Understanding the nuances behind data security and compliance can be challenging.
In healthcare, where procedural changes are constant, it’s critical to stay ahead of security and data regulatory compliance. Healthcare providers that fail to meet regulatory standards, like HIPAA, risk having to pay fines between $100 to $50,000 per violation. A little past halfway through this year, HIPAA fines have already exceeded $5.5 million.
While hospitals and clinics need to be compliant, you should know that compliance does not have to imply security.
In this article, learn about:
- What differentiates data security and compliance
- Data security compliance standards in healthcare
- How to remain compliant
Understanding Data Security Compliance Standards
Canada is considered as having some of the most effective data privacy laws in the world, ranking amongst the top 10 countries in the internet privacy index. Laws set requirements and control how data must be collected, used, disclosed and stored. That’s where compliance comes in.
Compliance ensures healthcare organizations are safely handling sensitive data. Since hospitals, clinics, and other healthcare facilities routinely work with personal information, risk management is a priority and subject to data security requirements.
The primary elements that compliance emphasizes are:
- Knowing what kind of data is covered
- How that data is stored
- What frameworks apply for that data’s protection
- Penalties resulting from violations
Frameworks in Compliance
Frameworks are a broad-encompassing term in data compliance standards. When dealing with data regulatory compliance, some healthcare providers may require multiple frameworks to ensure compliance. One way to think of frameworks would be as regulatory requirements, detailing the following:
- Policies
- Regulations
- Laws
Frameworks also cover physical, legal, financial, and other forms of risk. Where frameworks aid in compliance would be through the studying of an organization’s security processes. Detailing security at any given moment of time and ensuring that data security abides by industry regulations, legislation, or best practices are the core functions of frameworks in compliance.
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Safeguarding Personal Information with Data Security
Data security involves the processes and technical systems used to safeguard information and technology assets. In healthcare, it primarily concerns keeping a patient’s medical records protected. Other components associated with security include:
- Physical controls
- Network access
- Authentication mechanisms
- Secure IT environment
- Business processes
While compliance is more multifaceted than security, both work in unison to fulfill a healthcare organization’s data security compliance standards.
Where Compliance Meets Security
When an organization meets the minimum security measures and policies, they are known to be compliant.
While healthcare providers may be operating in compliance, that does not mean they have the security to ward off cyber attacks.
Healthcare Industry Data Compliance Standards
When healthcare organizations don’t fulfill data regulatory compliance standards, those violations often result in federal fines. The most common compliance issues amongst healthcare providers are issues relating to:
- Patient privacy
- Electronic health records (EHR)
- Electronic medical records (EMR)
- Billing practices
While compliance stems from an organization’s executives and governing body, a compliance program is only effective when enforced at an organizational level. For that reason, many healthcare practices hire compliance officers or a compliance department.
To empower compliance enforcement within your organization, you must grant compliance enforcers the authority to create programs. In healthcare, regulations and standards are ever-changing; that’s why compliance is a necessity.
Health Insurance Portability and Accountability Act
HIPAA establishes the national standards to protect individuals’ medical records and other medical information about care plans, health care clearinghouses, and providers who perform certain electronic health care transactions in the United States.
When breaking down HIPAA, it is composed of five sections known as Titles. For the section that covers information privacy and security, read Title 2. As enforced by the act, health records are only accessible to approved individuals.
To help ensure HIPAA compliance, healthcare organizations must maintain detailed audit trails. Detailed audit trails help improve a healthcare providers transparency in the form of a step-by-step record detailing:
- Who accessed the system/network
- When it was accessed
- The operations performed
HIPAA also gives patients rights over their medical information, including examining, obtaining a copy of their health records, and requesting corrections.
Personal Information Protection and Electronic Documents Act (PIPEDA)
The Personal Information Protection and Electronic Documents Act (PIPEDA) provides ground rules for the collection, use, and disclosure of personal information by private organizations in the course of commercial activity.
It requires organizations (including healthcare organizations) to obtain an individual’s consent before collecting, using or disclosing personal information. PIPEDA states that personal information can only be used for the reason it was collected; if an organization wants to use for it any other purpose, it needs to take consent again.
It sets out 10 fair information principles for organizations to follow:
- Accountability
- Identifying Purposes
- Consent
- Limiting Collection
- Limiting Use, Disclosure, and Retention
- Accuracy
- Safeguards
- Openness
- Individual Access
- Challenging Compliance
People whose data is being used, collected, or disclosed have the right to access their personal information and even challenge its accuracy.
British Columbia, Alberta, and Quebec have similar private-sector privacy laws, and organizations must comply with those instead of PIPEDA. New Brunswick, Ontario, Newfoundland and Labrador, and Nova Scotia also have similar laws regarding personal health information.
Sarbanes Oxley Act
The Sarbanes Oxley Act (SOX) is a critical framework for classifying, storing, and promptly accessing the financial data of public companies. The framework emerged to improve corporate culpability and outlines controls for the alteration, falsification, and destruction of data.
Section 404 of the SOX Act emphasizes increased responsibility for the development, maintenance, and accessibility of internal controls and procedures for healthcare businesses. The core objectives of Section 404 are:
- Improve management
- Strengthen risk management systems
- Invoke a high quality of financial statements
To be SOX compliant, organizations need to maintain a minimum of 5 years of spreadsheets, emails, chats, and financial records in case of auditing. That is why timely backups, automating workflows, and improving organizational efficiency through new technology are essential for seamless auditing.
Though Canadian companies are not subject to SOX, Canada has passed similar legislation called Keeping the Promise for a Strong Economy Act in Ontario. More commonly called, it has been accepted by all securities regulators in Canada and serves a similar purpose to SOX.
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General Data Protection Regulation
The GDPR came into effect on May 25th, 2018, in the European Union. The sole aim behind the creation of the GDPR was to blend European data privacy laws across Europe and to unify how businesses handle the information of those they work with.
In short, the GDPR focuses on regulatory transparency, consolidation, jurisdiction, and data protection.
Here are the three personal data types relevant to the healthcare industry from GDPR:
- Health-related data – The GDPR states that any data regarding a person’s physical or mental health is personal, protected data. Additionally, this includes information about the type of medical care patients receive.
- Genetic data – Any information regarding a person’s genetic composition, such as lab results and analysis of a biological sample or details relating to a patient’s physiology, are protected under GDPR.
- Biometric data – Biometric data, like facial images, fingerprints, gait traits, or any biometric data relating to an individual’s behavioral or physical characteristics, is protected through GDPR protections.
Payment Card Industry Data Security Standard
Abbreviated PCI DSS, the Payment Card Industry Data Security Standard provides a compliance framework for any organization accepting credit card payments. Additionally, the PCI DSS covers the storage, processing, and transmissions of cardholder data along with sensitive authentication data.
The PCI DSS compliance framework for healthcare providers has proven challenging as many organizations in healthcare are complex, vast, and bureaucratic. There are about 50 different policies, forms, checklists, and procedures required to fulfill compliance. From there, there are four levels of PCI DSS compliance determined through:
- Self-Assessment Questionnaires (SAQ)
- Onsite Assessments with Service Providers
Apart from setting up a firewall and regularly testing system security, the Payment Card Industry Security Cards Council relies on 12 requirements to ensure the safekeeping of cardholder data
California Consumer Privacy Act
The CCPA state-wide privacy law regulates how worldwide businesses can handle California residents’ personal information. Data points strictly covered include any information enabling the creation of a user profile depicting an individual’s:
- Attitude
- Behavior
- Preference
- Intelligence
CCPA compliance is only for large businesses with an income exceeding $25 million, companies handling the data points of more than 50,000 customers, and organizations that drive more than 50% of business revenue by selling customers’ personal information.
While the CCPA is far more strict than the GDPR, there is an exemption around HIPAA. To add, the CCPA does not apply to CMIA (Confidentiality of Medical Information Act) governed healthcare providers.
The CCPA does not exempt businesses associates under HIPAA.
Ensure Data Regulatory Compliance
With ongoing healthcare regulations taking effect, staying ahead and remaining compliant is a federal requirement for all healthcare providers.
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At Fusion Computing, we work with you to minimize the rigors of meeting industry compliance standards and provide you with healthcare security solutions to ensure compliance. Stop worrying about compliance and data security and focus on providing optimal care.
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