KENTUCKY REGIONAL EXTENSION CENTER

A Security Risk Analysis is an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic patient health information (ePHI). The HIPAA Security Rule requires all covered entities to conduct a Security Risk Analysis and states the Risk Analysis should be an ongoing process. Once you have completed the Risk Analysis, you must take any additional “reasonable and appropriate” steps to reduce identified risks to reasonable and appropriate levels. (45 CFR 164.308(a)(1)(ii)).

HIPAA Security Rule

The HIPAA Security Rule establishes national standards to protect individuals’ health information that is created, received, used, or maintained in electronic form by a covered entity (also known as ePHI). The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.
The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164.

Contact the Kentucky REC today for more information on how we can help with your security risk analysis.

Covered Entity

A covered entity is one of the following:

A Health Care Provider	A Health Plan	A Health Care Clearinghouse
This includes providers such as: Doctors Clinics Psychologists Dentists Chiropractors Nursing Homes Pharmacies ...but only if they transmit any information in an electronic form in connection with a transaction for which HHS has adopted a standard.	This includes: Health insurance companies HMOs Company health plans Government programs that pay for health care, such as Medicare, Medicaid, and the military and veterans’ health care programs	This includes entities that process nonstandard health information they receive from another entity into a standard (i.e., standard electronic format or data content), or vice versa.

The Administrative Safeguards provisions in the HIPAA Security Rule require covered entities to perform risk analysis as part of their security management processes. Specifically, the Security Rule states that covered entities are required to:

“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.” §164.308(a)(1)(ii)(A):

• A risk analysis process includes, but is not limited to, the following activities:

• Evaluate the likelihood and impact of potential risks to e-PHI

• Implement appropriate security measures to address the risks identified in the risk analysis

• Document the chosen security measures and, where required, the rationale for adopting those measures

• Maintain continuous, reasonable, and appropriate security protections

Risk analysis should be an ongoing process, in which a covered entity regularly reviews its records to track access to e-PHI and detect security incidents, periodically evaluates the effectiveness of security measures put in place, and regularly reevaluates potential risks to e-PHI.