiles for personal and work use, thereby preventing sharing of data. IT admins have control over the work profile (content, apps, policies) and zero control over the personal profile.

7.  Implement data loss prevention (DLP) – DLP aims to prevent unauthorized access to sensitive information. Organizations can define DLP policies on how to protect data. For example, the DLP policy should prevent staff from capturing screenshots of work data. IT admins can implement such a policy with Scalefusion to protect data within Office 365 apps on Android and iOS devices using Microsoft DLP.

Wrapping Up

Data protection regulations like HIPAA for the healthcare industry help protect people’s most personal information. While the transition of PHI into electronic format has increased mobility and efficiency, it has also increased security risks. The right device management solution will help organizations comply with guidelines while avoiding paying hefty fines. Healthcare professionals can focus on providing quality service to their patients by taking care of ever-evolving regulations.

Resources:

  1. HIPAA Journal

Thousands of businesses rely upon Scalefusion for managing their mobile device, desktops, laptops and other endpoints

Rajnil is a Senior Content Writer at Scalefusion. He’s been a B2B marketer for over 8 years and applies the power of content marketing to simplify complex technology and business ideas.
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