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    How to Create a HIPAA Disaster Recovery Plan

    Dr. Mary Williams, RN, DC

    About the author

    Dr. Mary Williams, RN, DC

    Dr. Mary Williams, R.N., D.C is a Doctor of Chiropractic with an extensive background as a Registered Nurse and experienced Core Instructor for the American Heart Association. She has over 30 years of hands-on medical and instructional experience.

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    The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was implemented to safeguard sensitive and private patient data, called protected health information (PHI). This requires every healthcare organization to be HIPAA compliant and implement safeguards to protect PHI and other sensitive data. 

    HIPAA also emphasizes the need for organizations to establish comprehensive disaster recovery plans to mitigate risks and ensure the availability, integrity, and confidentiality of patient data. Consequences of not having a plan can result in financial penalties, investigations by state agencies such as by the U.S. Department of Health and Human Services’ Office for Civil Rights, litigation from outside firms, and extensive measures to alert those people affected by the breaches.

    What is a HIPAA disaster recovery plan? 

    Disaster Recovery Planning (DRP) is outlined within the HIPAA Contingency Plan of the HIPAA Security Rule. This compulsory disaster recovery plan aims to create and carry out procedures to restore any healthcare data loss.

    A disaster can be defined as any event or circumstance that happens outside of your control. It has the potential to cause damage to your IT infrastructure, compromising PHI and other sensitive data. For healthcare organizations, a potential disaster could include but is not limited to the following:

    • System downtime that results in non-existent IT availability (data is not accessible when needed)
    • Cyberattacks such as ransomware that lock you out of your system or access and steal PHI
    • Extreme weather or natural disasters that result in flooding or extensive power outages

    A HIPAA disaster recovery plan describes an IT-focused strategy. It is designed to restore (recover) the operability of the system, computer facility, or application at a different site after an emergency. 

    Your disaster recovery plan will define the actions, resources, and data required to restore vital business processes that the disaster has damaged. Thus, an inventory of essential data and systems needs to be created. You will also need documentation of detailed procedures to restore your capabilities at the different sites. 

    Disaster recovery plans are essential for your business to maintain or obtain HIPAA compliance during unexpected events. Implementing effective measures is fundamental to streamlining administrative procedures while maintaining compliance. 

    HIPAA certification programs can ensure that your employees understand the primary HIPAA rules, how they apply to your healthcare organization, and the HIPAA disaster recovery requirements. 

    What should you consider when creating a HIPAA disaster recovery plan?

    There are four steps that you should consider when creating a HIPAA disaster recovery plan: 

    Step 1: Carry out a Business Impact Analysis (BIA)

    A BIA is a comprehensive evaluation and inventory of your healthcare organization’s virtual (cyber) status. 

    You need to consider the type and volume of data your business manages, where you store it, and how much time and resources you need to recover access to the different data types. You will also need to decide which data is the most important to your business operations. 

    Step 2: Perform a risk assessment

    A risk assessment involves running and evaluating hypothetical scenarios that can harm your business, such as: 

    • Cyberattacks such as ransomware
    • HIPAA violations from third party tracking pixels
    • Unauthorized employee access to PHI such as snooping
    • System failure or downtime
    • Extensive power failure
    • Natural disaster

    You should ensure that your scenarios are manufactured and consider the likelihood of these scenarios occurring. Records and sources of data that can be reviewed may include: 

    • Emergency service organization advice
    • Employee recollection of previous events and how they affected operations
    • Disaster recovery resource libraries from government agencies, like FEMA

    Step 3: Create a risk management strategy

    Once you identify the data processes and how the business will be impacted, you can develop a risk management strategy. Your strategy should consider disaster recovery and backup solutions for essential data. Factors to consider when creating your strategy include the following: 

    • Legal aspects, such as cloud computing and third party tracking.
    • Recovery point objectives 
    • Recovery time objectives 
    • Infrastructure after a disaster 

    Step 4: Configure and run testing exercises on your HIPAA disaster recovery plan

    Once you have established your risk management strategy, you must engage in testing and failover testing to ensure it is appropriately set up. Any testing exercises you run aim to ensure the data is backed up according to your recovery objectives.  

    Your plan is ready to use once you have verified that it is reliable. It is important to routinely test your design so you can refine and make changes if and when incidents occur. 

    Disaster recovery plans are required for compliance with the HIPAA Security Rule. Implementing disaster plans can ensure that your organization runs securely and efficiently. 

    Questions and answers about HIPAA disaster recovery plans

    The following answers common questions about HIPAA disaster recovery plans:

    When is my disaster recovery plan needed? 

    Your disaster recovery plan is typically needed when access to ePHI systems and data is interrupted. Under HIPAA requirements, the managed service provider must ensure that your healthcare organization can do the following: 

    • Failover your production services to a separate secondary location
    • Recover ePHI data before the disaster
    • Restore essential IT systems and services

    When do you need to declare a disaster? 

    Your healthcare organization will have a business agreement with your chosen IT service provider stipulating when a disaster is declared. In most healthcare organizations, declaring a disaster is a manual process that follows a rigorous authorization procedure. Check with your IT department on the steps you should take to do this. 

    Who do you contact during a HIPAA disaster? 

    Service providers that your organization has a business agreement with generally have automated monitoring systems that will automatically notify your disaster recovery team. 

    It is essential to make sure that the contact details of your disaster recovery team are published. Each disaster recovery personnel must know how communication flows and who they report to when the plan is implemented. 

    Why is a HIPAA disaster recovery plan essential?

    A HIPAA disaster recovery plan is a fundamental element of good business management. It allows healthcare organizations to act accordingly in the event of a disaster like a HIPAA violation. Due to the complicated nature of HIPAA rules, HIPAA violations can happen to any practice. 

    As email is one of the most widely used methods of communication (and common reasons for data breaches), healthcare organizations must ensure their email provider is secure and compliant. For example, confirming if Gmail is HIPAA compliant by utilizing Google Workspace and encryption methods.

    For healthcare organizations, one of the many requirements of HIPAA is to have administrative safeguards (a contingency plan) in place. This contingency plan comprises a data backup plan, testing and revision procedures, and an emergency mode operation plan.

    A HIPAA disaster recovery plan is not just a mere requirement; it is an essential tool that enables healthcare organizations to effectively respond to unforeseen events and maintain the security and integrity of PHI. 

    With effective planning, testing, and HIPAA compliance training in place, your healthcare organization can recover in the shortest time possible with minimal impact having occurred. You can ensure your practice is as secure as possible during an outage, natural disaster, or cyberattack.



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