Who conducts a risk assessment?

HIPAA risk assessments are conducted by internal staff or specialized external entities. Internally, designated teams or IT experts handle assessments using their internal knowledge. Externally, HIPAA compliance consultants, security firms, or specialized software tools bring industry-specific expertise for comprehensive evaluations. The choice depends on resources, expertise required, and assessment complexity.

Understanding HIPAA risk assessments

A HIPAA risk assessment is a multifaceted evaluation tailored to healthcare practices. It examines the entire cycle of protected health information (PHI), including creation, usage, storage, transmission, and disposal. The analysis aligns with the HIPAA Security Rule, stressing confidentiality, integrity, and availability of patient data.

PHI vulnerabilities extend beyond electronic threats. Physical breaches, human errors, and social engineering scams present significant risks. A holistic approach that considers these multifaceted threats ensures a more comprehensive risk assessment.

Read more: What is a HIPAA risk assessment?

Considerations for conducting a HIPAA risk assessment

• Focus on PHI security: Healthcare organizations must understand the life cycle of PHI. Addressing electronic, physical, and human-related threats ensures a comprehensive evaluation, defending against diverse vulnerabilities. 
• Involvement of key stakeholders: Engaging representatives from pertinent departments (IT, medical records, billing) enhances the assessment. Their insights provide a holistic view of PHI management, enhancing risk identification.
• Regular updates and ongoing compliance: Continuous assessments help adapt to evolving threats. Prompt reassessments after significant changes maintain compliance and robust security measures.

Who conducts a HIPAA risk assessment?

Internal resources: Designated staff or cross-functional teams often spearhead risk assessments within healthcare practices. These individuals or teams should possess expertise in security and compliance, understand the organization's intricacies, and effectively collaborate across departments. Using internal resources fosters a deeper understanding of the organization's operations. There may, however, be challenges in resource availability or specialized expertise.

External options: Engaging external entities like HIPAA compliance consultants, security firms, or specialized software tools offers a different approach. These external experts bring specialized knowledge and methodologies tailored explicitly to healthcare settings. They provide a fresh, unbiased perspective and often possess industry-specific expertise. However, this approach might come with a higher cost and require collaboration between external assessors and internal stakeholders.

Related: How to perform a risk assessment 

Identifying potential assessors

• Internally, designated staff from IT or compliance departments usually conduct assessments. These individuals possess an in-depth understanding of the organization's systems and processes. Collaborating across various departments ensures a holistic view of PHI handling.
• Externally, engaging HIPAA compliance consultants or security firms provide specialized expertise. These entities bring industry knowledge, diverse methodologies, and extensive experience in conducting risk assessments tailored to healthcare environments. Additionally, specialized software tools for healthcare settings offer effective risk assessment capabilities and guidance.
  
  

Tools for conducting risk assessments

Using recognized tools and frameworks simplifies the risk assessment process. The HHS Security Risk Assessment Tool offers specific guidance tailored to healthcare settings, including mental health practices. This tool assists in identifying vulnerabilities such as outdated software, insufficient access controls, or inadequate encryption measures that could compromise PHI security. 

According to the HHS, "The tool’s features make it useful in assisting small and medium-sized health care practices and business associates in complying with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule."

FAQs

How often should a HIPAA risk assessment be conducted?

HIPAA risk assessments should be conducted annually or whenever there are significant changes in the organization, such as new technology, processes, or personnel.

Do HIPAA risk assessments include physical security evaluations?

Yes, HIPAA risk assessments should evaluate physical security measures such as facility access controls, hardware security, and physical safeguards for PHI storage.

What should I do after completing a HIPAA risk assessment?

After completing a HIPAA risk assessment, organizations should create a remediation plan to address identified vulnerabilities, implement security improvements, and continuously monitor for new risks.