HIPA-26

Do you have a disaster recovery plan and emergency mode operation plan?

Explanation

This question is asking whether your organization has two specific plans required by HIPAA regulations: 1. A Disaster Recovery Plan (DRP): This is a documented process for recovering IT systems, data, and infrastructure after a disaster (natural or human-caused) that disrupts normal operations. For healthcare organizations, this ensures that critical patient data remains accessible even after significant disruptions. 2. An Emergency Mode Operation Plan (EMOP): This outlines how your organization will continue critical business processes that protect the security of electronic protected health information (ePHI) during emergency situations when normal systems may be unavailable. This question is being asked because HIPAA's Security Rule (specifically 45 CFR ยง 164.308(a)(7)) requires covered entities and business associates to establish policies and procedures for responding to emergencies that damage systems containing ePHI. The goal is to ensure continuity of critical business processes and protection of patient data even during disasters or emergencies. When answering this question, you should: - Clearly state whether you have both plans in place - Briefly describe the key components of each plan - Mention how often these plans are tested and updated - Note any relevant certifications or frameworks that guide your disaster recovery approach - Explain how these plans specifically address the protection and availability of ePHI Even if you're not directly handling ePHI, having these plans demonstrates your organization's commitment to business continuity and data protection, which is valuable for any security assessment.

Guidance

Refer to HIPAA regulations documentation for supplemental guidance in this section.

Example Responses

Example Response 1

Yes, our organization maintains comprehensive Disaster Recovery and Emergency Mode Operation Plans as required by HIPAA regulations Our Disaster Recovery Plan details procedures for recovering IT systems, data, and infrastructure following disruptive events, with specific recovery time objectives (RTOs) and recovery point objectives (RPOs) for systems containing ePHI The plan includes server restoration procedures, data backup recovery processes, and alternative processing site arrangements Our Emergency Mode Operation Plan outlines how we continue critical business processes that protect ePHI during emergencies, including manual procedures when electronic systems are unavailable, communication protocols, and role-specific responsibilities Both plans are tested annually through tabletop exercises and live simulations, with results documented and used to improve our procedures These plans were last updated in January 2023 and are reviewed annually by our compliance and IT security teams.

Example Response 2

Yes, we maintain both a Disaster Recovery Plan and Emergency Mode Operation Plan that align with HIPAA requirements Our DRP is built on a cloud-first architecture that leverages AWS's multi-region capabilities to ensure ePHI remains available even during regional outages We maintain real-time database replication across three geographic regions with automated failover capabilities, ensuring an RTO of 4 hours and RPO of 15 minutes for all systems containing ePHI Our EMOP details specific procedures for maintaining security controls during emergencies, including enhanced access monitoring, alternative authentication procedures when primary systems are unavailable, and secure communication channels for coordinating response efforts Both plans are tested quarterly through technical recovery exercises and annually through full-scale simulations Our plans were independently assessed during our last HITRUST certification process and deemed compliant with all applicable HIPAA requirements.

Example Response 3

No, we currently do not have formal Disaster Recovery and Emergency Mode Operation Plans that fully meet HIPAA requirements While we do perform regular data backups and have some informal procedures for handling outages, we recognize this is a gap in our compliance posture We are actively working to address this deficiency by engaging a consultant specializing in HIPAA compliance to help us develop comprehensive plans We have already completed a business impact analysis to identify critical systems containing ePHI and established preliminary recovery time objectives We expect to have draft plans ready for review within 60 days, followed by testing and implementation within the next quarter In the interim, we have implemented enhanced backup procedures and documented basic emergency response protocols to mitigate risks while we develop the full plans.

Context

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Case-Specific
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HIPAA Compliance

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