Trustwave SpiderLabs Uncovers Ov3r_Stealer Malware Spread via Phishing and Facebook Advertising. Learn More

Trustwave SpiderLabs Uncovers Ov3r_Stealer Malware Spread via Phishing and Facebook Advertising. Learn More

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How to Prepare for the Incoming Wave of HIPAA Audits

I joined some colleagues from Trustwave last week in Orlando, Fla. for HIMSS14, one of the nation's premier health care IT conferences. And wouldn't you know it? Educational sessions that focused on privacy and security of electronic health records were very popular at the show.

Many interesting observations could be gleaned from the conference, but I'll share what I believe to be the biggest: The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) is ramping up its Health Insurance Portability and Accountability Act (HIPAA) audit program, and business associates will be included in the set of organizations to be audited, alongside covered entities.

Speaking at HIMSS14, Susan McAndrew, deputy director for health information privacy for the OCR, said her agency is speeding up its hiring of auditors, and the pilot phase of the audit program will now give way to the development of a new, more targeted audit protocol.

As stated previously, and reiterated again last week at HIMSS, the new audit program will not be conducted using the protocol from the HIPAA audit pilot program. Instead, the new program will utilize new criteria that will force the audits to take a more targeted approach, focusing on the critical findings and key focus areas identified during the pilot phase.

Specifically, there will be an increased focus on risk assessments. This focus is a direct result of an analysis of the pilot program, which indicated organizations were conducting ineffective risk assessments and experiencing "nonperformance," placing them at risk of non-compliance with HIPAA.

Conducting a risk assessment is the first step in recognizing factors that may lead to HIPAA non-compliance. According to HIPAA, risk analysis is the basis for identifying safeguards and technologies to adequately protect health information and meet compliance standards and implementation specifications. The risk analysis requirement continues to be an area of struggle, as noted in the audit pilot program, and this shortcoming is further confirmed in results from "meaningful use" investigations and audits.

The OCR soon is expected to survey 1,200 organizations to determine which covered entities and business associates are suitable for this new round of audits. These audits are expected to begin in the spring and will serve as a bridge toward the formal audit program to be conducted in the fall by the OCR.

For more information on what's coming down the pike, or if you have questions, please feel free to reach out to me at

Christoffer Brown is a solutions development specialist on the Compliance and Risk team at Trustwave.

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