7-Step HITRUST Compliance Checklist: Step-By-Step Guide

Are you aware that around 90% of healthcare organizations face security breaches, and large hospitals amount to 30%?

This underlines why robust cybersecurity is crucial for safeguarding data in healthcare and HiTrust is one such compliance framework that aims for that. Established in 2007, HiTrust (Health Information Trust Alliance) ensures high data security standards. It provides a Common Security Framework (CSF) with guiding principles and specific rules for strong cybersecurity. Let’s explore the HiTrust requirements in detail and take a look at the checklist.

What is HITRUST Compliance?

HiTrust compliance helps organizations stay secure, handle risks, ensure vendors follow the security rules, and prevent data breaches. It also guides organizations to imbibe ongoing improvements to adapt to changing cybersecurity needs consistently.

Safeguarding Protected Health Information(PHI) in storage and during transmission is the top priority in the healthcare industry. HIPAA is another compliance regulation that strives to minimize the volume and intensity of breach scenarios in medical care. While both HiTrust and HIPAA aim to safeguard patient information, the HIPAA framework has certain drawbacks in terms of interpretation, whereas HiTrust offers a more integrated security approach that helps demonstrate HIPAA compliance to third-party auditors.

HITRUST Requirements Checklist

HiTrust requirements are determined by the level of implementation the company opts for. Although HTrust has a total of 135 controls, the level of implementation determines the number of controls required.

Before we dive deep into HiTrust implementation, it is important to understand HiTrust requirements. HiTrust regulation comprises over 135 controls that organizations need to adhere to based on the level of depth required in their implementation process. The levels of implementation are based on the organization’s risk profile, regulatory requirements, size and complexity, and the type of HITRUST assessment being carried out. The different levels of implementation are:

• Level 1: Baseline standard to help fulfill HIPAA requirements and has a minimum security requirement.
• Level 2: Required for organizations of bigger size and higher complexity. Adds additional security requirements in addition to level 1 implementation.
• Level 3: Required for large enterprises and necessitates implementation of all 135 controls.

Also check: HITRUST Audit [Easy Step by Step Guide]

HITRUST Controls checklist

The CSF constitutes 156 security and privacy-related control specifications spread out across 49 control objectives, which are made up of 14 control categories. The control objectives specify the end desired result, and specifications are policies, procedures, or controls required to achieve the above-stated objective.

The 135 security controls are spread out across 19 security domains and they are:

• Access Control 
• Business Continuity & Disaster Recovery
• Audit Logging & Monitoring
• Data Protection & Privacy
• Configuration Management
• Endpoint Protection
• Information Protection Program
• Education, Training & Awareness 
• Network Protection
• Incident Management
• Physical & Environmental Security
• Mobile Device Security
• Risk Management
• Password Management
• Transmission Protection
• Portable Media Security
• Wireless Protection
• Third-Party Security
• Vulnerability Management 

HITRUST Compliance: 7-Step Checklist

Before an external audit, assess internally and set security controls. Follow these steps for HiTrust compliance checklist:

Step 1: Define key roles and responsibilities

Before you start your HiTrust compliance journey, you are required to appoint a project coordinator or manager to oversee different aspects of security and compliance. The named leader should establish a team of security experts, guide the entire process, and collect and manage evidence. Also, roles and responsibilities of all employees and security teams, such as incidence response teams, endpoint management team, etc., should be defined right from the start.

Additionally, project managers are required to conduct meetings with leadership, stakeholders, and personnel who deal with sensitive information to define key security policies and procedures in line with HiTrust regulations. They are also required to identify security gaps, make use of the right tools, plan the project, and document everything along every step of the way. HiTrust recommends appointing a project manager at least two months before the audit.

Step 2: Define the organizational and the system scope

The scoping exercise helps establish the systems, departments, key personnel, and facilities that fall under the purview of HiTrust compliance. 

The scope of the organization can be defined by conducting a comprehensive review of the following components:

• Business units: Units operating in their individual capacity will require separate audits. The project coordinator should identify and create a list of key contacts such as leadership(directors, managers, department heads), compliance and risk personnel, information security personnel, system owners, and the HR department.
• Physical facilities: Identify critical systems within your organization that house or transmit sensitive data. Assess various stages of the data lifecycle to protect critical systems against breaches. 
• Regulatory factors: Account for other compliances as well that are relevant to your organization, such as HIPAA, NIST, FISMA, and PDPA. Prepare the scope accordingly to achieve comprehensive compliance across frameworks.

The next step is to define system controls that help pinpoint the exact technologies, systems, and devices that deal with sensitive information. Identify critical systems that store, access, or transmit sensitive data and are at a higher risk of a data breach. The project coordinator should focus on the following aspects of the data lifecycle:

Classify and Identify Protected Information

Begin by defining and categorizing the various types of protected information your company deals with, including Personally Identifiable Information, demographic data, medical records, billing information, and other sensitive data like PHI or cardholder information.

Trace Data Movements

Gain insights into how data enters, exits, and circulates within your environment. Engage with different departments to understand their interactions with protected data. Explore data collection methods—whether via web pages, phone, email, mail, or other means—and visualize the volume of protected data in each data flow.

Map Data Flows

Illustrate all the protected data flows within your environment, indicating involved departments and the systems through which the data passes. Consider aspects like backups, multiple facilities, and recordings in this mapping process.

Track Data Exit Points

Understand how protected data leaves your environment. Identify the forms in which data exits, its destination, and any agreements with entities receiving this information. Consider data transfer lifecycles, protection during transfer, and compliance with minimum necessary information protocols.

Review System Inventories

Verify and document the hardware and software systems used to handle protected information. Track attributes, versions, and mobile devices owned by the organization. Ensure accuracy in identifying servers, workstations, operating systems, applications, encryption tools, and storage locations, whether electronic or physical.

Step 3: Self-assessment

Use a security gap analysis to spot risks. Fill out questionnaires about your organization’s size, risk profile, and security status. This helps identify security controls needed for HiTrust compliance.

Also, use the MyCSF tool for risk assessments and a remediation plan. It saves time, streamlines compliance, and enhances reporting.

Step 4: Document findings

Evaluate security gaps and test controls, policies, and procedures. Document findings, discuss with management, and plan action items. Three key steps to get this done are: 

• Examine your current posture
• Interview stakeholders to establish a plan of action
• Test controls against CSF requirements

Employ an authorized HITRUST External Assessor for risk management.

Step 5: Technical Testing

Identify the level of HITRUST implementation based on organization size and complexity. Define control objectives and undergo technical testing (vulnerability assessment, penetration testing).

Step 6: Document Results

Analyze findings after technical testing. Prepare a report suggesting alternative controls, inform leadership, and communicate a remediation plan with timelines.

The management should review the submitted report to suggest a corrective action plan to fix vulnerabilities and test them again to validate their efficiency. This helps mitigate security and organizational risk.

Step 7: Get HiTrust certified

Now that you have identified and addressed the various requirements under HITRUST regulation, it is time to get HITRUST certified. The HITRUST certification process can be done by following these steps:

Continuous Compliance for 24/7 Peace of Mind

Conduct an external audit

Employ a third-party auditor authorized by the HITRUST Alliance to evaluate your self-assessment reports as well as the security controls and processes you have implemented.

Get Validated

The reports generated by third party auditors is then submitted to HiTrust. The HiTrust now evaluates your application and may demand evidence or make recommendations based on the audit report. Companies must comply with these requests within the specified timeframe and resubmit their application with changes addressed.

Receive a score from HITRUST

If your score meets the threshold required by HIRTUST, you are now HITRUST certified. If the score is not up to the mark, you will receive a letter stating gaps and a recommended action plan. After implementing the recommendations, you can try for HITRUST certification again.

Want to build your own custom framework tailored to your business requirements?

Tips and best practices to prepare for HiTrust Certification 

Organizations must implement a robust security program and meet the requirements of the HiTrust assessment to get certified. Having a deep understanding of the HiTrust regulatory framework and implementing controls in line with the requirements can help you get a step closer to HiTrust certification. Here are some best practices you should consider to achieve HiTrust compliance:

Understand the shared responsibility model

If an organization uses a cloud infrastructure, such as Amazon Web Services (AWS), they should know how both the cloud provider and client shoulder the responsibility of safeguarding data. The client is responsible for the security of data and applications on the cloud, whereas the provider is responsible for the security of physical infrastructure. Organizations must implement physical, technical, and administrative safeguards to protect their data and infrastructure.

Establish a plan of action for certification

HiTrust certification can be a daunting and time-consuming process. The security teams should be committed to building a robust security system. Establishing a plan of action with defined timelines can help them navigate through the HITrust compliance process. Documentation should be maintained at every step to assess and evaluate the organization’s cybersecurity posture and identify and address gaps.

Choose a Cloud Service Provider

Find a cloud provider meeting HiTrust standards. They should comply with HiTrust requirements. For instance, AWS offers 100+ HiTrust certified cloud services.

Considerations to choose a cloud service provider:

• Sign a Business Associates’ Agreement (BAA) to define responsibilities.
• Ensure the provider aligns with HiTrust regulations.

Implement Administrative Policies

Security teams should set SOPs for daily operations. Consider organization size, complexity, and cybersecurity aspects like:

• Vulnerability management
• Continuous monitoring
• Encryption
• Audit logging
• Access control
• Intrusion detection
• Incident response
• Employee training
• Disaster Recovery (DR)

Implement Security Controls

Provide tailored security solutions aligned with regulations:

• Least privilege access control
• Continuous monitoring
• Log analysis for anomalies
• Encryption for data at rest and in transit
• Backup and disaster recovery plans

Conduct Self-assessment

Internally audit security gaps, test controls against HiTrust. Collect evidence for HiTrust compliance.

Select Partners

Consider third-party partners or compliance tools like Sprinto for easier compliance:

•     Map services and controls to HIPAA and HiTrust
•     Detailed control information
•     Guidance and support throughout the compliance journey.

Collect security evidence for external security auditors

Once your organization has implemented security controls, it’s time to test them vigorously. Evidence should be collected at every stage to validate the efficiency of security controls. The documentation should report on the following:

• Report on security programs with respect to cloud providers and third-party vendors.
• Download and prepare certifications and attestations required under HiTrust certification
• Details on implemented security controls
• Up-to-date evidence on the performance of security measures

Put all your compliance needs on auto-pilot with Sprinto

With over 135+ controls across 19 security domains, getting HiTrust certified can prove to be a challenging task. Carrying out the compliance efforts manually is an even more tedious and time-consuming process. Also, it might not give the most accurate insights into your organization’s cybersecurity posture. 

Don’t worry, we are here to help.

Sprinto is a powerful security and compliance automation tool that helps you get compliant 10x faster across frameworks, such as SOC2, GDPR, ISO 27001, and HIPAA. A user-friendly yet powerful tool, Sprinto monitors your organization’s cybersecurity posture, consolidates risk, and implements security controls– at scale and at entity level– all in real-time, all from a single dashboard.

FAQs

What is the difference between HIPAA and HITRUST?

The key difference between HIPAA and HiTrust is that HIPAA is the health industry standard for safeguarding patient health information in the US, whereas HiTrust is a globally accepted risk management framework. 

What is the HITRUST certification process?

The HiTrust certification process requires an organization to partner with an authorized HITRUST External Assessor and validate that all industry standards are upheld while maintaining high standards of information risk management and data loss prevention. The organizations need to undergo a comprehensive security evaluation and are required to pass the threshold score required by HiTrust.

Who needs to be HITRUST compliant?

Organizations that deal with Patient Health Information(PHI) in the healthcare industry, such as hospitals, pharmacies, insurance companies, physician offices, healthcare vendors, and more, are required to have HITRUST CSF certification.

What is the purpose of HITRUST certification?

HiTrust certification helps build trust with stakeholders, customers, and vendors by providing assurance of integrity, transparency, and validity. HiTrust-certified organizations can share their certifications through a centralized, secure electronic distribution system.