I opened the doors of Taino Consultants a couple of decades ago with the intention of becoming a trusted source for healthcare professionals. While I have been involved in nearly every facet of the healthcare business, today I want to emphasize the importance of the Security Risk Analysis (SRA). Ensuring that you prioritize this process and the documentation included in these SRAs is crucial for your organization’s compliance and security.
SRA Basics
The challenge with SRAs is that, while the execution and retention are well-defined, many healthcare professionals struggle with the variables and specific requirements. For instance, the regulation doesn’t mandate an annual SRA, yet other guidelines do. Additionally, while the regulation does not require a third party to complete the SRA, many experts recommend it. Another key detail often missed is the requirement to keep copies of your HIPAA policies, including SRAs, for at least six years.
SRA Importance
SRAs are critical documents that attest to your organization’s compliance with regulations and help identify vulnerabilities. Venture capitalists often require previous SRAs for due diligence, and government organizations may demand them during routine audits or breach investigations. Those affected by MACRA should remember they likely need to attest to completing an SRA, making it essential to keep a copy for MIPS audits. The format and content of your SRAs can significantly influence the outcomes of these investigations and transactions.
Market Misrepresentation
One of the biggest issues is the misuse of the SRA term by some IT companies. They may claim to provide an SRA by checking for malware, potential unauthorized access, and ensuring IT infrastructure updates. However, while these actions are part of the HIPAA SRA, they only cover a portion of the required activities. Relying on these incomplete assessments can increase your liability and expose you to higher fines.
SRA Elements to Remember
While I won’t cover all the elements that should be included in an SRA, here are a few key aspects:
Equipment Inventory
HIPAA requires healthcare organizations to maintain an accurate inventory of equipment that receives, maintains, or transmits ePHI. This includes computers, laptops, smartphones, tablets, servers, and any other devices handling sensitive patient data.
Business Associates
Identifying and maintaining valid Business Associate Agreements (BAAs) is crucial. Business associates handle ePHI on behalf of covered entities, such as third-party vendors, consultants, or contractors.
Training and Security Reminders (164.308(a)(5))
HIPAA mandates regular training for the workforce on safeguarding patient information. Periodic security reminders should also be sent to reinforce best practices and raise awareness of potential risks.
Security Management Plan
A comprehensive Security Management Plan outlines an organization’s approach to safeguarding ePHI. It includes policies and procedures, risk assessment, risk management, and ongoing monitoring and evaluation. The SRA is vital for developing and implementing this plan by identifying potential risks and vulnerabilities.
Conclusion
The importance of the SRA cannot be overstated. This document serves multiple purposes and can determine your future. Consider your SRA as important as your malpractice insurance and keep the following advice in mind:
- Don’t wait until the end of the year to complete your SRA.
- Keep copies of SRAs for at least six years.
- Ensure your SRA includes a copy of your equipment inventory that handles ePHI.
- Address your Business Associates in your SRA.
- Develop a Security Management Plan based on your SRA findings.
For comprehensive SRA completion, consider the expertise of Taino Consultants Inc. Our decades of experience ensure that your SRA is thorough, compliant, and beneficial for your organization’s long-term success.