HIPAA Security Rule

The HIPAA Security Rule comprises three key components, namely the Administrative Safeguards, Physical Safeguards, and Technical Safeguards. The Administrative Safeguards include policies, procedures, and staff training. Physical Safeguards are measures to protect physical access to ePHI storage systems such as servers, computers, and hard drives. Examples of this include locked server rooms, workstation security, and secure storage of devices in transit. Technical Safeguards use technologies like firewalls, encryption, and secure and auditable logins to control access to ePHI.

Points every healthcare professional should know about the HIPAA Security Rule:

1. The Three Main Safeguard Categories

To comply with the Security Rule, healthcare organizations must implement reasonable and appropriate safeguards in three areas:

Important Administrative Safeguards

• Assign a security officer.
• Conduct risk assessments.
• Develop and enforce security policies and training.
• Have an incident response plan.

Important Physical Safeguards

• Restrict physical access to systems and devices.
• Secure ePHI with locks on server rooms and screen positioning.
• Manage device disposal securely to ensure data is fully destroyed on equipment such as printers, fax machines, scanners, thumb drives, and computers.

Important Technical Safeguards

• Control access to ePHI (e.g., individual user authentication, strong passwords).
• Use encryption for digitally stored and transmitted health data.
• Implement audit logs and automatic log-offs.

2. Minimum Necessary Access

• Staff should only access the information they need to do their jobs. This is called the “minimum necessary” standard.

3. Mandatory Risk Analysis

• Organizations must regularly assess security risks to ePHI in their care and document steps to mitigate them.
• This is not a one-time task — it must be updated with new technologies, threats, or changes in procedures.

4. Training is Required

• All staff must receive security awareness training, including:
  • Phishing and password safety
  • Safe use of email and mobile devices
  • Recognizing and reporting security incidents

5. Security Incidents Must Be Managed

• All security breaches (even attempted ones) must be:
  • Investigated
  • Documented
  • Reported to the appropriate parties/authorities
  • Prevented in the future with the implementation of appropriate safeguards

6. Penalties Are Serious

• Civil and criminal penalties can apply for non-compliance with the HIPAA Security Rule — even if the violation was unintentional.
• Maximum civil penalty: $50,000 per violation, up to $1.5 million per year.
• Criminal penalties may include fines and imprisonment.

7. Use of Mobile Devices is Risky

• If you access ePHI on phones, tablets, or laptops:
  • Devices should be encrypted and password-protected
  • Lost/stolen devices must be reported immediately

8. Security Rule Supports but Doesn’t Dictate Technology

• The Security Rule is flexible and scalable — it doesn’t prescribe specific software or devices, only technology requirements for compliance, such as:
  • Access Controls
  • Audit Capabilities
  • Integrity Controls against improper alteration or destruction
  • Transmission Security when appropriate
  • Device and media control policies