NIST Publishes Final Cybersecurity Resource Guide on Implementing the HIPAA Security Rule Foley Lardner LLP JDSupra

pppIn an important development for HIPAAregulated entities looking for practical assistance in understanding implementing and enhancing compliance with the HIPAA Security Rule the National Institute of Standards and Technology NIST has finalized its comprehensive guidance Implementing the Health Insurance Portability and Accountability Act HIPAA Security Rule A Cybersecurity Resource Guide Resource Guide This release follows the initial draft that NIST published for public comment in July 2022 and builds on NISTs foundational 2008 publication The updated Resource Guide comes at the heels of the US Department of Health and Human Services HHS releasing voluntary performance goals to enhance cybersecurity across the health sector last month and a Departmentwide Cybersecurity strategy for the health care sector in December of 2023ppAs a technologyneutral framework the HIPAA Security Rule recognizes the diversity in the size complexity and capabilities of regulated entities offering a flexible and scalable approach to safeguarding electronic protected health information ePHI Acknowledging that no single compliance strategy fits all organizations the Resource Guide presents an extensive set of guidelines that entities may adapt in part or in full to strengthen their cybersecurity posture and achieve compliance with the HIPAA Security Rule Moreover the Resource Guide is structured to cater to various organizational needs and maturity levels in cybersecurity practices It emphasizes that risk assessment and risk management processes are crucial to a regulated entitys compliance with the HIPAA Security Rule and the protection of ePHIppBelow is an overview of the content covered by the Resource GuideppPerhaps most helpful is that NIST has broken each HIPAA Security Rule standard down by key activities that a regulated entity may wish to consider implementing adding a detailed description and providing sample questions to guide entities in their compliance efforts This detailed guidance for each HIPAA Security Rule standard will be helpful for regulated entities struggling to adopt it with only the language in the HIPAA Security Rule and HHS guidance on the sameppIn an accessible tabular format the Resource Guide outlines considerations for implementing the HIPAA Security Rule highlightingppAs an illustrative example consider the standard on Security Incident Procedures which mandates the implementation of policies and procedures to address security incidents A key activity highlighted is Developing and deploying an incident response team or other reasonable and appropriate response mechanism To assist entities in evaluating their readiness and implementation of this standard NIST provides sample questions such asppTo further aid organizations seeking to implement the HIPAA Security Rule NIST also updated its Cybersecurity and Privacy Reference Tool CPRT The CPRT displays HIPAA Security Rule regulations complemented with direct links to further NIST tools and resources for enhanced understanding and implementationppThe Risk Assessment Guidelines section of the Resource Guide provides a methodology for conducting a risk assessment The HIPAA Security Rule requires that all regulated entities conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality integrity and availability of electronic protected health information held by the covered entity or business associate and then implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level This is known as the security risk analysis and risk management plan respectively The results of the security risk analysis should enable regulated entities to identify appropriate security controls for reducing risk to ePHI NISTs guidance with respect to risk assessments is similar to previous HHS guidance provided at the Guidance on Risk Analysis and Security Risk Assessment ToolppSimilar to previous HHS guidance NIST reminds regulated entities that the risk assessment is an ongoing activity not a oneoff exercise The assessment must be updated on a periodic basis in order for risks to be properly identified documented and subsequently managed The cybersecurity landscape is everevolving with threats morphing and new vulnerabilities emerging even as existing ones are mitigated Additionally changes in an organizations operations such as the introduction of new policies or technologies can alter the likelihood and impact of potential threat events This dynamic context underscores the necessity for risk assessments to be periodically revisited and updated Such regular updates ensure that risks are accurately identified documented and managed in a timely and effective manner aligning with the organizations evolving risk profile and enhancing its cybersecurity postureppMoreover failure to have a thorough and uptodate risk assessment is one of the top failures documented by HHS in resolution agreements with regulated entities Therefore regulated entities should take this opportunity to determine when its last risk assessment was conducted ensure the risk assessment meets previous HHS guidance and consider the NIST guidance in this Resource Guide as wellppNIST states that the Risk Management Guidelines introduce a structured flexible extensible and repeatable process that regulated entities may utilize for managing identified risks and achieving riskbased protection of ePHI The regulated entity will need to determine what risk rating poses an unacceptable level of risk to ePHI given the regulated entitys risk tolerance and appetite Ultimately the regulated entitys risk assessment processes should inform its decisions regarding the implementation of security measures sufficient to reduce risks to ePHI to levels within organizational risk toleranceppTo illustrate consider a scenario where an organization identifies a high risk to ePHI from ransomware attacks characterized by both a high likelihood and a high impact Upon implementing critical security measuresnamely Response and Reporting Data Backup Plan and Disaster Recovery Planthe organization reassess and significantly lowers the risk level from High to Low Although the likelihood of such an attack remains high the impact is now considered low due to these proactive measures aligning the risk with the organizations risk toleranceppNISTs Resource Guide should serve as an essential resource for HIPAAregulated entities offering guidance on risk assessment management and compliance with the HIPAA Security Rule In leveraging the Resource Guide organizations can maintain robust protection for ePHI and adapt to changes in the cybersecurity landscape  ppIn addition to the Resource Guide itself NIST has also provided supplementary content on its website to further assist HIPAAcovered entities and business associates with strategies to improve their cybersecurity in specific areas including TelehealthTelemedicine Mobile Device Security Medical Device Security Cloud Services Incident HandlingResponse and othersppView sourceppDISCLAIMER Because of the generality of this update the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situationspp Foley Lardner LLP var today new Date var yyyy todaygetFullYeardocumentwriteyyyy Attorney AdvertisingppRefine your interests ppBack to TopppExplore 2024 Readers Choice AwardsppCopyright var today new Date var yyyy todaygetFullYeardocumentwriteyyyy JD Supra LLCp