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Most healthcare professionals do their best to abide by HIPAA rules and most organizations check the box of HIPAA compliance. But there’s a gap between what’s required and what should be done to truly protect your organization. The Department of Health and Human Services (HSS) is trying to close that gap with additional requirements for HIPAA Security Rule compliance. Regardless of whether the proposed rule is finalized, I think organizations should adopt the guidelines as reasonable steps to greater protection from the nightmare of a data breach.
In this article, I’ll share some of the basic ways that you can better protect your organization from HIPAA hidden risks, without creating a greater burden for your already busy teams.
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What Do You Mean HIPAA Compliance Isn’t Enough?
Compliance and resilience are two different things. An organization can technically be compliant, but still experience a cybersecurity attack that compromises PHI. An organization can meet HIPAA compliance requirements, but face fines and lawsuits because an employee didn’t know the importance of communicating even the smallest of breaches.
Download a ready-to-use HIPAA breach notification policy and notification letter.
HIPAA compliance is required and an excellent foundation, but to truly protect your healthcare organization, you need to build resilience. This means taking action and going above and beyond just meeting requirements. Many of these extra steps are simple, but will help to eliminate the HIPAA hidden risks that are lurking in every healthcare organization.
Steps To Take Beyond HIPAA Requirements
Ongoing and Role-Specific Training
Ensuring staff complete annual HIPAA training — and documenting it — is only the starting point. To build true resilience, healthcare organizations should implement ongoing, role-specific training. Each role faces unique risks and needs to be equipped with the knowledge to recognize and mitigate them. (add example from webinar)
By delivering tailored, engaging training, every staff member is prepared for the HIPAA-related risks they may encounter in their role. It’s not going to prevent a breach, but this proactive approach strengthens defenses and puts your organization in the best position if PHI is compromised.
Engage Staff and Vendors in a Security Risk Analysis (SRA)
Completing an annual security risk analysis keeps you compliant, but without input from your staff and vendors you might be missing potential risks that could cost you. Here’s how to involve these critical groups in your healthcare security risk analysis:
Identify Vulnerabilities from a Staff Member’s Perspective: A lot of your staff that access company systems might know when there’s weaknesses or opportunities to improve security, so surveying them can help to identify hidden risks and empower them to take a more proactive approach moving forward.
Ensure Vendors Are Doing Their Part: You’ve likely got business associate agreements (BAAs) in place (if you don’t, download a template here), but are checking to be sure each vendor is completing their own SRA? Don’t stop there — make sure you see the results as well so you’re aware of potential vulnerabilities.
Share Results & Elicit Feedback: The last place the results of an SRA belong is in the inbox of just a few organization leaders. Even if you’re reluctant to share that report because it highlights vulnerabilities, put it in a way where your staff can understand it and have optimism to act on it.
Increase Staff Awareness of Threats
Preparing to speak during a MedTrainer Live, I completed deeper research on HIPAA Security Rule compliance and cybersecurity and learned new terms like “man in the middle” and others. There are likely many terms that your staff don’t see day-to-day. As a proactive leader, it’s up to you to ensure staff stay aware of emerging threats. Here are a few recommendations to achieve this:
- Create a wall of human interceptors: It’s your staff who are trained to pay attention, be aware, and alert the appropriate people if they see anything out of the ordinary.
- Go beyond email to keep staff informed: Staff may breeze through emails, so post information in common areas, hold meetings, and run contests to get their attention.
- Add job aides to your document management system: There’s no rule that you can only include HR documents and policies in your compliance software — add job aides to help educate employees and ensure they always have access.
Ensure Staff Know Their Role
Let’s go back to resilience. Say you have multiple policies related to HIPAA that have been shared and employees have acknowledged receiving them – you’re compliant, but your staff might not be prepared. Just because a policy has been acknowledged, doesn’t mean it’s fully understood and absorbed.
Ask this question to your staff: If you click on a link in an email and something starts happening with the screen, do you know what to do?
Do you turn off the computer? Pick up the phone? Send an email? When each member of your staff knows the answer when it comes to these situations, it can save your organization from breaches that could’ve been easily avoided.
Encourage Incident Reporting
Sometimes staff are hesitant to report incidents because they don’t want to face negative repercussions. When you foster a culture that encourages incident reporting, teams will be more inclined to open up, no matter how big or small the issue is. If your staff aren’t ready for 100% transparency, anonymous incident reporting can be a step in the right direction.
Cyber attacks are subtle and persistent. Create a human shield by enabling staff to report unusual requests, incorrect email domains, and overly personalized messages. When you provide clear reporting channels and recognize and reward vigilance, your team will be prepared to fend off any hidden risks that pop up. Once again, communication prevails.
MedTrainer Live: HIPAA Hidden Risks
How Technology Helps You Go Beyond HIPAA Compliance To Prevent Hidden Risks
Uncovering hidden compliance risks requires strong policies that are supported by role-based training. Encourage staff to communicate about cybersecurity risks from their perspective and build a culture of compliance — it starts with a solid foundation that is strengthened by technology.
With built-in alerts and real-time dashboards, teams can quickly identify gaps, follow up on incidents, and monitor trends over time. This proactive approach ensures that risks aren’t just documented — they’re understood, addressed, and prevented before they escalate. By implementing technology, teams can improve their HIPAA Security Rule compliance, discover whats hidden beneath the cracks, and adopt resilience.