HIPAA Security Risk Analysis-Compliance Vs Security


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By focusing on security, and leveraging a flexible analysis approach, a HIPAA Security Risk analysis can achieve both security as well as HIPAA compliance and meet HITECH Act meaningful use objectives.

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HIPAA Security Risk Analysis-Compliance Vs Security

  1. 1. HIPAA Security Risk Analysis: Compliance vs SecurityAs an independent provider of security assessments, we are keenly aware of the 2 primary drivers of anobjective security assessment – security or compliance. Roughly, these two views of risk management can bethought of as follows:  Security: For organizations in this camp, ensuring that ePHI is protected is mission critical to the business. Any impact to data security would be viewed as negatively impacting business value: whether it be monetary, brand value or customer loyalty, and minimizing the risk of a data breach is the goal of an assessment – this is pure risk management.  Compliance: On the other hand, organizations that are driven by compliance – while they don’t necessarily feel that data security is unimportant – the primary driver for doing a security assessment is to “check-the-box” that a HIPAA Security Risk Analysis has been completed per HIPAA or to address HITECH meaningful use objectives.In reality, of course, both of these objectives often factor into the need to perform a HIPAA Security RiskAnalysis. However, it’s important for healthcare organizations to be able to differentiate between thesedrivers, because the value of a risk assessment can be maximized if the effort is guided properly. In fact, withthe right guidance a risk analysis can achieve both.Security vs. ComplianceTo understand this, it’s important to understand how compliance relates to security; note the Venn diagram atleft. If one focuses purely on compliance during a risk analysis, then likely there will be a lot of residual riskthat is not identified during the analysis. In fact, there might be some wasted effort as a pure complianceeffort may place too much emphasis on certain areas of analysis that are not necessarily relevant to theenvironment in question (the light blue area of the diagram). WEB PHONE EMAIL WWW.REDSPIN.COM 800-721-9177 INFO@REDSPIN.COM
  2. 2. However, if one focuses on the intent of HIPAA Security Rule, then both security and compliance can beachieved. After all security is the intent of the Security Rule. While this may seem obvious, many complianceoriented risk analysis efforts leverage a static scope with little room for in-depth analysis of critical controls.Sure the control exists – say encryption on a device, for example – but the real question is whether the controlis actually working as intended. In our experience the vast majority of risk in health IT environments is notmissing controls, but rather controls that are not deployed correctly, and thus providing a false sense ofsecurity. This is often due to configuration error or a lack of effective process supporting the control.Furthermore, a static “check-the-box” risk analysis creates findings and recommendations that result in thedeployment of controls that are often expensive and don’t map into high areas of security risk. I can’t tell youhow many organizations I’ve seen spending precious IT department resources on low security risk issues, whileblatant easy-to-fix critical security risk just hangs out there for months. Sure it might be more fun and excitingto deploy an expensive intrusion detection system (IDS), however, doing this in a situation where its number37 on your priority list of issues, when in fact you have laptops that you think are encrypted but they are infact not can be disaster.How to achieve both security and complianceFirst off, leverage a risk-based approach to risk analysis in which the ePHI and IT processes around the datadrive the scope, as opposed to a static check box list-of-questions approach. No two IT environments are thesame and thus no two assessments of risk are the same. The HIPAA Security Rule is practical and flexible. Itspractical in that it was founded on sound principals and security best practices, and flexibility is clearly statedin the Security Rule:HIPAA Security Rule: § 164.306(b) Flexibility of approach(1) Covered entities may use any security measures that allow the covered entity to reasonably andappropriately implement the standards and implementation specifications as specified in this subpart.(2) In deciding which security measures to use, a covered entity must take into account the following factors:(i) The size, complexity, and capabilities of the covered entity.(ii) The covered entitys technical infrastructure, hardware, and software security capabilities.(iii) The costs of security measures.(iv) The probability and criticality of potential risks to electronic protected health information.From a compliance standpoint a HIPAA Security Risk Analysis is a foundational component of both HIPAAcompliance and HITECH Act meaningful use objectives. However, it is also a fundamental aspect of any robustinformation security program. By focusing on security (the intent of compliance) a risk analysis cansignificantly reduce the risk of an ePHI breach, save money by focusing IT resources on the most importantissues and….. achieve compliance. WEB PHONE EMAIL WWW.REDSPIN.COM 800-721-9177 INFO@REDSPIN.COM