What is the HIPAA Security Rule?

The HIPAA Security Rule establishes national standards to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI) through administrative, physical, and technical safeguards.

What is considered a HIPAA violation in cybersecurity?

A HIPAA violation occurs when PHI or ePHI is impermissibly used or disclosed or insufficiently safeguarded. Common causes include weak access controls, missing risk analyses, unencrypted devices, improper workforce training, and delayed breach reporting.

What are administrative, physical, and technical safeguards?

Administrative safeguards are policies, procedures, and training. Physical safeguards protect facilities and devices. Technical safeguards include access controls, audit logging, transmission security, and encryption.

Is a HIPAA risk assessment required annually?

HIPAA requires a regular and thorough risk analysis but does not mandate a specific frequency. Many organizations perform it annually and whenever significant changes occur, such as new systems, vendors, or workflows.

What should a HIPAA risk assessment include?

It should identify where ePHI resides, evaluate threats and vulnerabilities, assess likelihood and impact, review current controls, document risk levels, and define prioritized remediation steps and timelines.

What is the role of encryption in HIPAA compliance?

Encryption is an addressable implementation specification. If reasonable and appropriate, it should be implemented for data at rest and in transit. If not implemented, the decision must be documented and an equivalent alternative safeguard applied.

What is a Business Associate under HIPAA?

A Business Associate is any person or organization, other than a workforce member of a covered entity, that creates, receives, maintains, or transmits PHI on behalf of a covered entity. Examples include cloud providers, IT support, billing services, and certain consultants. A Business Associate Agreement (BAA) is required before PHI access.

Do business associates need to be HIPAA compliant?

Yes. Business associates must implement appropriate safeguards for PHI, comply with applicable HIPAA requirements, enter into a BAA, report incidents and breaches, and ensure their subcontractors that handle PHI also comply.

What happens if a business associate causes a breach?

Both the covered entity and the business associate have obligations. The business associate must investigate, mitigate, and notify the covered entity. Breach notifications to individuals, HHS, and in some cases the media may be required based on the incident size and circumstances.

How do I secure remote access to ePHI?

Use VPN or zero-trust access, require multi-factor authentication, enforce least-privilege access, encrypt devices, manage endpoints and patches, disable local data storage when possible, and monitor logs for suspicious activity.

Can employees use personal devices under HIPAA?

Yes, if governed by a BYOD policy that enforces device encryption, screen locks, remote wipe, mobile device management, separation of work data, and prohibits storing ePHI in unsecured apps or locations.

What is considered a HIPAA data breach?

A breach is an impermissible use or disclosure of unsecured PHI that compromises its security or privacy, such as ransomware, lost or stolen devices, misdirected emails, or unauthorized access, unless a documented risk assessment shows a low probability of compromise.

How soon must a HIPAA breach be reported?

Affected individuals must be notified without unreasonable delay and no later than 60 days after discovery. Reporting to HHS depends on the number of affected individuals; large breaches (500 or more) require more immediate reporting and, in some cases, media notice.

What are the penalties for HIPAA violations?

HIPAA penalties vary by tier based on level of culpability, with per-violation amounts and annual caps per violation type. Enforcement may include corrective action plans, settlement amounts, and monitoring. Actual amounts depend on the facts and current HHS guidance.

Can my practice be audited for HIPAA compliance?

Yes. HHS’s Office for Civil Rights conducts audits and investigations, particularly after breaches or complaints. Maintaining documentation, training records, and current risk analyses helps demonstrate compliance readiness.

What documentation is required to prove HIPAA compliance?

Keep current risk analyses, remediation plans, security and privacy policies, workforce training logs, incident response procedures, business associate agreements, access audit logs, and evidence of ongoing monitoring and evaluations.

What Good Cybersecurity Looks Like for a 30 Person Health Tech Startup

Feb 12

Written By L Trotter II

Your cybersecurity team's size matters, but it's not the end-all be-all.

It’s the system.

And that system gives builds confidence or raises concerns.

Yet most health tech teams of this size still frame security around one question:

“Are we HIPAA compliant?”

That’s not wrong.

It’s just not enough.

Here’s what security should actually look like for a growth‑stage health tech team.

You don’t need a bigger budget. You need better trust signals.

The best cybersecurity programs at this stage don't rely on big tech stacks.

They focus on process, expertise, and the culture.

That means:

Ensuring your processes rely on an educated workforce, not just software
Understanding how PHI moves across your ecosystem
Investing in CISO leadership to build a prioritized roadmap
Treating the administrative safeguards as important as the technical controls

If you can't confidently say you have these in place, your product isn't ready for health systems.

These are trust signals and they show up:

In your due diligence.

In your leadership decisions.

In your confident responses for buyers ask security questions.

How do you know if you're doing great?

It shows up when buyers decide whether to move forward or move on.

👉 Request our Strategic Compliance Guide that helps you improve your trust signals.

Cybersecurity is not a policy. It's practice.

Anyone can send a PDF.

But the best can show:

When the policy was last reviewed and by whom.
What framework your Compliance program is designed around.
Whether its been ChatGPT'd or tailored to your product.
Whether it's consistent across your other supporting documentation.

Anything less raises eyebrows during enterprise buyer risk reviews.

So if you’re relying on templates to cover access controls, incident response, or data flow diagrams, it’s only a matter of time...

Consistency beats complexity.

Simple, framework based, and operationalized policies outperform ones that are dressed up every time.

Most startups don’t struggle because of vulnerabilities.

They struggle because of inconsistent process.

They ignore ‘low’ vulnerabilities, assuming they don’t matter.

They fail to run scans at reasonable frequencies.

They fail to close the loop entirely.

This is a leadership issue.

The fix?

Assign clear CISO ownership.

Because without that, your product and reputation is are exposed.

👉 Our Strategic Compliance Guide helps you identify the cybersecurity controls your leadership should focus on.

Good cybersecurity includes your third parties. Not just your app.

Most breaches in 2025 didn’t start inside the app.

They started with vendors, APIs, Integrations, and Shadow AI.

And in 2026, third‑party risk will likely receive more scrutiny.

This means knowing your own controls and the controls your suppliers don't have.

To stay on top of this:

Review vendors security posture beyond SOC 2 Compliance
Know where your shared risk lives

Vendor due diligence is a maturity signal.

👉Request our Vendor Security Guide to get ahead of the questions and answer them with confidence.

Good security doesn’t scale by accident.

It scales through:

Organizational, system, and process risk reviews
Monitored access controls
Incident response exercises
Holistic audit trails
Cybersecurity leadership

This is table stakes for operating responsibly in 2026.

And operating responsibly is built through small, repeatable actions, not massive investments.

If you're a 30-person health tech team, here's the truth:

Forget about perfect.

Focus on readiness.

Because readiness builds trust.

And trust is paramount for healthcare.

Let security become your differentiator, not your bottleneck.

Use our Strategic Compliance Guide to get there.

Then use the Vendor Security Guide to stay there.

One Question for You

What’s one security challenge you want clarity on this year?

Drop it in the comments.

I’ll provide insights from responses in the next article.

L Trotter II

As Founder and CEO of Inherent Security, Larry Trotter II is responsible for defining the mission and vision of the company, ensuring execution aligns with the business purpose. Larry has transformed Inherent Security from a consultancy to a cybersecurity company through partnerships and expert acquisitions. Today the company leverages its healthcare and government expertise to accelerate compliance operation for clients.

Larry has provided services for 12 years across the private industry developing security strategies and managing security operations for Fortune 500 companies and healthcare organizations. He is influential business leader who can demonstrate the value proposition of security and its direct link to customers.

Larry graduated from Old Dominion University with a bachelor’s degree in Business Administration with a focus on IT and Networking. Larry has accumulated certifications such as the CISM, ISO27001 Lead Implementer, GCIA and others. He serves on the Board of Directors for the MIT Enterprise Forum DC and Baltimore.

https://www.inherentsecurity.com