Healthcare

The HIPAA Security Rule requires healthcare organizations to implement administrative, physical, and technical safeguards to protect electronic protected health information (ePHI). Key requirements include: conducting a comprehensive risk assessment to identify vulnerabilities, implementing security policies and procedures, designating a HIPAA Security Officer, providing workforce security awareness training, implementing access controls and audit logs for ePHI systems, encrypting ePHI in transit and at rest (addressable but highly recommended), establishing an incident response plan and breach notification procedures, and executing Business Associate Agreements (BAAs) with all vendors who handle ePHI. Compliance is not a one-time event but requires ongoing risk management, regular security assessments, policy updates, and workforce training. We guide healthcare organizations through implementing all required and addressable HIPAA safeguards in a systematic, cost-effective manner.

While HIPAA doesn't specify an exact frequency, HHS guidance and best practices recommend conducting a comprehensive HIPAA risk assessment annually at minimum. You should also conduct assessments whenever there are significant changes to your practice such as: implementing new EHR systems or medical devices, adding new locations or services, experiencing a security incident or near-miss, onboarding new business associates or IT vendors, or changing your technology infrastructure. Regular risk assessments are critical because the threat landscape constantly evolves, your practice changes over time, and OCR expects you to demonstrate ongoing risk management efforts. During OCR audits, they specifically look for evidence of periodic risk assessments and remediation of identified vulnerabilities. We help healthcare organizations establish annual risk assessment schedules and conduct focused assessments when significant changes occur.

If you discover a breach affecting protected health information (PHI), HIPAA requires specific notification steps based on the breach size. For breaches affecting 500 or more individuals: notify affected patients without unreasonable delay (within 60 days), notify HHS immediately, and notify prominent media outlets if the breach affects state residents. For breaches affecting fewer than 500 individuals: notify affected patients within 60 days and log the breach for annual reporting to HHS. All breaches regardless of size require documentation and a risk assessment to determine if notification is required. Failing to comply with breach notification requirements can result in significant fines ($100 to $50,000 per violation). Beyond regulatory requirements, you'll need to manage public relations, offer credit monitoring services to affected patients, investigate the root cause, and implement corrective actions. We help healthcare organizations develop breach response plans that address all notification requirements and coordinate the response process if a breach occurs.

Yes, HIPAA requires you to have a signed Business Associate Agreement (BAA) with any vendor, contractor, or service provider who creates, receives, maintains, or transmits protected health information (PHI) on your behalf. This includes: EHR/practice management system vendors, cloud storage and backup providers (Microsoft 365, Google Workspace, Dropbox, etc.), billing and transcription services, IT support companies with access to your systems, email providers and communication platforms, and website hosting services if patient data is involved. The BAA must specify the vendor's HIPAA obligations, permitted uses of PHI, requirements to implement safeguards, breach notification procedures, and your right to audit their compliance. Many cloud providers offer standard BAAs, but some require you to request them. We help healthcare organizations identify which vendors require BAAs, negotiate appropriate terms, and manage BAA renewals as part of ongoing vendor risk management.

Securing your EHR system requires multiple layers of protection: implement multi-factor authentication (MFA) for all users accessing the EHR, maintain offline backups of your EHR database tested regularly for restoration, keep the EHR software and all servers updated with security patches, restrict access based on role (providers, nurses, billing staff get only necessary access), enable audit logging to track all access to patient records, train staff on phishing recognition since email is the primary ransomware delivery method, implement email filtering to block malicious attachments and links, segment your EHR network from guest wifi and other less-secure networks, and develop an incident response plan specifically for EHR downtime or ransomware. If your EHR is cloud-hosted, ensure the vendor has appropriate security controls and a valid BAA in place. We conduct specialized EHR security assessments that evaluate both the software configuration and the infrastructure supporting your EHR, identifying vulnerabilities before they're exploited.