April 21, 2005 has come and gone
pretty much without a peep. That date was the deadline for the Health Insurance
Portability and Accountability Act (HIPAA)
security compliance. Was the lack of hubbub due to all the lead time we had to
prepare, or was there some other reason that the deadline became a nonevent?

Unfortunately, I think it was
because the current rule gives organizations an “out” in the form of
a “good faith” stipulation. The enforcement rule proposed by the
Department of Health and Human Services on April 18, 2005 has a provision that
allows the Centers for Medicare and Medicaid Services
(who enforce the non-privacy rules) and the Office for Civil Rights (who
enforces the privacy rules) to “stray from its philosophy of investigating
the compliance status of covered entities only upon receipt of a complaint of

In other words, this rule says
that (1) the process will remain largely complaint-based and (2) should there
be complaints, the above departments will work with non-compliant entities to help them
become compliant, reserving civil fines or filing criminal complaints only if an entity does not cooperate. In
essence, as long as you can show that you made “good faith” efforts
to comply, you won’t be penalized—you’ll just have to become compliant.

I hate this kind of compliance. The caveat above is full of wiggle room, giving
some department heads the license to gamble with the HIPAA law. After all, no
one will know until a complaint is made, right?

The language
of the final HIPAA security rule doesn’t help matters either. While the
proposed rule had more specific guidelines for implementing security, the final
rule’s language is more focused on providing a model for information security, not actual specifications for how
to implement it. In fact, there are only 13 required implementation
specifications and the rest are “addressable”. This means that
decisions regarding the reasonableness
and appropriateness of implemented
security measures are up to the individual entity. In other words, for those
specifications that are deemed addressable, it will be up to the entity
(knowing its own environment—hopefully) to determine how to or whether to achieve the

wishy-washy language is unfortunate because to implement the final security
rule correctly (even just the 13 required specifications) can be expensive,
depending on the size of the organization. If the rule remained as it was in
draft form, there would be a greater impetus to make sure that one complied
with the letter of the law. However, as it is now, the temptation is there for
others to gamble on not getting caught—and, in the process, to gamble with your career. When it comes time to
request funding for HIPAA compliance, it might go like this: “Well Bob, I
see your budget request for us to comply with the HIPAA security standards is
pretty large. I’m afraid we can’t handle that. “Do the best that you can.”

But whose
head will be on the chopping block once a security complaint is filed and it is
leaked to the press? You can bet it won’t be the person who denied your

should you do to prepare for this situation?

  1. Determine if you are a covered entity or not. (You should have done
    this already but late is better than never). If you work in an IT
    department for Health Departments, EMS, hospitals, or correctional
    facilities that give medical care, you are covered by HIPAA law.
  2. Get VERY familiar with the final security rule, particularly the
    security standards matrix: http://www.cms.hhs.gov/hipaa/hipaa2/regulations/security/03-3877.pdf
  3. Develop a plan to achieve ALL the provisions, not just the required
    13. However, give priority to the 13 required specifications.
  4. Begin implementing your plan. This is the part where you will
    “Do the best that you can.” Make sure to document that you are
    making the best effort to implement the rule, and document all of your
    barriers to doing so. This includes keeping track of your budget requests
    and any other requests that you make in trying to reach compliance. Yes,
    your deadline for compliance was April, but if you missed
    it, you are probably not the Lone Ranger. The key is to be able to show
    that you have been making a “good faith” effort towards
    compliance should a complaint be filed.

summary, don’t let the permissiveness and flexibility of the security rule or
its enforcement lull you into a sense of complacency. Even if others are
inclined to gamble with compliance, and thus deny the resources to accomplish
your goals, you must try to reach compliance as soon as possible anyway.
Furthermore, you must document your
labor in great detail, not just to show your good faith efforts in case of a
complaint, but to help insure against the gamblers who would risk your career
and reputation.

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