HIPAA Compliance & Cybersecurity: How They Differ
In a time when everyone in healthcare is discussing data, the concepts of HIPAA compliance and cybersecurity can kind of blend together, so much so that it is unclear where one begins and the other ends.
This article discusses these two concepts and helps outline the ways they differ. While there is a certain degree of overlap between the two, it’s important for entities within the healthcare industry to be able to differentiate the roles of HIPAA and cybersecurity. Armed with this understanding, organizations can make impactful decisions toward greater compliance and a stronger cybersecurity posture.
HIPAA Compliance
HIPAA is not just a recommendation or an industry standard. It is a US federal law. The Health Insurance Portability and Accountability Act was enacted in 1996 to ensure that personal health information (PHI) is protected against emerging security and privacy risks. The law applies to any and all US healthcare providers. Insurance providers, healthcare clearinghouses, and third-party service providers (also known as business associates) involved in the collection, storage, and transference of PHI are also bound by these regulations.
What data is protected by HIPAA?
So HIPAA protects personal health information, but what exactly does that cover? The answer is any information that could be used to identify the person to which the health information belongs.
This covers 18 data types, including obvious identifiers like patient names, social security numbers, and telephone numbers, as well as less obvious identifiers like medical device serial numbers, website URLs, and biometric information.
The 5 Rules of HIPAA
HIPAA outlines five stringent provisions to meet compliance. This includes the well-known Privacy Rule and Security Rule, but also the lesser-known Breach Notification Rule, Enforcement Rule, and Omnibus Rule.
Providers must adhere to these rules or risk severe consequences, including legal and financial penalties. The Office for Civil Rights (OCR) of the US Department of Health and Human Services (HHS) may impose civil monetary penalties and demand a corrective action plan (CAP) to fix the deficiencies.
In addition to these serious monetary penalties and legal concerns, noncompliance can permanently damage the reputation of a healthcare organization. This can have a catastrophic impact on patient trust and potential revenue.
1. Privacy Rule
The Privacy Rule establishes standards for the protection of medical records and other PHI. Patients must provide their written consent before any of their PHI can be disclosed. It also requires the implementation of controls to procedures to ensure PHI remains protected at all times.
2. Security Rule
The Security Rule outlines how personal health information is handled when being stored, transferred, or shared. This includes requirements for the integrity, confidentiality, and availability of electronic PHI (ePHI). A thorough risk analysis is required to identify vulnerabilities within healthcare IT systems and procedures, so that the risks can be mitigated as necessary. Healthcare organizations often choose to invest heavily into HIPAA-compliant software solutions to protect themselves and patient information against data breaches.
3. Breach Notification Rule
In the event that PHI is leaked in one way or another, the entity should respond by immediately notifying the HHS and the affected patients. In some cases, healthcare organizations may also need to notify the media.
4. Enforcement Rule
The Enforcement Rule establishes procedures for investigating and sanctioning organizations that violate HIPAA provisions. The Department of Health and Human Services has the authority to launch investigations into any complaints. If the complaint is found to be true, the department can impose monetary penalties to punish the organization for its HIPAA noncompliance.
5. Omnibus Rule
The Omnibus Rule was not originally a part of HIPAA when it was passed in 1996. Instead, it was added in 2013 to include a set of amendments to HIPAA. These amendments applied updates brought about by the Heath Information Technology for Economic and Clinical Health (HITECH) Act and the Genetic Information Nondiscrimination Act (GINA).
Cybersecurity
Cybersecurity is a field within information technology (IT) focused on protecting computer systems, networks, and data. It is tasked with mitigating the risks of authorized access and data theft. Hackers, cybercriminals, malicious agents, and even insiders (those working within an organization) can pose a serious threat to digital assets and data.
What data is protected?
Cybercriminals concentrate on obtaining data that enables them to engage in fraudulent activities, assume false identities, and infiltrate protected computer systems and networks without permission. Cybersecurity teams implement controls to protect data types that are regularly targeted by cybercriminals:
- personally identifiable information (PII)
- protected health information (PHI)
- payment and bank account information
- social media data
- login credentials
- intellectual property
- system configurations
5 Key Cybersecurity Measures
There are dozens, if not hundreds, of proven measures to stop cybersecurity attacks from compromising computer systems. While this article couldn’t even begin to cover all of them, here is a sampling of 5 important measures:
1. Zero Trust and Access Controls
The zero trust model operates off the idea that all credentials within a network should be treated as untrustworthy. And because every credential is deemed untrustworthy, credentials are only given access to the exact systems and permissions they need. When access control is handled with this granularity, the impact of stolen credentials is far less.
Permissions are regularly reviewed by IT professionals to ensure that credentials are not holding onto permissions that they no longer need.
2. Data Encryption
Data encryption uses cryptographic algorithms to convert readable data into an encrypted format. Organizations can decrypt data back into plain text with the secret encryption key, but if malicious actors manage to access encrypted data, it will be useless to them without the key.
3. Network Segmentation
A large network is at increased risk of intrusion because it has a greater number of intrusion points, making it difficult to protect. Organizations can utilize network segmentation practices to break their network into smaller, isolated subnetworks.
Each segment has its own access controls and firewalls. If a cybercriminal wants to move laterally through the network, they must be able to break through these controls at each level. With segmentation, the impact of an attack will be limited.
4. Regular Updates and Patches
Implementing regular software updates and patches helps IT teams address security vulnerabilities as they are identified and fixed. It can be difficult to coordinate these updates for organizations with many assets, but it’s essential to reduce the risks.
5. Employee Training
Most security breaches and unauthorized access are traced back to an unwitting mistake made by an employee. Employee training can help prevent these incidents by ensuring staff understands how to choose strong passwords, identify phishing emails, and avoid suspicious websites.
The Difference Between HIPAA Compliance and Cybersecurity
Though HIPAA compliance and cybersecurity may appear to be two sides of the same coin, aiming to safeguard sensitive information, their true nature reveals distinct differences between them:
The Realm of Influence
HIPAA compliance hones in on the meticulous protection of PHI, exclusively within the realm of healthcare. In contrast, cybersecurity casts a wider net, encompassing the entire spectrum of IT, as it fortifies digital access across every industry.
While HIPAA compliance remains a mandate solely for those organizations, clearinghouses, and business associates that engage with PHI, cybersecurity measures stand as an indispensable pillar for any contemporary organization.
Governing Principles
HIPAA is a federally mandated law with specific requirements that healthcare organizations must follow. In contrast, general cybersecurity practices are not actually a legal requirement that organizations must adhere to.
There are a few notable exceptions to this, but there’s no need to cover them here. Even though there are few cybersecurity laws, the industry has developed some specific standards, frameworks, and best practices, such as the NIST Cybersecurity Framework, ISO/IEC 27001, or the CIS Critical Security Controls.
Authority and Enforcement
The US Department of HHS holds the reins when it comes to enforcing HIPAA, carrying the authority to levy fines and sanctions against those who fail to comply. In contrast, cybersecurity operates in a less regulated environment, though organizations may still fall under the purview of regulatory bodies, depending on their industry niche (such as finance) and geographical location.
Focus
HIPAA sets its sights on a particular industry and data type, concentrating on the privacy and security of PHI. Meanwhile, cybersecurity takes a broader approach, aiming to shield an array of digital assets, including networks, systems, applications, and sensitive information. IT professionals work diligently to protect an organization’s entire infrastructure from end to end.
Flexibility and Adaptability
Even though HIPAA outlines stringent standards, it offers a certain degree of flexibility in implementation. One example of this flexibility is the Security Rule, which includes “addressable” implementation specifications. In simpler terms, a company can evaluate the correct prevention measures for its specific systems and operations.
Cybersecurity typically requires a more tailored approach that considers an organization’s unique risk profile, threat landscape, and technology infrastructure. Organizations need to make a whole list of considerations, from what type of data they store to what their infrastructure looks like. From there, they can implement the security measures that would best protect their systems.
The Synergy Between HIPAA Compliance and Cybersecurity
In the dynamic world of data protection, HIPAA compliance and cybersecurity join forces to create a formidable barrier against potential threats. Though they may target distinct aspects of information security, their combined efforts foster a comprehensive approach to safeguarding sensitive data.
By embracing the principles of HIPAA compliance alongside robust cybersecurity measures, organizations can bolster their defenses, ensuring the integrity, confidentiality, and availability of valuable information.