Disaster Recovery Planning for HIPAA Compliance
If a disaster strikes, you want to make sure you are prepared. Healthcare companies and their business associates are required by HIPAA to establish a disaster recovery program in case something disrupts their operations.
Below, we’ll lay out HIPPA disaster recovery requirements and best practices for disaster recovery in healthcare organizations.
What Is a Disaster Recovery Plan?
A HIPAA Disaster Recovery Plan (HIPAA DRP) is a collection of policies, procedures, and employee duties that can be relied upon if a natural or manmade disaster blocks a healthcare organization’s access to patients’ electronic protected health information (PHI).
In emergency operations mode, a HIPAA disaster recovery plan protects PHI so that business operations may continue until regular systems and services are restored. Afterward, a DRP allows for fast and orderly restoration of normal procedures.
What Are the HIPAA Disaster Recovery Requirements?
HIPAA requires disaster recovery planning under the Security Rule’s administrative safeguards provision for contingency plans.
HIPAA lays out five implementation requirements for a DRP, including:
- Data Backup Plan (required). Organizations subject to HIPAA must establish and implement processes to maintain and retrieve an exact healthcare data backup.
- Disaster Recovery Plan (required). HIPAA compliance requires healthcare organizations to establish and implement procedures for restoring electronic PHI (ePHI) to its original state.
- Emergency Mode Operation Plan (required). Healthcare organizations must create procedures for maintaining critical business functions while protecting PHI during a disaster, including alternative communication protocols and processing methods.
- Application & Data Criticality Analysis (addressable). Organizations must assess and identify the most critical programs and data for patient care and business operations so these can be prioritized for data backup, emergency operations access, and data recovery.
- Testing & Revision Procedures (addressable). HIPAA requires organizations to periodically test and revise their contingency plans to optimize their effectiveness.
What Disasters Should Healthcare Organizations Plan For?
When creating a HIPAA Disaster Recovery Plan, you should consider a variety of circumstances that could damage your IT infrastructure and compromise sensitive data.
Such a disaster could be any of the following:
- Cyber assaults that prevent users from accessing computer systems or networks
- Extreme weather that causes extended power disruptions
- System outages leading to limited or disrupted IT availability
Benefits of a HIPAA Disaster Recovery Plan
Disaster recovery plans are a HIPAA requirement, so the failure to implement these requirements can result in costly HIPAA violations and fines.
However, avoiding fines related to HIPAA compliance isn’t the only benefit of following best practices for disaster recovery in healthcare organizations.
Proper disaster recovery planning guarantees that the business can stay up and running in the worst-case scenario. With a tested plan already in place, you can focus on the continuity of care and the challenges of the situation rather than scrambling for logistical solutions.
Ensuring your data backup and recovery meet HIPAA standards also enables you to respond to security issues faster and reduce downtime.
How to Develop a Disaster Recovery Plan
Creating a HIPAA Disaster Recovery Plan can be a daunting process, but let’s break it down step by step.
Step 1: Define DRP Roles & Responsibilities
First, you need to organize who will be responsible for developing, maintaining, and implementing your disaster recovery plan.
Assign clear roles and responsibilities and assign backup staff for people who have an important role in implementing the plan during an emergency.
Step 2: Conduct a Risk Analysis
After forming your team, your next step is to consider how various threats or disasters might impact your business.
Make a list of every catastrophic threat to HIPAA compliance your company faces. For each threat, you’ll want to assess the likelihood it will occur.
For each scenario, you should consider the ways it will affect your business in the short and long term, assessing the scope of potential impacts to:
- Daily operations
- Communication channels
- Patient safety
- Loss of revenue
- Length and cost of downtime
- Cost of repairing your reputation
- Loss of customer/investor confidence, short- and long-term
- Penalties due to HIPAA violations
Using the likelihood of an event combined with the potential impact, you can prioritize which scenarios you should address first.
Step 3: Inventory Your Assets
Next, you need to inventory all HIPAA-critical assets that you must be able to manage during a disaster to maintain operations.
This includes detailing:
- The types of data your organization manages
- The size of each category of data
- Where data is stored and where/how/how often healthcare data backup occurs
- Which data is most vital to critical business operations
- ‘Critical’ for assets absolutely required for normal business operations
- ‘Important’ for assets that would impact business operations but not shut them down entirely
- ‘Unimportant’ for infrequently used assets that aren’t essential to normal operations
- The maximum amount of time and resources needed to recover each type of data if lost
Step 4: Create Disaster Recovery Processes & Procedures
This is where the rubber meets the road. You should have a plan for data recovery for HIPAA during/after each potential threat or disaster. It should be detailed and specific but allow for flexibility should unforeseen circumstances arise.
Things your Disaster Recovery Plan should account for include:
- Who has the authority to activate the plan? Who else is involved in authorizing it? How long does an outage need to last before the plan is activated? What other criteria must be met? What is the process for plan activation?
- How will you activate IT resources to fix the problem? Who are the resources, and how can they be contacted? Who does the contacting?
- What processes need to be followed to recover the data? How will communication flow during recovery? What’s the chain of command?
- What is the data restoration hierarchy?
- For each category of data, what will your Recovery Time Object (RTO) be? In other words, how quickly does each type of data need to be restored?
- To which point in time should each type of data be recovered? This is known as the Recovery Point Objective (RPO).
Step 5: Create Emergency Operations Processes and Procedures
While IT is working to restore data, the rest of your operation needs to keep running under less-than-ideal circumstances. As with disaster recovery planning, Emergency Operations Plans need to be detailed and specific but contain a certain amount of flexibility.
Things your Emergency Operations Plan should account for include:
- How will you notify other employees about the emergency operations?
- How will they transition to emergency operations?
- How will they access detailed emergency operations procedures and processes?
- What alternate processes will they use until data restoration is achieved?
- How will communication flow during emergency operations? What is the chain of command?
Step 6: Test Your Disaster Recovery & Emergency Operations Plans
One of the most common mistakes in HIPAA-compliant disaster recovery plans is a lack of adequate testing and revision.
Once your initial DRPs and EOPs are documented, schedule testing procedures and use them to check their reliability and effectiveness. Consider the challenges you’re seeing and decide whether they reveal critical flaws in the plan or just a lack of practice. Don’t be afraid to revise and adjust the plan as you discover real-world snags.
You should also be prepared to repeat drills on data recovery for HIPAA. Full testing is recommended annually, paired with more frequent partial testing.
Step 7: Train Employees on Disaster Recovery & Emergency Operations Plans
While testing procedures can serve as a type of rehearsal, employees need training in the related policies and procedures so they’re primed to carry out the plan amid external challenges.
You’ll also need to integrate training on these procedures into onboarding processes so that new employees going forward will also be prepared.
Don’t Forget Regular HIPAA Compliance Training
While it’s important to plan for worst-case scenarios, you can’t lose sight of the daily challenges of following HIPAA during normal operations.
Your HIPAA security is only as good as your employees’ training.
We offer online, role-specific HIPAA courses that will target the aspects of HIPAA compliance that each employee needs to know. We’ve got you covered with HIPAA for Healthcare Workers, HIPAA for Medical Office Staff, HIPAA for Dental Offices, and even HIPAA for Business Associates.
Check out our business solutions for bulk pricing, comprehensive compliance training solutions, a free LMS, and more!
