Risk Assessment
What is Risk Assessment in HIPAA?
In general, risk assessment refers to the process of identifying, evaluating and documenting potential risks involved in any scenario. With reference to HIPAA, risk assessment refers to evaluating the processes involved in storing, managing, sharing, and deleting Protected Health Information (PHI), and identifying gaps in security and privacy.
Risk assessments are an important part of any overall HIPAA compliance practice. The HIPAA Security Rule explicitly requires covered entities and business associates to perform ongoing risk assessments. This ensures that organizations can anticipate technical, physical, and administrative threats, and implement appropriate safeguards.
How Do Risk Assessments Help Healthcare Organizations?
Healthcare is a high-value target for cybercriminals, which is why ransomware, phishing, and insider threats are on the rise. Regular risk assessments help uncover gaps in data privacy and security that can be easily penetrated by cybercriminals. Early detection of weak points, such as unencrypted devices or unsecured email, prevents data breach incidents.
Documenting the risk assessments also demonstrates due diligence during audits and investigations conducted by the Office of Civil Rights (OCR). This goes a long way in ensuring ongoing HIPAA compliance. The OCR has issued fines ranging from $50,000 to millions for organizations that failed to conduct proper assessments.
Steps in a HIPAA-Compliant Risk Assessment
- Identify where PHI resides: Examine systems, devices, cloud platforms, paper files, and email communications.
- Map data flows: Understand how PHI is created, transmitted, stored, and disposed of.
- Evaluate threats and vulnerabilities: List possible threats to the current process, like cyberattacks, human error, natural disasters, insider misuse, etc. It is better to assume a threat and look for ways to mitigate it than to dismiss risks as irrelevant and improbable.
- Determine likelihood and impact: Assign risk ratings to each identified vulnerability.
- Document and prioritize risks: Create a written report that becomes part of compliance evidence.
- Implement corrective actions: Apply encryption, access controls, or training updates to close gaps.
- Review and update regularly: Conduct assessments annually or after major changes to systems or workflows.
Brightsquid supports compliance by helping organizations identify secure communication risks and close gaps with HIPAA-compliant messaging tools and training.
Related Terms
Two Factor Authentication
End-to-End Encryption
Privacy Policy