A HIPAA Gap Analysis may not be a mandatory requirement of the HIPAA Security Rule, but performing one will make HIPAA compliance much easier to achieve.
First, it’s important to establish what a HIPAA Gap Analysis is, and how it differs from a Risk Analysis.
A HIPAA Gap Analysis is an optional evaluation that allows a covered entity to understand if and how it has implemented the necessary safeguards to satisfy compliance requirements. HIPAA Gap Analyses work by taking the requirements of the HIPAA Privacy and Security Rule and identifying the gaps between those requirements and the safeguards a covered entity, or its business associates, currently have in place.
This differs from a HIPAA Risk Analysis, which is designed to identify potential risks and the specific security measures that an organization must take to reduce those risks to a “reasonable and appropriate” level.
Unlike the Gap Analysis, the HIPAA rules require all covered entities to complete a risk analysis.
A Gap Analysis, in other words, looks at the big picture of compliance with the HIPAA security rule, while the Risk Analysis offers a more detailed look at your precise threats and vulnerabilities.
It’s for that reason that many healthcare organizations see the HIPAA Gap Analysis as an ideal first step in their pursuit of compliance.
How to Conduct a HIPAA Gap Analysis
1. Acquaint yourself with HIPAA Privacy and Security Rules
To conduct a HIPAA Gap Analysis, it’s necessary to understand the ins and outs of the Privacy and Security Rules. In short, the HIPAA privacy and security rule requires covered entities to use appropriate administrative, physical and technical safeguards to protect electronic patient health information (ePHI) and ensure that all ePHI that is created, received, maintained or transmitted is fully secure. A HIPAA Risk Analysis is a requirement of the Security Management Process, which is also the first standard of the Security Rule’s Administrative Safeguards.
In addition to a HIPAA Risk Analysis, the Security Management Process features three additional implementation specifications, including the risk management processes, the sanction policy and the information systems activity review.
Furthermore, the HIPAA Security Rule also requires healthcare providers to regularly review and update their processes in response to changes that could affect the protection of the ePHI they maintain or transmit.
2. Determine the Scope of Your Analysis and Get Your Team on Board
Will your Gap Analysis look at your entire institution or one department or team within it?
Once you’ve decided on the scope—the smaller the better if it’s your first Gap Analysis—you can determine who you’ll need to talk to and get the appropriate team members on board.
3. Create a Plan Using a HIPAA Gap Analysis Template
If you’re eager to get your own Gap Analysis underway but aren’t sure where to start, a HIPAA Gap Analysis template can be an invaluable tool to help you prepare your own analysis.Given that the HIPAA Security Rule does not specify the exact format that healthcare organizations might follow to conduct a gap analysis (or a risk analysis, for that matter), a HIPAA Gap Analysis template developed by our experts is the best way to determine whether you’re meeting all of the controls and safeguards required for storing and using ePHI.
4. Develop your HIPAA Gap Analysis plan
To follow through on your HIPAA Gap Analysis template, you’ll need to:
- Seek out and review the appropriate documentation
Upon familiarizing yourself with the HIPAA Privacy and Security Rules, you’ll need to develop a list of the necessary documentation for the various requirements. Make sure to take detailed notes, which can serve as the basis for your interviews
- Interview staff members
Specifically, those who can speak to the safeguards in place and who can confirm whether policies and procedures are being followed. Aim to interview team members in small groups and prepare by determining your questions ahead of time.
- Conduct assurance testing
For example, monitor staff following the compliance procedures, policies and observe their response to threats.
- Document your process
Preferably with enough detail and clarity that it can be re-used in the future
Getting the Right Experts for Your HIPAA Gap Analysis Template
Completing the gap analysis allows you to understand the threats and vulnerabilities you face and to determine which safeguards are missing, thus allowing you to develop an appropriate plan for closing those gaps.
It’s important to properly prepare for the next steps.
Let Techumen help you navigate the highly important (and highly complex) process of conducting a HIPAA Gap Analysis.