After a breach, the first question organizations often ask is: “May I review your security risk assessment?”
Following a data breach, conducting breach assessments and regular risk evaluations is essential. This helps security leaders stay informed about vulnerabilities and proactively address security gaps and threats. Provider SRAs protect patient data, ensure HIPAA compliance, and strengthen your organization’s cybersecurity posture against growing threats.
What Are Provider SRAs and Why Do They Matter?
Healthcare providers across the United States have the incredible opportunity – and responsibility – to help deliver improved patient outcomes, and ultimately elevate public health. Although healthcare professionals touch lives every day, they are also subject to some of the most stringent regulatory hurdles in the country. Because they have access to highly sensitive protected health information (PHI), they are expected to operate with a high level of organizational security and best practices when it comes to securely storing patient data.
To safeguard sensitive data from malicious threats or accidental breaches, the HIPAA Security Rule requires healthcare organizations and other critical businesses to perform comprehensive risk assessments. These evaluations ensure that both their digital and physical environments are secure and compliant with regulatory standards.
Failing to dedicate sufficient time and resources to securing patient data can leave your organization vulnerable to audits and potential fines from the Office for Civil Rights. Prioritizing data security is just as crucial as developing effective care strategies to protect both your patients and your organization.
There is good news – there are best practices and insights available to help you and other healthcare providers operate with high confidence in your security, privacy, and HIPAA compliance practices.
How Often Should You Update Provider SRAs?
Despite the fact that there is no one-size-fits-all approach to properly managing your organizational risk, government regulators such as HHS and the Office for Civil Rights believe that quality risk analysis is the first step in remaining compliant with government laws to protect patient information.
According to the U.S. Department of Health and Human Services, “All e-PHI created, received, maintained or transmitted by an organization is subject to the Security Rule,” meaning that physicians must use appropriate administrative, physical, and technical safeguards to ensure the confidentiality, integrity and security of this information.
For healthcare providers, every annual Security Risk Assessment should be guided by a set of essential questions.
In ClearDATA’s capacity as a healthcare cloud security company, we have observed clients that review their SRAs quarterly, annually, or even with years’ gap SRAs. It’s important to remember that even though there is no single approach that can best serve every healthcare provider. We typically recommend that healthcare providers review their SRAs at least every 6-12 months.
In addition to reviewing your organization’s SRA based on a pre-determined amount of time, many healthcare providers benefit from reviewing their SRA in response to operational changes and/or security incidents. Of course, it’s advisable to review your SRA before a negative incident occurs; but reviewing your existing tactics, techniques, and procedures after a cyber incident can be a valuable step in your team’s debrief to ensure no repeat security failures.
What Systems Should Be Included in Your Provider SRAs?
As part of your SRA, do you include all information systems containing, process, and/or transmitting ePHI? ClearDATA recommends including all relevant information systems because it is remarkably difficult to protect your data if you aren’t even sure where it’s being transmitted.
All healthcare providers should maintain a complete and accurate PHI inventory of every known and officially managed IT asset in your organization – establishing optimal security controls. Many inventories of healthcare provider IT assets can be recorded and updated using a well-designed, digitally stored spreadsheet.
What Documentation Is Essential for Effective Provider SRAs?
What goes into your SRA documentation? We recommend that it includes possible threats and vulnerabilities, which have been assigned possible impact and probability ratings. Based on these ratings, organizations can determine potential severity of risks and prioritize healthcare risk management accordingly.
For example, some choose to establish a data classification policy that categorizes data as: Sensitive, Internal Use, or Public Use. Once you have determined these classifications, you can organize data accordingly. Organizational policies should cover all user interactions with sensitive data. They should clearly state the consequences if data is lost or compromised. al policies should address all user interactions with sensitive data and make expressly clear the consequences if lost or compromised. After all, human error is one of the leading causes of cybersecurity events. Effective IT asset management is essential for maintaining strong cyber hygiene across all organizational assets, including medical devices. Optimize your medical device management and strengthen cybersecurity with proper IT asset tracking.
Boosting Provider SRAs with Strong Leadership
Once your security policies are established and you have closely reviewed existing data, the next step is to confirm the teams and/or individuals responsible for developing and implementing information security policies and procedures. In many instances, this responsibility is assigned to the CIO or CISO, who operates as the security officer, and is a member of the workforce identified by name in policy documents.
As organizations grow, employees may interact less across the organization and may not know who is responsible for the security of the data they use every day. ClearDATA recommends healthcare providers take the time to introduce the CIO or CISO – and their responsibilities as the security officer – to the organization as a whole.
Why Regular Provider SRAs Are Critical for Patient Data Security
Security Risk Assessments are a critical best practice – and a HIPAA regulatory requirement – for healthcare providers.
If you have read about the early questions for your organization’s SRA, we can help. Check out our next blog, “Peeling Back The Onion: A Deeper Dive on Provider SRAs.”
You can also contact our HIPAA experts to discuss your Provider SRAs.