Preventing Healthcare Data Breaches with the HITRUST CSF®

How to Prevent Data Breaches in Healthcare?

To prevent data breaches in healthcare, organizations should implement a combination of technical, administrative, and physical safeguards. 

Here are some of the safeguards you can implement to prevent data breaches:

1. Become HIPAA Compliant

HIPAA (Health Insurance Portability and Accountability Act) sets rules to protect patient health information. These guidelines help healthcare organizations keep health records secure and private.

Following HIPAA is important not just for protecting patient data but also for avoiding penalties for poor healthcare data security practices. HIPAA applies to any organization that handles sensitive patient information, such as:

• Healthcare providers
• Healthcare clearinghouses
• Business associates (like third-party vendors who access patient data)

You also need to follow the HIPAA rules like:

• Privacy Rule. Sets standards for protecting patient PHI and grants patients the right to access, correct, and control their health information.
• Security Rule. Establishes safeguards for managing and protecting electronic PHI (ePHI) through administrative, technical, and physical measures.
• Transactions Rule. Regulates the use of standardized codes in HIPAA-related transactions to ensure accuracy and security.
• Unique Identifiers Rule. Defines three unique identifiers for healthcare entities—NPI, NHI, and Standard Unique Employer Identifier for HIPAA transactions.
• Enforcement Rule. Outlines penalties for HIPAA violations and establishes compliance requirements for security breach reporting and contracts involving PHI.

IS Partners’ expert shares a common mistake that healthcare organizations often commit that almost always leads to non-compliance or inefficiency,

2. Strengthen User Authentication

To enhance security, you need to control who has access to your systems and sensitive documents. Hence, implementing strong user authentication measures can help ensure that only authorized individuals can access specific features and information. Here’s how to do it:

• Set up user authentication for printers. Require users to log in with a password or ID card before accessing the systems or printing documents.
• Implement the Principle of Least Privilege (PoLP). Grant users only the minimum access necessary to perform their job functions. This limits the potential damage from a compromised account, as the user won’t have access to sensitive data or systems beyond their immediate needs.
• Limit feature access: Restrict certain system functions to specific users or roles within your organization.
• Secure document storage: Ensure that scanned documents are automatically stored in encrypted locations and accessible only to authorized users.
• Strengthen password policies: Implement complex password requirements and enforce regular password changes to enhance security.
• Use multi-factor authentication (MFA): Add an extra layer of security by requiring users to verify their identity using a second factor (e.g., mobile phone or biometric scan).

3. Conduct Security Risk Assessments

Healthcare organizations need to perform an annual HIPAA security risk analysis to ensure their data protection measures are effective. 

The good news? HIPAA actually requires periodic risk assessments, so this is a win-win—it helps you stay compliant while also keeping your data safe from breaches. Here’s how to make it happen:

• Set a reminder for the annual assessment. Put it on the calendar. Make sure to schedule your risk analysis at least once a year, ideally at a time that works with your fiscal planning.
• Spot any weakness. Take a close look at your systems, are there any vulnerabilities? This might include outdated software, weak passwords, or gaps in access control. 
• Check your security measures. Review your encryption, firewalls, and other security tools to make sure they’re still up to par. 
• Update policies as needed. After identifying risks, revise your procedures and policies. Maybe it’s time to implement new training, or upgrade your security tools, whatever you find, act on it.
• Get the right people involved. Bring in your IT, legal, and healthcare compliance teams to get a full picture of where things stand.

4. Conduct Cyber Security Training and Awareness 

One of the main reasons healthcare data breaches happen is because employees aren’t aware of the cyber risks or how to spot potential threats. 

To avoid this, every healthcare organization, whether it’s a small clinic or a large hospital, needs to make sure its staff is properly trained in cybersecurity. Here’s how you can implement it if you are still wondering about how to prevent healthcare data breaches – 

• Offer regular training. Provide onboarding and annual refresher courses.
• Use real examples. Focus on common threats like phishing and malware.
• Tailor to roles. Customize employee training based on staff responsibilities.
• Test knowledge. Run phishing tests and quizzes.
• Promote security culture. Encourage staff to report suspicious activity.

5. Encrypt Your Data

Encrypting patient data means converting it into a secure, coded format that only authorized users with the decryption key can access. 

With the healthcare industry generating about 30% of the world’s data, protecting patient information through encryption is much needed to maintain privacy and meet legal requirements like HIPAA and GDPR.

Here’s how to implement strong data encryption:

• Encrypt sensitive data. Ensure all patient data, both in transit and at rest, is encrypted using strong encryption methods (e.g., AES-256).
• Set up unique user IDs. Assign unique identifiers to all users accessing sensitive data, ensuring traceability and accountability.
• Create an emergency access procedure. Have a secure process in place for emergency access to encrypted data without compromising security.
• Ensure proper decryption controls. Only authorized personnel should have access to decryption keys.

What is the Probability of a Data Breach for a Healthcare Organization?

Data breaches are common in the healthcare sector because of the nature of the data involved. In the last decade, there have been 2,100 single healthcare data breaches in the United States. 

“In 2023, the healthcare sector saw significant cybersecurity challenges, with 725 data breaches reported to the Office for Civil Rights (OCR). These breaches led to the exposure or improper disclosure of over 133 million records,” according to HIPAA Journal.

This means that the probability of a malicious attack being attempted is high for any organization. Yet, the probability that an attack will be successful depends on the security policies and procedures that an organization has in place. 

In fact, we don’t know how many attempted attacks there are in healthcare over a given period of time; we only have statistics about actual breaches reported.

The good news is that, with the help of risk management programs, businesses are getting better and better at detecting hacking attempts, preventing breaches, and minimizing damages.

What Are the Repercussions of Data Breaches in Healthcare?

The HHS Office of Civil Rights (OCR) is responsible for enforcing HIPAA Privacy and HIPAA Security Rules for most covered entities. The OCR enforcement process includes investigating complaints about potential HIPAA violations and carrying out regulatory compliance reviews for covered healthcare entities.

Penalties for HIPAA non-compliance are expensive. They vary from $100 to $50,000 per violation – or per record breached – with a maximum fee of $1.5 million per year for identical violations. 

Fines increase depending on the number of patients affected and the degree of neglect which led to the breach. Penalties for HIPAA violations can also include jail time.

However fines imposed by the OCR are not the only repercussions for data breaches in the medical field. The average data breach costs healthcare entities $6.5 million, which is higher than any other industry. And these costs are on the rise, with the negative impact lasting for several years following the incident. 

To date, the largest data breach in this industry – affecting Anthem, Inc. in 2015 – cost the insurance giant $16 million in fines imposed by the OCR. But it also cost the company $115 million in a class action settlement for the cybersecurity compliance failure that exposed the personal information of 79 million patients. 

Plus, it agreed to pay out $39 million settlement to a group of State Attorney Generals involved in investigating the hack. These are just some of the average costs that can add up quickly.

“Cybercrime represents big money for cybercriminals, and unfortunately, that equates to significant losses for businesses,” Wendi Whitmore, Global Lead for IBM X-Force Incident Response and Intelligence Services.

Why Choose the HITRUST CSF Framework for Cybersecurity Risk Management?

The HITRUST CSF is a revolutionary security and privacy framework for protecting vital electronic healthcare information. Healthcare, health information technology, and information security leaders worked together with HITRUST to build the HITRUST CSF framework. 

It was developed to address the many security, privacy and regulatory challenges that face healthcare organizations and organizations in other industries that handle sensitive healthcare data.

IS Partners’ Director of Healthcare Compliance, Philip LaRocca, adds,

Full Coverage

HITRUST takes a proactive approach to security by bringing together key controls from industry standards like HIPAA, ISO, NIST, and PCI. This integration provides a complete picture of your security risks, so you can tackle compliance with several regulations at once.

Instead of worrying about keeping track of multiple different standards, you get a single framework that covers them all, making your job a lot easier.

Flexibility

One of the best things about HITRUST is that it’s flexible. It lets organizations customize their security controls depending on their specific risks and industry needs. Whether you’re in healthcare, finance, or another sector, you can adjust the framework to fit your particular situation. 

This means you can implement the best security practices for your business without being locked into a one-size-fits-all solution.

Regular Updates

Cyber threats and regulations are constantly changing, and HITRUST keeps up with those changes. The framework is regularly updated to reflect the latest trends in cybersecurity risks and emerging regulations. 

Moreover, some of the basic security risks that the HITRUST CSF helps organizations to combat include the following:

• Security control redundancies and inconsistencies at all levels.
• Misinterpretation of cybersecurity standards and regulations.
• A lack of communication within the IT department and with third-party service providers about shared responsibilities.
• Confusion regarding acceptable minimal controls and application of those controls.
• Potential and future risks, as well as evolving cyber threats.
• Get more information on the HITRUST Certification Process and refer to our Dictionary of HITRUST CSF Terminology.

Dive Deeper

Understand the HITRUST Certification process as our experts simplify it for you.

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Prevent Compromised Healthcare Data with HITRUST Assurance

Healthcare organizations face a growing threat of data breaches, putting sensitive patient information and operational data at risk. Without a robust framework for risk management and compliance, organizations may struggle to keep up with evolving security challenges and regulatory requirements.

IS Partners specializes in guiding organizations through the HITRUST certification process. Whether you’re assessing your current security posture, conducting a HITRUST CSF Assessment, or working toward certification, we simplify the process and help you secure your data while ensuring compliance with industry benchmarks.

Here’s what you can do next:

Not sure where to start? Let’s have a conversation. We can help you save time, avoid unnecessary risk, and ensure that your data is secure. Reach out today to see how we can make the process easier for you.

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About The Author

Robert Godard

Robert is a Principal with IS Partners, LLC’s Business Process/Advisory Services practice in Horsham, PA. Robert has conducted a variety of Financial Statement Audits for a range of industries such as banking, healthcare, payroll, employee benefit plans (Pension, Health and Welfare), Unions and Construction.

Robert’s specialty is in audits of IT Controls and Infrastructure, Financial Statements, SOC 1 and SOC 2 audits, HITRUST CSF Assessments, Model Audit Rule (MAR), including evaluating business process as well as IT General Controls surrounding the reporting of financial information. He also has experience with analyzing Health Insurance information from AmeriHealth, Blue Cross Blue Shield, Express Scripts and Delta Dental. Additionally, Robert has performed audits for Construction and Special Tax related credits (Historical Tax Credits). He has prior work experience using ISSI, Great Plains and Peach Tree.

Prior to joining IS Partners, LLC, Robert was employed with Novak Francella in the Financial Statement Audit division, where he worked as an associate on external audit engagements in accordance with GAAP and DOL requirements.

Robert has a Bachelor of Science degree in Finance and Accounting from LaSalle University, Philadelphia, PA.