The HIPAA Security Rule explained
Modern healthcare providers use electronic health records (EHR) and other technology every day. These tools help them serve their patients faster than manual methods. However, the increased adoption of this type of technology can increase security risks. Companies dealing with electronic protected health information, or ePHI, must keep that data safe.
In this article, we explore what the Health Insurance Portability and Accountability Act (HIPAA) Security Rule is. Plus who it applies to and how organizations can use it in a way that maximizes ePHI security while meeting all applicable security requirements.
What is the HIPAA Security Rule?
The HIPAA Security Rule informs organizations on how to protect electronic protected health information. All covered entities and their business associates must follow the security requirements. If they don't, the Department of Health and Human Services (HHS) could penalize them.
These security regulations explain how organizations can apply the HIPAA Privacy Rule by:
- Focusing on measures to store and send ePHI
- Protecting the data from security threats
- Keeping the data with the authorized users only
- Ensuring compliance across the whole workforce
Even though businesses must stick to the rules, there is flexibility in how they set up security measures. HHS realizes that all companies are different. Different sizes, different human and technological resources, different budgets. Plus, they're exposed to different levels of risk with their data management.
Why does the HIPAA Security Rule matter for organizations?
The HIPAA Security Rule is crucial in maintaining the privacy and safety of sensitive medical data in the digital healthcare ecosystem. With more providers using digital platforms to store and share patient records, the risk of data breaches and unauthorized access increases.
The Security Rule establishes a national standard to safeguard ePHI, helping organizations reduce vulnerabilities and mitigate potential threats. It also supports patient trust by ensuring their personal health data is protected. Failure to comply can result in legal action, reputational harm, and financial penalties. Understanding and applying the rule's security requirements helps organizations avoid these risks while maintaining regulatory compliance.
The main goal of the HIPAA Security Rule
The primary purpose of the HIPAA Security Rule is to safeguard the public’s electronic medical information by setting security requirements that prevent unauthorized access, use, or disclosure of ePHI. It ensures that individuals’ health information remains confidential, is not altered or destroyed improperly (integrity), and is available when needed (availability).
The rule provides a flexible framework rather than a one-size-fits-all approach, allowing organizations to assess their own risk levels and tailor solutions accordingly. For example, a small private practice might use simpler safeguards compared to a large hospital system. This flexibility helps ensure that the Security Rule is applicable across various sectors and organizations handling healthcare data, including covered entities and their business associates.
Who does the Security Rule apply to?
The HIPAA Security Rule applies to all covered entities that deal with ePHI. For example, hospitals, health plans, healthcare clearinghouses, and their business associates.
It's important to note that the security rule and other HIPAA compliance standards apply to any entity that works with ePHI. This entity could be a contractor, freelancer, or subcontractor who works with a covered entity or a business associate. These regulations apply to them if they work with individually identifiable health information.
It also extends to third-party service providers such as contractors, freelancers, or subcontractors who handle ePHI on behalf of a covered entity or business associate. These individuals or organizations must comply with the same security requirements, even if they are not part of the healthcare provider’s internal staff.
As digital collaboration becomes more common, all parties working with ePHI must understand and implement HIPAA compliance measures. Covered entities must ensure that these external collaborators are properly trained and have secure systems in place.
3 main HIPAA security rule safeguards
The security rules consist of three components to ensure sensitive medical info is not exposed. These include Administrative safeguards, Physical safeguards, and Technical safeguards.
Administrative safeguards
Administrative safeguards are policies and procedures designed to manage the selection, development, implementation, and maintenance of security measures that protect ePHI. These controls include assigning a dedicated security officer to oversee HIPAA compliance, implementing workforce training programs, and conducting regular risk assessments.
Covered entities must document their security plans and update them as threats evolve. They are also required to establish procedures for incident response and sanctions for non-compliance. Regular evaluations must be performed to measure the effectiveness of current policies.
This layer of protection ensures that human actions, whether intentional or accidental, do not compromise security requirements.
Physical safeguards
Physical safeguards are designed to limit physical access to facilities and devices that store or process ePHI, protecting against unauthorized entry and environmental hazards. This includes security measures such as surveillance systems, locked server rooms, and visitor access controls. Workstations should be positioned to prevent unauthorized viewing, and policies should address the use of mobile devices.
Covered entities must ensure secure device disposal and data destruction practices to prevent information leaks. Equipment containing ePHI must be logged and tracked, and physical access logs should be maintained to monitor entry points and protect data assets.
Technical safeguards
Technical safeguards refer to the technology and policies used to protect and control access to ePHI. This includes access control mechanisms like unique user IDs, automatic logoff, and multi-factor authentication (MFA) to verify user identity.
Organizations must also implement audit controls that record and examine access and activity in systems containing ePHI. Integrity controls ensure that data is not improperly altered or destroyed. Additionally, encryption is recommended (and often expected) when ePHI is transmitted over open networks, ensuring that intercepted data remains unreadable to unauthorized users. These safeguards support secure communication and limit exposure in the event of a cyber-attack.
Where does risk analysis fit into these rules?
Covered entities should perform risk analysis before they apply the three safeguards. The results of the risk assessment will guide how they carry out the security measures. This could be different for each organization based on its resources. The assessment will uncover potential risks to ePHI and the best security solution to keep the data secure. Plus, document the choices and reasons for them and maintain those security measures.
HIPAA security rule requirements use case
The security rule includes mandatory standards and security requirements for healthcare organizations. These focus on keeping ePHI confidential and secure and granting access only to users who must work with the data. Organizations are also required to ensure compliance throughout their entire workforce.
One way covered entities can restrict access to ePHI is by having strict access controls on their network. Network security solutions should help the security team manage exactly what resources users can access and what they can do with that data. Verifying user identities is critical for keeping ePHI secure. This kind of solution often includes multi-factor authentication (MFA). MFA blocks unauthorized access but lets the right users verify their identity quickly.
Protecting sensitive medical information from a data breach is essential for any business that works with ePHI. By implementing the HIPAA Security Rule’s administrative, physical, and technical safeguards, organizations take key steps toward fulfilling regulatory security requirements and preserving patient trust.
Looking ahead: The future of the HIPAA Security Rule
As the healthcare industry continues to evolve and threats grow more sophisticated, updates to the HIPAA Security Rule are being considered. In April 2023, the U.S. Department of Health and Human Services (HHS) proposed new changes aimed at strengthening the rule. These updates focus on improving cybersecurity standards, clarifying existing policies, and enhancing safeguards for electronic protected health information.
The proposed rule emphasizes accountability, timely breach response, and better security practices among covered entities and business associates. If adopted, these changes could reshape how organizations approach HIPAA compliance in the coming years. To stay protected and compliant, organizations should monitor these regulatory developments closely.
Disclaimer: This article is for informational purposes only and not legal advice. Use it at your own risk and consider consulting a licensed professional for legal matters. Content may not be up-to-date or applicable to your jurisdiction and is subject to change without notice.