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.
For this part of the security risk analysis, 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.
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.”
After an organization determines the likelihood of threat occurrence, it must assess the impact of potential threats to confidentiality, integrity, and availability of ePHI. This can be done by assessing the severity of the impact resulting from a threat that triggers or exploits a vulnerability. The assessment should be documented.
A useful way to document Impact severity, is by describing the severity numerically (i.e., assigning a number to how severe an impact is, on a scale of 1 to 10, with 10 being “most severe”).
The level of risk is determined by evaluating ALL threat likelihood and threat impact combinations identified in the risk analysis so far.
The level of risk is highest when a threat 1) is likely to occur; AND 2) will have a significant or severe impact on an organization. For example, if a network is completely unsecured, and that network stores all of the organization’s ePHI, two things are likely to happen: A threat will occur, and its occurrence may have a severe impact on the organization. When threat likelihood and severity are both high, the level of risk should be classified as “high.”
On the other hand, if there is a low risk of a threat occurring, AND the threat’s occurrence will have little to no impact on the organization, the level of risk is relatively low.
Once the organization has assigned risk levels, it should document those levels, and document what corrective actions are needed.
Finally, once all six elements have been addressed, all documentation should be finalized. In addition, the security risk analysis should be periodically reviewed, and updated, as needed.
Covered entities and business associates can address their security risk analysis by working with Compliancy Group to address federal HIPAA security standards. Completing a security risk analysis is required to become HIPAA-compliant.
Our ongoing support and web-based compliance app, The Guard™, gives health care organizations the tools to address HIPAA Security Rule standards so they can get back to confidently running their business.
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