In the digital era, Electronic Health Records (EHRs) are crucial in healthcare, making Electronic Protected Health Information (ePHI) an essential asset. However, ePHI is vulnerable to threats like cyber attacks and natural disasters, making disaster recovery planning (DRP) vital.
Healthcare organizations must implement HIPAA-compliant DRPs to protect ePHI, ensuring continued operation during disasters. This blog explores the importance of DRP in the context of EHRs and provides insights for healthcare CIOs to establish or enhance their DRP.
Why Is Disaster Planning Important for Healthcare Organizations?
Healthcare organizations need to maintain system and network availability for critical operations to safeguard patient health. The significance of disaster recovery planning is emphasized below:
- Patient Safety: Ensures safety and care for patients during disasters.
- Data Protection: Safeguards sensitive data, preventing legal and financial issues.
- Service Continuity: Ensures essential healthcare services remain operational.
- Regulatory Compliance: Meets requirements like HIPAA that mandate disaster recovery plans.
- Financial Stability: Mitigates the financial impact of disasters, including costs from data breaches or loss of revenue.
- Reputation Management: Maintains trust with patients and stakeholders by demonstrating effective disaster response.
Disaster recovery planning is essential for healthcare organizations to ensure uninterrupted service during unexpected events.
Despite its importance, it’s often neglected in IT budgeting. Hence, healthcare CIOs need to prioritize and allocate resources for it.
What is a Contingency Plan Policy?
According to the Contingency Plan Policy in HIPAA section 164.308(a)(7)(i), covered entities must “formulate and execute, as needed, guidelines and procedures to respond to emergencies or other incidents (like system failure, fire, vandalism, or natural disaster) that damage systems containing ePHI.”
While entities can choose their methods for HIPAA disaster recovery planning, HIPAA mandates basic requirements in section 164.308(a)(7)(ii), requiring organizations to address certain aspects.
- Data Backup Plan (Mandatory): Formulate and execute strategies to generate and preserve accessible exact replicas of electronic protected health information.
- Disaster Recovery Plan (Mandatory): Develop (and apply as necessary) strategies to recover any data loss.
- Emergency Mode Operation Plan (Mandatory): Formulate (and apply as necessary) strategies to ensure the continuation of vital business processes for the protection of the security of electronic protected health information during emergency operations.
- Testing and Revision Procedures (Addressable): Enforce strategies for regular testing and modification of contingency plans.
- Applications and Data Criticality Analysis (Addressable): Evaluate the relative importance of specific applications and data in support of other contingency plan elements.
Implementing Business Continuity and Disaster Recovery Measures for Covered Entities:
Let’s talk about how Covered Entities can implement Business Continuity and Disaster Recovery Measures. It’s not as complicated as it sounds!
Identify and Catalog ePHI Assets:
Create an Inventory:
Begin by creating a comprehensive inventory of all critical assets within the healthcare organization. These assets can be tangible, like medical equipment and IT hardware, or intangible, like Electronic Health Record (EHR) systems, Picture Archiving and Communication Systems (PACS), Laboratory Information Systems (LIS), and other software applications that store, process, or transmit ePHI.
Detail the Assets:
Catalog each asset in the inventory with its specific details. This should include:
- Specifications: Record assets’ technical details, including model, capacity, software version, and type of ePHI data handled by software applications.
- Location: Document the physical or digital location of assets, including on-premise servers, cloud storage, or third-party data centers for ePHI data.
- Personnel Responsible: Note the contact details of personnel responsible for asset maintenance and security, such as IT administrators or department heads.
This asset identification and cataloging helps healthcare organizations understand ePHI storage, processing, and transmission.
Perform ePHI Risk Assessment:
Identify threats to ePHI assets, including natural disasters, technical issues, and security threats.
Assess the potential impact on ePHI assets post threat identification, considering downtime, data loss, and financial implications.
- Downtime: Estimate potential downtime of an ePHI asset due to a threat. Data
- Loss: Determine possible ePHI data loss extent due to a threat.
- Financial Implications: Evaluate potential financial loss from a threat, including recovery costs, HIPAA violation penalties, and revenue loss during downtime.
Perform ePHI Business Impact Analysis (BIA):
Quantify Potential Effects:
Start the BIA process by assessing the potential impacts of a disruption to critical healthcare operations from a disaster. This includes estimating potential revenue loss, additional expenses such as recovery costs or HIPAA violation penalties, and intangible effects like reputation damage or regulatory compliance issues.
- Critical Functions: Identify key operational functions, including patient care services, IT systems managing ePHI, and supply chain systems.
- Recovery Resources: Identify resources for recovery, including trained personnel, compliant equipment and IT systems, data backup solutions, and secure facilities.
Develop an ePHI Recovery Strategy:
Choose a Recovery Method:
Determine a restoration method for ePHI assets in disasters, aligning with the organization’s continuity plan and risk tolerance.
Set up backup and recovery procedures:
Develop protocols for duplicating and restoring ePHI data during data loss events.
- Off-site backups: Store backups at a location separate from the primary site, such as on DVDs, CDs, or cloud storage.
- Cloud backups: Store backups on the cloud to provide easy access from any location and eliminate the risk of physical damage to storage media.
Maintain duplicate systems or data to fall back on in case of a failure. Examples include:
- RAID systems: Use RAID (Redundant Array of Independent Disks) for data storage across multiple disks to enhance data reliability and performance.
- Mirrored servers: Maintain servers with real-time ePHI copies. If the primary server fails, the mirrored server ensures minimal downtime.
Consider Alternate Site Options:
If the primary site is inoperable, ensure an alternate site for healthcare operations.
- Hot sites: Have facilities for immediate takeover post-disaster.
- Warm sites: Maintain hardware-equipped sites for eventual operation.
- Cold sites: Provide basic facilities for necessary equipment installation.
Assign ePHI Roles and Responsibilities:
Designate roles for ePHI recovery:
A team leader to oversee recovery, an IT team for technical restoration ePHI data, and a damage assessment team.
Establish an ePHI Communication Strategy:
Create a communication plan to inform key stakeholders (like healthcare professionals, management, patients, and third-party service providers) in the event of an ePHI disaster. The plan should outline:
- How will communication occur? This could be via email notifications, phone calls, or emergency meetings.
- Who will communicate? This could be the disaster recovery team leader or a designated communication officer.
- What will be communicated? This could include the nature of the disaster, the expected impact on ePHI data, and the steps being taken for recovery.
Conduct ePHI Tabletop Exercises:
Conduct simulated exercises to test the ePHI disaster recovery plan. These exercises can reveal plan gaps and train the recovery team, ensuring preparedness for real ePHI disasters.
If you’re interested in more on Tabletop Exercises, I can create a blog post. By implementing a comprehensive DRP, organizations can lessen disaster impact and ensure quick, efficient recovery.
We’ve identified key elements in a Disaster Recovery Plan (DRP) for HIPAA standards. Addressable policies can be managed within or outside the DRP. Regular testing and adjustments are essential due to changes in ePHI applications. With the rise in natural disasters and security breaches, a functional DRP is crucial for business continuity, regardless of HIPAA mandates