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.

5 ways to signal trust to providers before product demos.

Sep 16

Written By L Trotter II

Treat HIPAA like it’s the first thing a health system sees.

Not after the demo.

Not after the case study.

Not after they ask about cost.

Here are 5 ways to do it:

✅ Publish a HIPAA statement on your website
→ Show you take patient rights and safety serious

✅ Include security articles in your blog
→ Show you care about more than just your features

✅ Brag about your risk assessments
→ Find clever ways to mention it in your marketing deck

✅ Assign a dedicated owner (not your Devs)
→ Providers don't see health tech CISOs often

✅ Ask them about their SLA requirements
→ This signals you understand uptime is critical

This is how you prove your product is safe, secure, and provider-ready!

So why does it matter?

So many health tech organizations are knocking on the door of health systems about their new solution with AI features. Innovation is a good thing, but at the same time providers are concerned about AI security and privacy.

So how to you differentiate yourself? Don’t only make the solution benefits as part of your pitch. Talk about your AI governance strategy…a lot! Features aren’t the only way to differentiate yourself. Make cybersecurity a part of your mission. After all, patients lives are at stake.

Governance = Trust

If HIPAA compliance leaves your engineers overwhelmed, let us help you manage it.

Our trusted vCISO service helps you secure your systems so your team can focus on what they do best! Schedule a call now to talk with an expert.

Breach of the Week!

CVS Under HIPAA Investigation

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

5 ways to signal trust to providers before product demos.

So why does it matter?

Governance = Trust

Breach of the Week!

Inside NYBCe, US HealthConnect & MedicSolution Breaches: Key Lessons for Health Tech Founders

Connect with us on LinkedIn