5 Steps for Post-Audit Cloud PHI Remediation
Protecting patient data after a cloud PHI audit is critical. Here’s how healthcare organizations can address compliance issues effectively:
- Review and Prioritize Audit Findings: Sort issues by risk level - critical, high, medium, or low - to focus on the most urgent threats to PHI security.
- Create an Action Plan: Define clear steps, assign tasks, and set deadlines to tackle identified gaps, starting with the highest risks.
- Fix Technical Issues: Implement tools like encryption, data loss prevention (DLP), and automated monitoring systems, followed by regular security tests.
- Update Security Policies: Strengthen access rules, refine emergency response plans, and provide ongoing staff training to reinforce compliance.
- Set Up Continuous Monitoring: Use automated systems for real-time tracking and compliance reporting to maintain PHI security.
Key Tools: Platforms like Censinet RiskOps™ streamline risk management, automate assessments, and centralize compliance efforts.
Step 1: Review and Sort Audit Results
Examine Audit Reports
Start by carefully reviewing the audit findings. Pay close attention to areas like technical vulnerabilities, security policies, and daily operations.
Focus on these three categories:
- Technical: Check infrastructure, encryption methods, and access controls.
- Policy: Go through security policies, compliance documents, and governance frameworks.
- Operations: Evaluate daily practices, staff protocols, and incident response measures.
Once you've reviewed the findings, organize them based on their level of risk.
Sort Issues by Risk Level
Organize issues by their potential impact and urgency to ensure the most critical problems are addressed first. Here's a breakdown:
-
Critical Risk:
Immediate threats to patient data, direct HIPAA violations, or active system vulnerabilities. -
High Risk:
Points where PHI (Protected Health Information) could be exposed, incomplete security measures, or gaps in access management. -
Medium Risk:
Issues like missing policy documentation, outdated training programs, or areas needing process improvements. -
Low Risk:
Minor technical fixes, documentation updates, or small operational tweaks.
When prioritizing, consider factors like patient safety, PHI confidentiality, operational risks, resource availability, and timelines.
Using tools like automated risk assessment platforms can make this process faster and more efficient. For example, the Censinet RiskOps platform helps healthcare organizations pinpoint gaps in their cybersecurity programs and investments [1].
It's also important to document your risk assessment approach and keep detailed records of how you prioritize issues. This not only helps with future audits but also demonstrates a strong commitment to maintaining compliance.
Step 2: Create an Action Plan
Outline Necessary Actions
Once you've prioritized audit findings by risk level, it's time to map out specific steps to address each issue. Focus first on the problems that pose the biggest threat to PHI security. For every compliance gap, detail exactly what needs to be done, such as:
- Defining technical updates
- Revising policies
- Modifying operational processes
- Allocating the right resources
- Identifying task dependencies
Be precise with your action items. For instance, instead of saying "improve encryption", specify "implement AES-256 encryption for all cloud-stored PHI databases."
After creating this list, assign clear responsibilities and set deadlines for each task.
Delegate Tasks and Set Deadlines
Now that you have a detailed list of actions, organize them by assigning tasks to the appropriate team members and establishing timelines. Keep in mind:
- Team members' skills and availability
- How complex each task is and how long it will take
- Dependencies between tasks
- Current workloads
- Available resources
Set deadlines that prioritize urgent risks while spreading out less critical tasks over a manageable timeline.
Monitor Progress
Use tools like Censinet RiskOps to keep tabs on remediation efforts in real time. Pay attention to:
- Regular updates on task status
- Documentation of completed work
- Verification of changes made
- Evaluation of the impact of those changes
- Identification of any obstacles
Hold weekly check-ins to review progress, tackle any issues, and adjust plans if needed. Keep a detailed record of all updates and decisions to ensure you have a clear audit trail for your remediation process.
Step 3: Fix Technical Issues
Set Up Security Tools
Use advanced security tools to address vulnerabilities found during your cloud PHI audit. A strong cloud security strategy depends on multiple layers of defense working together.
Set up automated systems for security monitoring and threat detection to get real-time alerts about suspicious activity or potential breaches. Use role-based authentication (RBAC) to restrict access to sensitive data, ensuring only approved personnel can reach it. Enable detailed audit logs to track every interaction with PHI.
These steps create a solid base for adding more specific protections for PHI.
Add PHI Protection Systems
Install tools specifically designed to safeguard sensitive healthcare data. These should include:
- Tools that scan and identify PHI in your cloud environment
- Encryption to secure data both in transit and at rest
- Data loss prevention (DLP) solutions to block unauthorized sharing
- Automated systems to monitor compliance continuously
- Backup and disaster recovery solutions to prepare for emergencies
Once these systems are in place, regular testing is crucial to ensure they work as intended.
Schedule Security Tests
Plan for regular security evaluations. Perform monthly vulnerability scans, quarterly penetration tests, and compliance checks every two months. Document all results in your risk management system. These consistent tests help confirm that your security measures remain effective and provide a clear record for compliance audits.
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Step 4: Update Security Rules
After addressing technical vulnerabilities, it's time to focus on tightening policies and procedures.
Strengthen Access Rules
Enhance controls for accessing cloud-based PHI by implementing:
- Strict access workflows to ensure only authorized personnel can gain entry.
- Quarterly reviews to regularly evaluate and adjust access permissions.
- Immediate access revocation when roles or responsibilities change.
- Emergency access protocols to handle urgent situations without compromising security.
Revise Emergency Plans
Prepare for potential security incidents by refining your emergency protocols. Create a clear, actionable response plan for cloud PHI breaches that includes:
- Containing the breach immediately.
- Notifying affected parties promptly.
- Preserving evidence for investigation.
- Outlining recovery procedures.
- Documenting compliance steps.
Test these plans regularly using tabletop exercises with relevant stakeholders. Use the results to refine and strengthen your procedures.
Provide Staff Training
"Censinet RiskOps enables us to automate and streamline our IT cybersecurity, third-party vendor, and supply chain risk programs in one place. Censinet enables our remote teams to quickly and efficiently coordinate IT risk operations across our health system" [1]
Offer initial and quarterly training sessions covering PHI handling, security tools, and adherence to updated policies. Use real-world scenarios to test understanding and ensure staff are prepared for practical challenges. Align the training with the new access and emergency procedures for seamless implementation across the organization.
Monitor training completion rates and comprehension scores to pinpoint areas that require further focus or improvement.
Step 5: Set Up Ongoing Checks
Install Monitoring Systems
After addressing technical issues and updating policies, keeping a close eye on operations is a must. Use monitoring systems to keep track of cloud PHI compliance in real time. Automated tools can provide immediate insights into PHI access and potential risks. These tools should:
- Keep a constant watch on access logs
- Track how data moves within cloud environments
- Identify unusual access activities
- Send automated alerts for compliance issues
Set up a dashboard to highlight critical metrics like authorized vs. unauthorized access attempts, data transfer volumes, failed logins, and configuration changes.
"Censinet RiskOps enables us to automate and streamline our IT cybersecurity, third-party vendor, and supply chain risk programs in one place. Censinet enables our remote teams to quickly and efficiently coordinate IT risk operations across our health system."
- Aaron Miri, CDO, Baptist Health [1]
This kind of monitoring ensures you have a clear view of compliance and helps maintain a continuous oversight process.
Create Compliance Reports
Use a reporting system to keep detailed records of your compliance efforts. Generate reports daily, monthly, and quarterly to track access attempts, evaluate risks, and monitor compliance trends.
Store these reports securely for future audits. Regularly reviewing them can help you spot patterns, address potential issues early, and show your dedication to meeting regulatory requirements.
Censinet RiskOps™ Integration
Bringing in a specialized remediation platform can make compliance management much more efficient. Censinet RiskOps™, designed for cloud PHI compliance, simplifies complex processes into manageable, automated workflows that are easy to track.
With Censinet RiskOps™, you can:
- Automate Assessment Workflows: Replace manual tracking with digital processes that automatically flag critical issues and assign tasks to the right people.
- Centralize Risk Management: Consolidate all PHI compliance activities into one platform, eliminating the need for scattered spreadsheets and disconnected communication.
- Enable Real-time Collaboration: Connect remote teams through a unified system, ensuring steady progress and seamless communication on remediation tasks.
These features deliver measurable results. For example, Baptist Health has successfully coordinated IT risk operations across its distributed healthcare systems using this platform. Aaron Miri, CDO at Baptist Health, shared:
"Censinet RiskOps enables us to automate and streamline our IT cybersecurity, third-party vendor, and supply chain risk programs in one place. Censinet enables our remote teams to quickly and efficiently coordinate IT risk operations across our health system" [1]
Key tools for supporting post-audit remediation include:
- Automated Risk Assessments: Continuously check compliance against Health Sector Cybersecurity Performance Goals (HPH CPGs).
- Real-time Risk Monitoring: Keep track of remediation progress with automated alerts and updates.
- Comprehensive Reporting: Create detailed reports to highlight progress on compliance efforts.
- Vendor Risk Management: Oversee third-party vendors to ensure they meet PHI protection standards.
Censinet RiskOps™ acts as a central hub for managing all aspects of cloud PHI compliance. It helps healthcare organizations maintain consistent oversight while meeting regulatory demands effectively.
Conclusion
A well-organized remediation process plays a key role in ensuring cloud PHI security. Here's a breakdown of the steps into actionable measures.
Using data to guide risk management helps healthcare organizations make smarter decisions about cybersecurity investments and resource use. By following the five steps in this guide, organizations can:
- Speed Up Risk Assessment: Quickly pinpoint and address critical vulnerabilities.
- Enhance Security: Put strong measures in place to protect PHI.
- Stay Compliant: Continuously meet regulatory requirements.
- Safeguard Patient Data: Use effective protocols to secure sensitive information.
Organizations have also benefited from improved efficiency through a unified remediation strategy. Will Ogle from Nordic Consulting highlighted their experience:
"We looked at many different solutions, and we chose Censinet because it was the only solution that enabled our team to significantly scale up the number of vendors we could assess, and shorten the time it took to assess each vendor, without having to hire more people" [1]
Building an effective remediation process requires ongoing dedication to managing PHI risks. By consistently applying these steps and using the right tools, organizations can protect sensitive data while maintaining smooth operations.
