Navigating HIPAA compliance as a mental health provider

Understand your role as a covered entity.

In the eyes of HIPAA, you, as a mental health provider, are considered a covered entity. This means that HIPAA regulations apply to your practice, and you are responsible for ensuring the confidentiality, integrity, and availability of protected health information (PHI).

PHI includes identifying details, or any information that can be used to identify an individual, as well as health data, or information that relates to their past, present, or future physical or mental health condition. The Department of Health and Human Services (HHS) lists out 18 identifiers that count as PHI, including patient names, email addresses, geographical elements, and more.

Conduct a thorough risk assessment.

Before you dive into implementing specific safeguards, conduct a comprehensive risk assessment for your practice. There’s a downloadable Security Risk Assessment Tool available through HealthIT.gov, which can run as a desktop program or Microsoft Excel workbook. Either way, the tool walks you through a security risk assessment with multiple-choice questions, threat and vulnerability assessments, and vendor management. Once the assessment is completed, a report is generated. Similarly, the HIPAA Journal also offers a HIPAA Risk Assessment Checklist.

The goal when conducting any risk assessment is to identify and assess potential risks to the security of PHI, both digital and physical. This process helps you understand where vulnerabilities may exist, allowing you to develop a targeted and effective HIPAA compliance strategy.

Establish policies and procedures.

HIPAA compliance is not a one-time task but an ongoing process that requires clear policies and procedures. Develop and document protocols for how you handle, store, and transmit PHI. Outline the steps your practice will take to ensure the security and privacy of patient information in both digital and paper formats. Having well-defined policies creates a roadmap for you and your staff to follow consistently.

Examples of HIPAA-compliant policies include:

Automatic logoff policy: Ensure nobody accidentally glances at sensitive information if you’ve temporarily left your desk by instating an automatic logoff policy for computers inactive for longer than a few minutes.
Secure conversations: Only discuss PHI with other people who have access to PHI, and use a moderate tone of voice when doing so.
Authorization for disclosure: You need to obtain a patient’s signed permission to allow a covered entity to use or disclose an individual’s PHI. However, there are several situations that would allow providers to disclose PHI without consent. For example, in an emergency situation, HIPAA regulations allow healthcare providers to disclose PHI without the patient's consent if, in good faith, they believe it is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others. You can consult the HHS HIPAA Privacy Rule for more information.

Implement physical and technical safeguards.

To ensure the security of PHI, HIPAA mandates the implementation of physical and technical safeguards. Physical safeguards involve controlling access to physical spaces where PHI is stored, such as offices and file rooms. You’ll want to periodically change door access codes, lock doors or filing cabinets, and turn documents face down on your desk whenever possible.

Technical safeguards, on the other hand, focus on securing electronic PHI (ePHI) through measures like encryption, password protection, and regular system audits. Invest in secure and HIPAA-compliant technologies to protect digital records from unauthorized access.

Train your staff on HIPAA compliance.

Your team plays a crucial role in maintaining HIPAA compliance. Provide thorough training to all staff members on the importance of safeguarding patient information, recognizing potential security threats, and following established policies and procedures. Regular training sessions ensure that everyone in your practice remains vigilant and informed about their responsibilities in maintaining HIPAA compliance.

With Headway, providers receive HIPAA training so you can feel confident you’re adhering to compliance standards.

Address breaches promptly and effectively.

Despite your best efforts, breaches can occur. In the event of a security incident or breach of PHI, it's essential to have a response plan in place. HIPAA requires you to investigate and mitigate breaches promptly, notifying affected individuals, the Department of Health and Human Services (HHS), and, in some cases, the media. Having a well-defined response plan minimizes the impact of a breach on your practice and demonstrates your commitment to resolving issues responsibly.

Determine if you need a signed business associate agreement.

If you’re a provider using a HIPAA-compliant EHR, you are not fully HIPAA compliant until you sign a business associate agreement, or BAA. “What that means is: You, as the provider, are using a business associate such as SimplePractice, TherapyNotes, or another EHR, to store your PHI,” explains Michael Heckendorn, Headway’s clinical lead of clinician education. “And you need an agreement with that business associate to technically be HIPAA compliant.”

Headway providers don’t need to create and sign a business associate agreement because they are contractors. Only providers using third-party platforms require BAAs to be HIPAA compliant.

Keep up with changes and updates.

HIPAA is not static; it evolves to address emerging challenges in healthcare and technology. Make it a point to regularly assess and update your security measures to align with the latest best practices and compliance requirements, which are released through the U.S. Department of Health and Human Services.

Navigating HIPAA compliance may seem like a daunting task, but with a proactive and informed approach, you can establish a secure environment for your private mental health practice. Through Headway’s HIPAA training, you'll not only protect your clients' sensitive information but also build trust and credibility in your private practice journey.

Compliance and documentation