How to Become HIPAA Compliant in Illinois

For many Healthcare organizations in Illinois who are in need of meeting compliance with the Health Insurance Portability and Accountability Act, also known as HIPAA, the challenge of compliance can seem like a daunting task. However, this article may help you navigate the obstacle by summarizing the requirements for compliance and exploring the options that your Healthcare organization has to comply.

How to Become HIPAA Compliant in Illinois

The HIPAA Security Rule goes over the requirements for protecting patient health data that is covered under the regulation. It includes technical and non-technical standards that healthcare organizations must adhere to in order to be considered compliant.

Covered healthcare entities and their business associatesmust keep protected health information private, secured and available at all times. Covered entities include all medical providers, insurance companies, and healthcare clearinghouses. The integrity of the data these organizations store must also be maintained. The organizations also need to know the cybersecurity threats that could lead to this information being compromised and the solutions necessary to stop that from happening.

The HIPAA Security Rule also addresses the necessity of the workforce complying with these standards and the protection of protected health information against impermissible use.

While you have a set of standards to cover, the Security Rule is flexible to accommodate the varied technology needs and capacities of each organization. You have the flexibility to bring in new technology and change your policies while still remaining HIPAA compliant.

Options for HIPAA Compliance

The route that you take for HIPAA compliance depends on the resources that you have available in-house, your budget for bringing your healthcare organization into compliance, and the potential to bring in external partners experienced in HIPAA Security Rule compliance.

Do-it-Yourself HIPAA Compliance

For healthcare organizations who have the resources and expertise in-house (such as an internal IT department) a do-it-yourself approach to handling HIPAA compliance may be feasible. Several resources are available to ensure that your healthcare organization is complying with all of the Security Rule requirements.

Self-Assessment Checklist

This self-assessment checklist by HIPAA Journal provides a comprehensive guide that you can use to go over all of the Security Rule requirements. You can check which areas you have covered and the ones that you still need to put into place.

When you need to audit your compliance measures in the future, you can come back to the self-assessment checklist to review your adherence to these rules, look for ways that you can improve your HIPAA compliance, and make protected health information even safer for your patients.

Risk Assessment Tool

The risk assessment tool by the Office of the National Coordinator for Health Information Technology is a valuable resource for determining your healthcare organization’s security risks. It walks you through risk categories that could threaten protected health information or take you out of HIPAA compliance.

You discover where your security gaps are and potential vulnerabilities that attackers can exploit. Once you go through this process, you can put together an action plan that addresses these areas to improve your cybersecurity for the future.

Go through the risk assessment process on a periodic basis. New types of attacks appear on a regular basis. You may have everything covered right now, but in a year from now the IT security landscape may look very different.

NIST HSR Toolkit

The NIST HSR Toolkit complements the risk assessment measures that you have in place, whether you’re using the solution in the previous section or going through your own process. You’re presented with a number of questions that walk you through HIPAA Security Rule requirements so you can determine how well you’re complying with them and the problem areas that should be on your radar.

Do-it-Yourself Isn’t for Everyone

The DIY approach requires your organization to have sufficient in-house resources to thoroughly go through these tools. Adhering to the HIPAA Security Rule puts a lot on your IT department. They already have many responsibilities and may have a difficult time fitting in these additional duties.

You’re faced with the choice of pulling your IT team away from other important tasks to address these requirements. Other projects may go on hold during this process, which can impact your operations. If you end up with IT emergencies, you may be faced with a choice of addressing that critical situation and bringing your healthcare organization into compliance.

That choice is a difficult one to make, as failure to comply with the HIPAA Security Rule can put you in a position where you have to pay fines, face civil or criminal penalties, and worry about the impact that it has on your reputation.

Outsourced HIPAA Compliance to an MSP

The Do-it-Yourself approach may not be the best option for many healthcare organizations. Some organizations simply will not have the resources available to understand and implement the requirements specified by the regulation. Furthermore, for organizations that do have the expertise on staff, the DIY approach may seem appealing at first, but it can lead to an organization’s IT resources being stretched too thin. Therefore, many will find the outsource approach to be the better option.

When you work with experts who specialize in healthcare IT, you’re getting people who know the Security Rule inside and out. They’ve helped many organizations through this process and have the hands-on experience to know the best ways to implement needed cybersecurity measures.

You also get a helpful outside perspective. They have worked with businesses that have gone through data breaches and other healthcare IT challenges. They’re on top of the latest HIPAA regulations and know the best practices for maintaining compliance.

A Managed IT service Provider (MSP) specializing in HIPAA compliance is an excellent resource even if you have a fully staffed IT team. They work alongside your on-site staff to find the best approach to putting the right cybersecurity measures in place and provide comprehensive risk assessment processes.

The HIPAA Security Rule guides healthcare organizations into properly managing and protecting protected health information, but implementing these measures can exceed the capacity of your on-site IT team. Partnering with a managed IT service provider is the best choice in many scenarios, both from a cost and compliance standpoint.

Working with an MSP: The Compliance Process

When working with a Managed Service Provider (MSP) who specializes in HIPAA compliance, the process to get your healthcare systems and procedure to meet compliance follows three main sections: Gap Analysis, Remediation, and Cybersecurity Monitoring & Maintenance.

Gap Analysis

The first step towards compliance will require the MSP to discover how far away your organization is from meeting the requirements of HIPAA. This process is called the Gap Analysis and it is designed to discover inadequacies in systems and procedures that may not meet requirements.

The results of a gap analysis may reveal issues with:

  • How access to information systems is controlled
  • How managers and information system administrators are trained
  • How data records are stored
  • How security controls and measures are implemented
  • How incident response plans developed and implemented

The results of the Gap Analysis will serve as the basis for the Remediation plan.

Remediation

Next, the MSP will perform the necessary updates required based on the findings of the Gap Analysis. Remediation may involve minor and inexpensive updates to a network and/or processes, or may involve more extensive rebuilds to meet compliance.

Cybersecurity Monitoring & Maintenance

After the remediation work has been completed, the MSP will have the tools, processes, and personnel to monitor, detect, and report on the cyber incidents to your Healthcare organization. Regular scheduled maintenance of your systems will ensure you’re always in compliance with HIPAA so you never have to worry about whether you’re properly protecting your patients’ data.

Beyond HIPAA

Beyond HIPAA, an MSP will also mitigate the IT risks to your organization as part of a modern Business Continuity strategy. A business continuity strategy seeks to ensure consistent uptime of your healthcare organization’s technology so you can focus on delivering exceptional care to your patients and customers, and not struggle or worry about your IT.

To speak to our IT Professionals in Illinois about your options for HIPAA compliance or our IT Services for Healthcare organizations, feel free to contact us.