HIPAA Security Rule and ePHI Requirements
The Health Insurance Portability and Accountability Act (HIPAA) Security Rule is focused on protecting the confidentiality, integrity, and availability of electronic protected health information (ePHI) which is created, received, maintained, or transmitted by any covered entity (CE) against reasonably anticipated threats, hazards, and impermissible uses and/or disclosures. Covered entities include: covered healthcare providers, health plans, healthcare clearinghouses, Medicare prescription drug card sponsors and business associates. By meeting the requirements set forth in the Security Rule for ePHI, CEs will also meet the ePHI requirements of the Privacy Rule.
To achieve compliance with the HIPAA Security Rule, CEs must adhere to the six main sections, each consisting of several standards and implementation specifications, including:
- Security Standards - General Rules – includes the general requirements all covered entities must meet to ensure reasonable and appropriate protection of ePHI.
- Administrative Safeguards - are defined as the “administrative actions and policies, and procedures to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and to manage the conduct of the covered entity's workforce in relation to the protection of that information.1
- Physical Safeguards - are defined as the “physical measures, policies, and procedures to protect a covered entity's electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion.2
- Technical Safeguards - are defined as the “the technology and the policy and procedures for its use that protect electronic protected health information and control access to it.3
- Organizational Requirements - includes standards to ensure appropriate safeguards are in place at business associates and others who share ePHI.4
- Policies and Procedures and Documentation Requirements - ensures that covered entities have formal plans (i.e., policies, procedures and documentation) in place for the reasonable and appropriate implementation of ePHI security.5
The HIPAA Security Rule requirements have most recently been expanded via the Health Information Technology for Economic and Clinical Health (HITECH) Act, which establishes mandatory federal security breach reporting requirements with expanded criminal and civil penalties for non-compliance. Business associates of covered entities are now required to address the security rule requirements.