A Security Risk Assessment Guide for Multidisciplinary Spina Bifida Programs

A multidisciplinary spina bifida program coordinates care across specialties, locations, and systems. That collaboration can make care more connected, but it also creates many ways for sensitive information to be accessed, shared, stored, or exposed.

A structured security risk assessment helps your program understand where electronic protected health information (ePHI) moves, identify potential weaknesses, and choose safeguards that fit your work. Use this guide to organize the assessment around your team, facilities, technology, and partners.

Define Security Scope and Assessment Objectives

Start by setting a clear scope. Identify the clinics, departments, staff, services, and technologies involved in the program, including any affiliated hospitals or remote-care operations. Include the systems and processes that create, receive, maintain, or transmit ePHI for program activities.

Set objectives before gathering information. Your assessment should help you understand how threats or vulnerabilities could affect the confidentiality, integrity, and availability of ePHI, and whether existing measures adequately address those risks. A risk analysis is foundational to applying the HIPAA Security Rule’s safeguards; the results should inform risk management decisions.

Establish who will participate and how decisions will be recorded. Include clinical, administrative, privacy, information technology, security, and facilities representatives, along with people who understand the program’s day-to-day workflows. Define the period being assessed, the method for scoring risks, and how the team will handle gaps or disagreements.

Map Clinical Workflows and Information Systems

Follow the patient journey through the program, from referral and intake to visits, care coordination, follow-up, and transitions to other providers. For each step, note who handles information, what systems they use, and how information is shared. Include workflows such as scheduling, imaging, laboratory testing, equipment coordination, and referrals.

Build an inventory of relevant systems and devices. Depending on the program, this may include electronic health records, scheduling and billing applications, patient portals, secure messaging, telehealth platforms, shared drives, mobile devices, clinical equipment, and systems managed by a parent organization.

For each workflow, document how staff sign in, which roles can view or change records, and whether information is downloaded, printed, emailed, or entered into another system. Include routine workarounds and downtime procedures; informal practices can create security gaps even when the main system is well controlled.

Identify Protected Health Information and Data Flows

Identify the information the program creates, uses, stores, and shares. This may include contact and insurance details, medical histories, diagnoses, treatment plans, imaging, laboratory results, and care-coordination notes. Consider information about minors and family members, as well as information collected through remote care or patient communications.

Map where ePHI enters the program, where it is stored, who can access it, and where it goes next. Track transfers between specialties, clinics, hospitals, laboratories, pharmacies, equipment suppliers, and other partners. Note whether each transfer occurs through an electronic record, a secure exchange, email, fax, paper documents, or another channel.

Record the safeguards that apply at each point, such as user permissions, secure transmission, device protections, and retention or disposal practices. The HIPAA Security Rule focuses on protecting ePHI and uses administrative, physical, and technical safeguards to support its confidentiality, integrity, and availability.

Evaluate Facility and Physical Access Controls

Review where staff can view or handle ePHI, including reception areas, exam rooms, workstations, records rooms, and shared clinical spaces. Consider whether computer screens, printed schedules, charts, or conversations can be seen or overheard by people without a work-related need to know.

Assess how the program controls entry to offices and restricted areas. Examine visitor procedures, staff badges or keys, access to server and network equipment, after-hours access, and the secure storage and disposal of records and devices. Include laptops and mobile devices used in clinics, during home visits, or while traveling between locations.

Observe how controls work in practice. Check whether staff lock screens when stepping away, keep devices secure, and store paper records when not in use. Consider how the program would respond to a lost device, a broken lock, or a visitor entering a restricted space.

Assess Cybersecurity and Third-Party Risks

Review technical safeguards that protect systems and ePHI. Areas to assess include unique user accounts, access based on job responsibilities, timely removal of access when roles change, authentication, encryption decisions, security updates, malware protection, backups, and system monitoring. Consider how the program detects and responds to suspicious activity.

Examine remote access, telehealth, and mobile-device practices. Determine whether staff use approved tools, whether personal devices can access ePHI, and how the program protects information when staff work outside its facilities. Check that the team knows how to report suspected phishing, a lost device, or an unusual account alert.

Identify vendors and other partners that create, receive, maintain, or transmit ePHI for the program. Review what information each partner handles, what services it provides, how access is controlled, and how security incidents are communicated. Where required, confirm that appropriate business associate agreements are in place and reflect the parties’ responsibilities for safeguarding information.

Consider risks that may affect a vendor or service the program depends on, including outages, compromised accounts, insecure data transfers, and unavailable backups. Document the program’s reliance on third parties and how it would maintain essential care coordination if a service became unavailable.

Prioritize Threats and Document Findings

For each identified concern, describe the affected information or system, the threat or weakness, the safeguards already in place, and the possible effect on care and ePHI. Consider both the likelihood of an incident and its potential impact. Examples might include overly broad access, an unprotected device, a misdirected referral, or an interruption to a system used for care coordination.

Use a consistent method to rank findings. A simple scale for likelihood and impact can help the team compare risks and focus on the most consequential issues, provided the scoring criteria are defined and applied consistently. Record assumptions and explain why a risk received its rating.

Keep the assessment documentation practical and traceable. Include the scope, participants, systems and workflows reviewed, findings, current safeguards, risk ratings, and decisions about follow-up. A documented risk analysis helps the organization identify potential threats and vulnerabilities affecting ePHI and evaluate the likelihood of occurrence.

Develop a Risk Mitigation and Review Plan

Turn priority findings into specific actions. For each action, name an accountable owner, a target date, the resources needed, and how completion will be verified. Measures may include adjusting user access, improving device controls, updating procedures, training staff, strengthening backups, or working with a vendor to address a weakness.

Include administrative safeguards in the plan, such as assigning security responsibilities, maintaining policies, training staff, and preparing incident-response procedures. Coordinate technical changes with clinical teams so safeguards support rather than unnecessarily disrupt the workflows needed to provide care.

Review progress regularly and update the assessment when meaningful changes occur, such as new systems, new vendors, a change in how care is delivered, a security incident, or a significant workflow change. Set a recurring review schedule appropriate to the program, and ensure unresolved risks remain visible to the people responsible for decisions.

In short, an effective assessment connects the program’s care workflows and information systems to the safeguards that protect ePHI. By documenting risks, assigning owners, and reviewing changes over time, your multidisciplinary team can make security part of reliable care coordination.

FAQs

What does a HIPAA security risk assessment cover for a spina bifida program?

It examines the program’s ePHI, workflows, systems, facilities, workforce access, and vendors to identify potential threats and weaknesses. It also reviews existing safeguards and documents risks and actions to address them.

How should a multidisciplinary team map access to electronic protected health information?

Trace the patient journey and identify, at each step, which roles access ePHI, which systems they use, and how information is shared or stored. Include routine practices, remote access, and downtime workflows, then compare access with each person’s job responsibilities.

Which security safeguards should a spina bifida program assess?

Assess administrative safeguards such as policies, assigned responsibilities, and workforce training; physical safeguards such as facility and device security; and technical safeguards such as user access, authentication, monitoring, and protections for stored or transmitted ePHI. Consider vendor controls and business associate agreements where applicable.

How often should the program review and update its security risk assessment?

Set a recurring review schedule that fits the program and revisit the assessment when significant changes occur, such as new systems or vendors, changes to care workflows, or a security incident. Keep findings and mitigation actions current between reviews.