Performing daily business transactions and communications through electronic technologies is accepted, reliable, and necessary across the nation’s healthcare providers, payers and suppliers. As a result, email has become a standard in the healthcare industry as a way to conduct business activities that commonly include:
- Interacting with patients
- Real time authorizations for medical services
- Transcribing, accessing and storing health records
- Appointment scheduling
- Referring patients
- Explanation of benefits
- Marketing offers
- Submitting claims to health plan payers for payment of the services provided
Collaborative efforts amongst healthcare providers have improved the delivery of quality care to patients in addition to the recognized increase in administrative efficiency through effective use of email and other types of digital communication. Patients are becoming more and more comfortable with emailing their physician’s office to schedule an appointment, discuss laboratory results, or request refills on medication. Medicare and some other insurance payers also recognize and pay for virtual care where the health provider and patient interact over video (telemedicine).
Using digital communications, undoubtedly, poses concerns about the privacy and security of an individual’s information. In healthcare, the confidentiality of a patient’s information has been sacred since the days of the Hippocratic Oath (Hippocrates – the Father of Medicine, 400 B.C.). Today, merely taking an oath to respect one’s privacy has been overshadowed by regulations that govern how certain healthcare establishments must handle an individual’s health information. So, if a healthcare organization employs email as a means of communicating medical and/or mental health data to appropriate parties, including patients and customers, they must also ensure that information is well safeguarded.
This article addresses the specific issues that healthcare provider, payers and suppliers must address in order to be in compliance with HIPAA and HITECH certified. It will also lay out how LuxSci enables healthcare organizations to meet these requirements though HIPAA compliant email outsourcing.
Overview of HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) implemented new rules for the healthcare world. Mandating compliance with its Privacy and Security Rules, the federal government is committed to enforcing patients’ rights. Industry professionals – financial, administrative and clinical – are no strangers to the regulatory compliance culture. HIPAA laws apply to a covered entity; i.e. healthcare providers, suppliers, clearinghouses and health plan payers that meet certain conditions. In essence, most providers are covered entities if they employ digital communications, meaning they function by storing and exchanging data via computers through intranets, Internet, dial up modems, DSL lines, T-1, etc. Additionally, HITECH extends the requirements of HIPAA to any business associate of a covered entity and to all business associates of business associates (all the way down the line) who may come into contact with Protected Health Information originating from a covered entity.
HIPAA email security applies specifically to protected health information, not just personal information. Protected Health Information (PHI), as defined in HIPAA language, is health information of an identifiable individual that is transmitted by electronic media; maintained in any electronic medium; or transmitted or maintained in any other form or medium. For example, all administrative, financial, and clinical information on a patient is considered PHI and must abide by the following standards:
- Privacy Standards: The HIPAA Privacy Rule sets standards for protecting the rights of individuals (patients). Covered entities must follow the laws that grant every individual the right to the privacy and confidentiality of their health information. Protected Health Information is subject to an individual’s rights on how such information is used or disclosed.
Privacy Standard Key Point: Controlling the use and disclosure of oral, written and electronic protected health information (any form).
- Security Standards: Taking the Privacy Rule a step further, HIPAA implemented the Security Rule to cover electronic PHI (ePHI). To this end, more secure and reliable information systems help protect health data from being “lost” or accessed by unauthorized users.
Security Standard Key Point: Controlling the access to electronic forms of protected health information (not specific to oral or written).
The Privacy and Security Rules focus on information safeguards and require covered entities and their business associates to implement the necessary and appropriate means to secure and protect health data. Specifically, the regulations call for organizational and administrative requirements along with technical and physical safeguards.
Starting on February, 2010, the HIPAA rules were enhanced by the American Recovery and Reinvestment Act. The HITECH section of this act implements significant penalties for breaches of HIPAA and requires that the business partners of organizations covered by HIPAA must themselves obey the HIPAA Privacy and Security Rules, and face liability if there are any unauthorized disclosures. For more information on what HITECH has done to HIPAA, see: HIPAA 2010: HITECH Impact on Email and Web Outsourcing. Starting in September 2013, the Omnibus rule goes into effect, further expanding the scope of coverage and drastically strengthening the penalties and enforcement of HIPAA. For more information on Omnibus, see: How the HIPAA Omnibus Rule Affects Email, Web, FAX, and Skype.
Provisions of the HIPAA Email Security Rule
The HIPAA language uses the terms required and addressable. Required means that complying with the given standard is mandatory and, therefore, must be complied with. Addressable means that the given standards must be implemented by the organization unless assessments and in depth risk analysis conclude that implementation is not reasonable and appropriate specific to a given business setting. Important Note: Addressable does not mean optional.
With regard to addressable, an organization should read and decipher each Security standard separately and deal with each piece independently in order to determine an approach that meets the needs of the organization.
The General Rules of the Security Standards reflect a “technology-neutral” approach. This means that there are no specific technological systems that must be employed and no specific recommendations, just so long as the requirements for protecting the data are met.
Organizational requirements refer to specific functions a covered entity must perform, including the use of business associate contracts and the development, documentation and implementation of policies and procedures.
Administrative requirements guide personnel training and staff management in regard to PHI and require the organization to reasonably safeguard (administrative, technical and physical) information and electronic systems.
Physical safeguards are implemented to protect computer servers, systems and connections, including the individual workstations. This section covers security concerns related to physical access to buildings, access to workstations, data back up, storage and obsolete data destruction.
Technical safeguards affect PHI that is maintained or transmitted by any electronic media. This section addresses issues involving authentication of users, audit logs, checking data integrity, and ensuring data transmission security.
Risk Analysis
Risks are inherent to any business and, therefore, with regard to HIPAA, each organization must take into consideration the potential for violating an individual’s right to privacy of their health information. HIPAA allows for scalability and flexibility so that decisions can be made according to the organization’s approach in protecting data. Covered entities and their Business Associates must adopt certain measures to safeguard PHI from any “reasonably anticipated” hazards or threats. After a thorough yearly risk analysis, a yearly assessment of the organization’s current security measures should be performed. Additionally, a cost analysis will add another important component to the entire compliance picture. A plan to implement secure electronic communications starts with reviewing the Security Rule and relating its requirements to the available solution and your business needs.
HIPAA Administrative and Physical Safeguards
Below are the administrative and physical safeguards as outlined in the Federal Register. These requirements are items that must generally be addressed internally, even if you are outsourcing your email or other services. We will discuss these safeguards in more detail below.
| Standard: ADMINISTRATIVE SAFEGUARDS |
Sections |
Implementation Specification |
Required or Addressable |
| Security Management Process |
164.308(a)(1) |
Risk Analysis |
R |
|
|
Risk Management |
R |
|
|
Sanction Policy |
R |
|
|
Information System Activity Review |
R |
| Assigned Security Responsibility |
164.308(a)(2) |
|
R |
| Workforce Security |
164.308(a)(3) |
Authorization and/or Supervision |
A |
|
|
Workforce Clearance Procedures |
R |
|
|
Termination Procedures |
A |
| Information Access Management |
164.308(a)(4) |
Isolating Health Care Clearinghouse Function |
R |
|
|
Access Authorization |
A |
|
|
Access Establishment and Modification |
A |
| Security Awareness and Training |
164.310(a)(5) |
Security Reminders |
A |
|
|
Protection from Malicious Software |
A |
|
|
Log-in Monitoring |
A |
|
|
Password Management |
A |
| Security Incident Procedures |
164.308(a)(6) |
Response and Reporting |
R |
| Contingency Plan |
164.308(a)(7) |
Data Backup Plan |
R |
|
|
Disaster Recovery Plan |
R |
|
|
Emergency Mode Operation Plan |
R |
|
|
Testing and Revision Procedure |
A |
|
|
Applications and Data Criticality Analysis |
A |
| Evaluation |
164.308(a)(8) |
|
R |
| Business Associates Contracts and Other Arrangement. |
164.308(b)(1) |
Written Contract or Other Arrangement |
R |
| Standard: PHYSICAL SAFEGUARDS |
Sections |
Implementation Specification |
Required or Addressable |
| Facility Access Controls |
164.310(a)(1) |
Contingency Operations |
A |
|
|
Facility Security Plan |
A |
|
|
Access Control and Validation Procedures |
A |
|
|
Maintenance Records |
A |
| Audit Controls |
164.312(b) |
|
R |
| Integrity |
164.312(c)(1) |
Mechanism to Authenticate EPHI |
A |
| Workstation Use |
164.310(b) |
|
R |
| Workstation Security |
164.310(c) |
|
R |
| Device and Media Controls |
164.310(d) |
Disposal |
R |
|
|
Media Re-use |
R |
|
|
Accountability |
A |
|
|
Data Backup and Storage |
A |
Importance of Encryption for Email Communication
The security risks for email commonly include unauthorized interception of messages en route to recipient, messages being delivered to unauthorized recipients, and messages being accessed inappropriately when in storage. These risks in using the Internet are addressed in the Security Rule’s technical safeguards section, particularly:
- Person or Entity Authentication – required procedures must be implemented for identification verification of every person or system requesting access to PHI. This means the identity of the person seeking information must be confirmed within the information system being utilized. It also means that shared logins are not permitted.
- Transmission Security – addressable data integrity controls and encryption reasonable and appropriate safeguards.
- Business Associates – if you outsource your email services to another company and your email may contain ePHI in any form, then that company must be HIPAA compliant, sign a Business Associate Agreement with you, and actively safeguard your ePHI. The restrictions on Business Associates are quite strict and have changed as of Feb, 2010 and again, becoming even more strict as of September, 2013.
Each healthcare organization using email services must determine, based on technologies used for electronic transmission of protected health information, how the Security standards are met.
Addressable specifications include automatic log off, encryption, and decryption. Covered entities must also assess organizational risks to determine if the implementation of transmission security which includes integrity controls to ensure electronically-transmitted PHI is not improperly modified without detection is applicable. E.g. it is applicable for any ePHI going over the public Internet; it may not be necessary for information flowing between servers in your own isolated office infrastructure. Encryption of ePHI at rest (as it is stored on disk) is also addressable and not a requirement under HIPAA regulations; however, a heightened emphasis has been placed on encryption due to the risks and vulnerabilities of the Internet.
Ultimately, according to the Department of Health and Human Services, covered entities and their business associates can exercise one of the following options in regard to addressable specifications:
- Implement the specified standard;
- Develop and implement an effective security measure to accomplish the purpose of the stated standard; or
- If the specification is deemed not reasonable and appropriate for the organization but the standard can still be met, then do not implement anything.
Reasonable and appropriate relate to each organization’s technical environment and the security measures already in place.
Questions to Consider When Choosing an Email Service Provider
When your organization is responsible for critical data such as protected health information, choosing an email provider is more than a matter of trust. Does the email service provider build on the administrative, physical and technical safeguards while delivering to its customers:
- Signed Business Associate Agreement
- Awareness of their responsibilities under HITECH and Omnibus
- Solutions that meet or exceed HIPAA’s Security Standards
- Willingness to work with you and advise you on your security and privacy choices
- Protect data integrity
- Flexible, scalable services – no account is too small
- Administrative access to assign or change a user’s password
- Controls to validate a user’s access
- Audit controls to track user access and file access
- Allow access to users based on role or function
- Automatic log off after specified time of inactivity
- Data transmission security
- Unlimited document or email transfer
- Ability for encryption
- Emergency access for data recovery
- Minimal server downtime
- Secure data back up and storage
- Secure data disposal
- User friendly, web-based access without the necessity of third party software
- Privacy in not selling or sharing its client contact information
A Scalable, Flexible and HIPAA-Compliant Solution in Electronic Communications
Lux Scientiae (LuxSci for short) offers secure, premium email services including extensive security features, Spam and virus filtering, robustness, and superior customer service. The offerings are scalable to any size healthcare organization.
In addition to LuxSci itself protecting your ePHI by following the HIPAA Security and Privacy Rules as required by the HITECH amendment to HIPAA, LuxSci also provides a clean set of guidelines for using its services that enable your ePHI to be safeguarded; these guidelines are automatically enforced by the use of any “HIPAA Compliant” account. If you follow these guidelines and sign LuxSci’s Business Associate Agreements, LuxSci will certify your account as HIPAA compliant and give you a HIPAA Compliance Seal.
Take a look at the table below to see examples of how LuxSci enables you to meet HIPAA’s requirements for protecting electronic communications in your organization.
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
| Access Control |
164.312(a)(1) |
Unique User Identification |
R |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Assign a unique name and/or number for identifying and tracking user identity.”
Solution: Use of unique usernames and passwords for all distinct user accounts. No shared logins; but sharing of things like email folders between users is permitted. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
|
|
Emergency Access Procedure |
R |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Establish (and implement as needed) procedures for obtaining necessary electronic protected health information during an emergency”
Solution: PHI in email communications can be accessed from any location via the Internet. There are also mechanisms for authorized administrative access to account data. Optional Email Archival and Disaster Recovery services provide enhanced access to email in case of emergency. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
|
|
Automatic Logoff |
A |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Implement electronic procedures that terminate an electronic session after a predetermined time of inactivity.”
Solution: An organization can set screen savers on their desktops to log users out. Additionally, WebMail and other email access services (e.g. POP, IMAP, and Mobile) automatically log off all users after a predetermined amount of time; the WebMail session time is user- and account-configurable. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
|
|
Encryption and Decryption |
A |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: Implement a mechanism to encrypt and decrypt electronic protected health information.
Solution: All usernames, passwords, and all other authentication data are be encrypted during transmission to and from LuxSci’s servers and our clients using SSL/TLS. Additionally, SecureLine permits end-to-end encrypted email communications with anyone on the Internet, SecureForm enables end-to-end encryption of submitted web site form data, and WebAides permit encryption of sensitive documents, passwords databases, and internal blogs. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
| Audit Controls |
164.312(b) |
|
R |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.”
Solution: Detailed audit trails of logins to all POP, IMAP, SMTP, LDAP, SecureLine,and WebMail services are available to users and administrators. These include the dates, times, and the IP addresses from which the logins were made. Auditing of all sent and received email messages is also available. SecureLine also permits auditing of when messages have been read. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
| Integrity |
164.312(c)(1) |
Mechanism to Authenticate ePHI |
A |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Implement policies and procedures to protect electronic protected health information from improper alteration or destruction.”
“Implement electronic mechanisms to corroborate that electronic protected health information has not been altered or destroyed in an unauthorized manner.”
Solution: To prevent unauthorized alteration or destruction of PHI, the use of SSL, TLS, PGP, and SecureLine will verify message and data integrity. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
| Person or Entity Authentication |
164.312(d) |
|
R |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Implement procedures to verify that a person or entity seeking access to electronic protected health information is the one claimed.”
Solution: Username and Password are used for access control (Two-factor verification is also available); strict control is given over who can access user’s accounts. LuxSci’s privacy policy strictly forbids any access of email data without explicit permission of the user (unless there are extenuating circumstances). Also, use of SecureLine end-to-end encryption in email and document storage ensures that only the intended recipient(s) of messages or stored documents can ever access them. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
| Transmission Security |
164.312(e)(1) |
Integrity Controls |
A |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network.”
“Implement security measures to ensure that electronically transmitted electronic protected health information is not improperly modified without detection until disposed of.”
Solution: SSL-based encryption during the transmission of data to/from our clients for WebMail, POP, IMAP, SMTP, and document storage services is provided. SMTP TLS-based encryption of inbound email at LuxSci ensures that all email sent internally at LuxSci meets “Transmission Security” guidelines and allows you to securely receive email from other companies whose servers also support TLS. LuxSci also provides SecureLine for true end-to-end encryption of messages to/from non-clients. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
|
|
Encryption |
A |
| HIPAA COMPLIANT SOLUTION from LuxSci |
The Rule States: “Implement a mechanism to encrypt electronic protected health information whenever deemed appropriate.”
Solution: SSL encryption for WebMail, POP, IMAP and SMTP services is provided. Additionally, encrypted document and data storage is available and use of SecureLine for end-to-end security is enforced. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
| Device and Media Controls |
164.310(d) |
Data Backup and Storage |
R |
| HIPAA COMPLIANT SOLUTION from LuxSci |
| The Rule States: “Create a retrievable, exact copy of electronic protected health information, when needed, before movement of equipment.”Solution: Daily on-site and weekly off-site backups ensure exact copies of all ePHI are included. Live data is stored on redundant RAID disk arrays for added protection. Furthermore, Premium Email Archival provides permanent, immutable storage on servers in multiple geographic locations. |
| Standard: TECHNICAL SAFEGUARDS |
Sections |
Implementation Specification |
R/A? |
|
|
Data Disposal |
R |
| HIPAA COMPLIANT SOLUTION from LuxSci |
| The Rule States: “Implement policies and procedures to address the final disposition of electronic protected health information, and/or the hardware or electronic media on which it is stored.”Solution: Clients can delete their data whenever desired. Additional security comes in automatic expiration of data backups (cease to exist after 1 month). Alternate expiration plans are available for large clients. |
Healthcare staff using LuxSci can send and receive email from anywhere in the world using existing or new email clients or web browsers. A comprehensive solution for a complex law – managed by your account administrators in-house or remotely by our company. Risk assessments for potential HIPAA violations can be performed by administrators through the use of audit trails. Reliability and cost effective solutions are the backbone of LuxSci – even for extremely large client organizations. And, count on the physical security of our servers.
Chart of LuxSci Services and the HIPAA Rules they Satisfy
If you are interested in specific services at LuxSci and would like to know exactly which of the HIPAA rules each service meets, the following charts will assist you. Please contact LuxSci for more information.
| HIPAA Rule |
1. View Email: Secure WebMail, POP, IMAP, or Mobile Sync |
2. Send Email: Secure WebMail, SMTP, or Mobile Sync |
3. Encryption with SecureLine combined with 1 and 2 |
4. Secure Collaboration (WebAides) |
| Access Control – Unique User Identification |
 |
|
|
|
| Access Control – Emergency Access |
|
|
(a) |
(a) |
| Access Control – Automatic Logoff |
|
|
|
|
| Audit Controls |
|
|
|
|
| Integrity |
|
|
(b) |
(b) |
| Person or Entity Authentication |
|
|
(b) |
(b) |
| Transmission Security > Integrity Controls |
(c) |
(c) |
|
|
| Transmission Security > Encryption |
(c) |
(c) |
|
|
| Device and Media Controls > Data Backups |
|
|
|
|
| Device and Media Controls > Data Disposal |
|
|
|
|
(a) Our secure document storage service and use of SecureLine for communications may assume that the recipients have special passwords for their “Secure data access certificates” (PGP or S/MIME). These passwords are may be stored in a “Password Escrow” (a special secure password database) if the users so choose. In these cases, passwords to security keys can be retrieved in case of emergency or in case of loss.
(b) Our secure document storage service and use of SecureLine for communications encrypts data so that only the intended recipient(s) can ever view the data. The encryption process also allows the recipient(s) to verify that the data was not altered since it was sent or stored using digital signatures.
(c) SSL/TLS solutions encrypt the message during transport to and from LuxSci’s servers and your personal computer. Email sent from LuxSci to external addresses is secured with the use of SecureLine (Solution #3).
Solutions #3 provides complete transport layer and end-to-end email security compatible with any email user anywhere, no matter what software s/he may have.
References
Health Insurance Reform: Security Standards – Federal Register, Vol. 68, No. 34, 45 CFR Parts 160, 162, 164.
Centers for Medicare and Medicaid HIPAA Security Series
