HIPAA MFA

What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) is a piece of United States federal legislation that was introduced in 1996. It aims to set standards for the collection and transmission of protected health information (PHI) by health entities.

It also prohibits health entities from sharing information about patients without their consent. Amendments have been made to HIPAA over the years to keep up to date with challenges raised by electronic protected health information (ePHI).

What is the HIPAA Security Rule?

In 2003, the Security Rule was introduced as part of HIPAA in order to add protections for ePHI specifically. The HIPAA Security Rule mandates that the ePHI created, received, maintained, or transmitted by a regulated entity must be safeguarded against reasonably anticipated threats, hazards, and unauthorized uses or disclosures.

Some Security Rule guidelines are mandatory, and some are a framework for each organization to work from to create data privacy and cybersecurity policies that work for their unique situation.

Who does the security rule apply to?

It’s not just your family doctor that needs to comply with HIPAA. Many healthcare-related entities must also comply with the HIPAA Security Rule, including:

• Covered Healthcare Providers: Individuals or organizations that offer medical or health-related services or supplies and electronically transmit any health information related to transactions that follow standards set by the Department of Health and Human Services (HHS).
• Health Plans: Any individual or group insurance plan that offers or covers the cost of medical care.
  Healthcare Clearinghouses: Public or private organizations that process healthcare transactions, converting them between standard and non-standard formats for other entities.
• Business Associate: A person or organization that performs specific functions or activities involving the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. Business associates are responsible for complying with the HIPAA Security Rule and are accountable for their own violations.

What are the three sections of the HIPAA Security Rule?

There are three sections of the HIPAA Security Rule that must be considered when implementing a data privacy and cybersecurity strategy: Administrative Safeguards, Physical Safeguards, and Technical Safeguards.

HIPAA Administrative Safeguards

Administrative Safeguards involve actions that personnel at covered entities need to take in order to create a cyber secure environment. This includes things like:

• Risk Assessment: A covered entity must identify and assess potential risks to e-PHI and implement security measures that effectively reduce these risks and vulnerabilities to a reasonable and appropriate level. These risks and security measures must be regularly evaluated for new vulnerabilities or gaps.
• Information Access Management: Covered entities are required to develop role-based access procedures that allow access to ePHI on a “minimum necessary” cybersecurity level.
• Workforce Training and Security Personnel: A dedicated security personnel must develop and implement cybersecurity procedures. All members of the workforce that handle ePHI must be trained on the proper way to handle and transit data.

HIPAA Physical Safeguards

Physical Safeguards are elements that prevent the unauthorized release of ePHI through means of physical threat or compromise. These include:

• Facility Access Policies: Access to areas where ePHI is stored or can be accessed must be protected through physical access controls.
• Device Security: Access to workstations or devices where ePHI is stored must be physically protected.

HIPAA Technical Safeguards

Technical Safeguards are technologies or technical policies implemented to protect the access, storage, and transmission of ePHI. This includes:

• Access Controls: Access to ePHI must be properly authorized and authenticated using relevant tools and technologies.
• Audit Controls: Access logs must be recorded and examined in order to ensure only authorized access has taken place, and identity attempts to gain unauthorized access.
• Transmission and Integrity: Tools and technologies must be in place to ensure ePHI cannot be and hasn’t been tampered with or changed either in storage or transmission.

Is HIPAA MFA required?

As part of HIPAA Security Rule’s technical safeguards, access must be protected through secure authentication and authorization. Multi-factor Authentication (MFA), also known as ‘Two-factor Authentication (2FA)’, is the most common way that security personnel meet this requirement.

MFA utilizes two or more identity proofs (something you know, something you have, something you are) to secure logins. This is a simple and effective way to prevent account compromise and meet HIPAA requirements.

How to implement MFA for HIPAA

The HIPAA Security Rule was designed to be intentionally flexible to allow organizations to develop their own unique deployment of security guidelines. However, because of this flexibility, it can be hard to know how exactly to develop cybersecurity procedures without implementation specifications.

When it comes to something like MFA, which impacts the daily logins of every user, it’s important to get it right. A bad MFA deployment can negatively impact your bottom line, and your help desk resources.

By following these steps, you’ll be well on your way to a full, successful MFA deployment.

1. Risk Assessment: HIPAA and many other compliance standards recommend starting with a risk assessment matrix that will help you identify potential threats and categorize their severity. From this assessment, you’ll have a list of areas that most need protecting. For an MFA-specific assessment tool, we recommend trying the MFA Gap Calculator.
2. MFA Deployment: Once you’ve identified where MFA most needs to be implemented, find an MFA solution that works for your needs and price point. Ensure it’s implemented for every required user, and on every required application or service.
3. Test MFA Systems: Ensure you test your MFA implementation to ensure it functions correctly and efficiently. Finding an MFA solution that can do this automatically will help you in the long run.
4. Regularly Update and Review MFA Policies: Continuously review and update your MFA policies to adapt to emerging threats. Ensure that the MFA implementation aligns with the latest security standards and any new HIPAA guidelines.
5. Provide Comprehensive Training: Educate your workforce on the importance of MFA and train them on how to properly use it. Ensure that employees understand how MFA contributes to HIPAA compliance and data security.

Best practices for HIPAA MFA

In addition to the initial deployment, there are some MFA best practices to consider as you build out your MFA strategy. Here are some things to consider when implementing MFA for HIPAA compliance at your healthcare organization:

• Strong Authentication Methods: Select MFA factors that offer robust security, such as biometrics, phishing-resistant security keys, or hardware tokens, in addition to passwords.
• User-friendly MFA: Pick an MFA solution that won’t slow down your users, or cause unnecessary headaches for your help desk team. Users are less likely to attempt to bypass security controls that are easy for them to understand and use.
• MFA Everywhere: Go beyond the requirements. Implement MFA not just for remote access, but also for VPNs, email accounts, administrator or root accounts, and any other applications or systems that handle ePHI.
• Role-Based Access Controls: Pair MFA with role-based access controls to ensure that ePHI is only accessible to individuals whose roles specifically require it, further limiting the risk of unauthorized access.
• Audit MFA Activity: Choose an MFA solution that allows you to monitor and log all MFA activities to detect and respond to suspicious behavior. Conduct audits to ensure compliance with HIPAA’s Security Rule.

These best practices will help ensure that your MFA implementation meets HIPAA compliance and enhances security.

Get a free HIPAA MFA strategy session

Implementing Multi-factor Authentication (MFA) is a crucial step in securing electronic protected health information (e-PHI) and ensuring HIPAA compliance. By adopting robust MFA practices, healthcare organizations can significantly reduce the risk of unauthorized access and protect sensitive patient data. However, the process of selecting, deploying, and maintaining an effective MFA solution requires careful planning and expertise.

If you’re ready to strengthen your organization’s security and ensure compliance with HIPAA regulations, our team is here to help. Book a call with us today to discuss a tailored MFA strategy that meets your specific needs and safeguards your patient data.