Effective HIPAA Policy Management
HIPAA policy management has the objective of ensuring that policies and procedures implemented to comply with HIPAA are current, accessible, and applied consistently across the organization. Effective management of HIPAA policies is one of the most constructive ways in which organizations can support HIPAA compliance by ensuring policies and procedures are applied consistently across the organization.
HIPAA covered entities and business associates must develop, implement, maintain, and review policies and procedures with respect to Protected Health Information (PHI) that are designed to comply with all applicable standards, implementation specifications, and other requirements of the HIPAA Administrative Simplification Regulations.
In addition, organizations must provide HIPAA training on policies and procedures that are relevant to workforce members’ roles, and ensure all workforce members are aware of policies and procedures implemented to support compliance with the HIPAA Security Rule. Further training is also required when there is a material change to a policy or procedure.
What is HIPAA Policy Management?
Depending on the nature of a covered entity’s operations, or the services provided by a business associate, an organization may have to develop, implement, maintain, and review hundreds of HIPAA policies and procedures – each one potentially subject to modification whenever there is a regulatory, operational, or technical change that affects an applicable standard.
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HIPAA policy management is the practice of staying abreast of what policies and procedures are required for HIPAA compliance, when they require modification, and what training must be provided to ensure workforce members’ HIPAA knowledge is kept up to date. In some cases, it also involves being aware of when non-HIPAA regulatory changes impact HIPAA compliance.
Reviews of HIPAA policies and procedures are not only necessary when a change occurs. Periodic reviews of documentation and non-technical evaluations of security policies and procedures are required by the HIPAA Security Rule. Organizations that fail to conduct periodic reviews may be found in violation of HIPAA in the event of a compliance investigation or audit.
The Challenges of HIPAA Policy Management
The challenges of HIPAA policy management go beyond ensuring policies and procedures are kept up to date and training is provided to workforce members whose roles are affected by a material change. In many cases, workforce members whose roles are not affected by a material change may need to be made aware that a change has occurred in order to ensure policies and procedures are applied consistently across the organization.
This is particularly important when regulatory, operational, or technical changes have secondary impacts on other areas of HIPAA compliance. For example, the recent changes to the HIPAA Privacy Rule to protect reproductive health care information – although now vacated – not only required changes to HIPAA privacy policies and procedures, and additional workforce training, but also changes to organizations’ Notices of Privacy Practices.
Notifying all members of the workforce to changes in policies and procedures, and any secondary impacts, is not only a challenge of HIPAA policy management in itself. Workforce members who do not understand how a policy change will affect their roles are likely to have questions, and responding to the questions or finding the time and resources to provide additional training can also be challenging.
The Challenges are Only Likely to Increase
Historically, regulatory changes to HIPAA have been infrequent and limited in scope. However, there have recently been several regulatory changes that affected HIPAA policy management – including the introduction of standards to protect reproductive health care information and amendments to Part 2 regulations relating to uses and disclosures of SUD records. Further proposed regulatory changes are likely to increase the challenges of HIPAA policy management.
Possibly the most significant proposed changes are those to strengthen cybersecurity for electronic PHI. Among the proposals are a number of measures that would increase the challenges of HIPAA policy management, including:
- The written documentation of all HIPAA Security Rule policies, procedures, plans, and analyses.
- The development of a technology asset inventory and a network map to be reviewed at least annually.
- Strengthened requirements for planning policies and procedures for contingencies and security incidents.
- Written security incident response plans and procedures documenting how security incidents are reported.
- Written procedures for testing and revising written HIPAA security incident response plans.
- The verification of business associates that they have deployed the technical safeguards required by the HIPAA Security Rule.
In addition to the number of changes to HIPAA policies and procedures potentially made necessary by future regulatory changes, HIPAA policy management may be further challenged by the increasing adoption of AI in healthcare. When PHI is used by AI-driven technologies, policies must be developed and implemented to ensure that PHI is used by these technologies in compliance with HIPAA.
The Benefits of a HIPAA Policy Portal
Considering the potential volume of changes, developing, implementing, maintaining, and reviewing HIPAA policies and procedures manually is unlikely to be an effective method of HIPAA policy management in the near future. The likelihood exists that changes to policies may be overlooked, that some workforce members may be excluded from HIPAA training in error, or that some departments may be unaware of the changes and continue using out of date procedures.
One way to overcome this risk and better support HIPAA compliance is to implement a HIPAA policy portal. A HIPAA policy portal maintains all policies and procedures in one place, allows Privacy Officers and Security Officers to cross-reference policies and procedures, and alerts training providers when HIPAA training is required by members of the workforce due to a regulatory, operational, or technical change – or because refresher HIPAA training is due.
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HIPAA Policy Management
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Your Privacy Respected
HIPAA Journal Privacy Policy
A searchable HIPAA policy portal that is also accessible by workforce members ensures that, if a doubt exists about what policy applies in specific circumstances, workforce members can log into the portal, search for the answer to their question, and perform their roles in compliance with HIPAA. HIPAA covered entities and business associates managing HIPAA policies and procedures manually are advised to review their HIPAA policy management practices and determine whether their organization could benefit from a portal of this nature.
