What is a HIPAA Security Risk Assessment?

You’ve probably heard of a HIPAA security risk assessment. You may even know that your healthcare organization is required to complete one annually. If you do, you’re ahead of the curve. What you’re likely still wondering is what a HIPAA SRA entails and how do you complete one?

The HIPAA Security Rule requires that covered entities (health plans, health care clearinghouses, and health care providers who electronically transmit any health information in connection with a HIPAA-related transaction), and business associates (read more about business associates here), implement security safeguards.

These security safeguards must protect the confidentiality, integrity, and availability of electronic protected health information (ePHI). ePHI is any protected health information that is created, stored, transmitted, or received in any electronic format.

Performing a HIPAA security risk assessment is the first step in identifying and implementing these safeguards.  A security risk assessment consists of conducting an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI. 

What is the Scope of a HIPAA Security Risk Assessment?

According to guidance issued by the Department of Health and Human Services (HHS), the scope of security risk assessment includes potential risks and vulnerabilities to the confidentiality, availability, and integrity of all ePHI that an organization:

  • Creates;
  • Receives;
  • Maintains; and
  • Transmits

This includes ePHI in all forms of electronic media. Types of electronic media include hard drives, CDs and DVDs, smart cards, personal digital assistants, and portable electronic storage devices. 

Security Risk Analysis

The term “electronic media” is defined broadly, to include something as small as a single workstation, up to something as large complex networks connected among multiple locations. Security risk assessment must take into account all ePHI, regardless of the medium in which it was created, received, maintained, or transmitted, and regardless of its source or location.

Security risk assessment includes six elements:

  • Collecting Data
  • Identifying and Documenting Potential Threats and Vulnerabilities
  • Assessing Current Security Measures
  • Determining the Likelihood of Threat Occurrence
  • Determining the Potential Impact of Threat Occurrence
  • Determining the Level of Risk

Element 1: Collecting Data  

To begin the security risk assessment, an organization must identify where its ePHI is stored, received, maintained, or transmitted.  It can do this in several ways, by:

  • Reviewing past or existing projects
  • Performing interviews
  • Reviewing documentation. 
Security Risk Analysis

The data gathered on the ePHI gathered during data collection must be documented.

Element 2: Identifying and Documenting Potential Threats and Vulnerabilities

An organization must then identify and document threats to ePHI that are reasonably anticipated. Organizations must also identify and document vulnerabilities, which, if triggered or exploited by a threat, would create a risk of improper access to or disclosure of ePHI.

Element 3: Assessing Current Security Measures

For this part of the HIPAA security risk assessment, organizations should address their “state of security.” They should do so by:

  • Assessing and documenting the security measures they use to safeguard ePHI.
  • Assessing and documenting whether security measures required by the Security Rule are already in place.
  • Assessing and documenting whether current security measures are configured and used properly.

Element 4: Determining the Likelihood of Threat Occurrence

Organizations must then assess the likelihood of potential risks to ePHI. The results of this assessment, combined with the list of threats identified in element 2, will reveal what threats should be regarded as “reasonably anticipated.”