Comprehensive HIPAA Glossary: Understanding Healthcare Compliance Terms

HIPAA Overview

The Health Insurance Portability and Accountability Act (HIPAA) sets national standards for safeguarding health information and governs how you create, use, and share patient data. This HIPAA glossary focuses on practical terms that drive day‑to‑day compliance decisions across privacy, security, and breach response.

HIPAA’s core rules work together. The HIPAA Privacy Rule governs how Protected Health Information (PHI) may be used and disclosed. The Security Rule establishes safeguards for electronic PHI (ePHI) and sets expectations for Security Rule Compliance. The Breach Notification Rule outlines Data Breach Notification duties after unauthorized access, use, or disclosure. Enforcement provisions establish investigation and penalty processes.

• Covered Entity (CE): A health plan, health care clearinghouse, or health care provider that transmits health information electronically in standard transactions.
• Business Associate (BA): A person or organization that performs services for a CE and handles PHI or ePHI (for example, cloud hosting, billing, analytics).
• Minimum Necessary: Limit PHI uses, disclosures, and requests to what is reasonably needed to achieve the purpose.
• Notice of Privacy Practices (NPP): A document that explains how your organization uses and discloses PHI and the rights patients have over their information.
• Designated Record Set: Records used to make decisions about individuals; central to access and amendment rights.

Protected Health Information Definitions

Protected Health Information (PHI) is individually identifiable health information related to health status, health care, or payment for health care, created or received by a CE or BA. It covers any medium—paper, verbal, or electronic. When the same information is in electronic form, it is ePHI.

• Individually Identifiable Health Information (IIHI): Data that identifies a person or for which there is a reasonable basis to believe it can identify a person.
• ePHI: PHI stored or transmitted electronically (systems, devices, cloud services, backups, and integrations).
• Identifiers: Elements that can identify a person, such as name, address, contact information, Social Security number, medical record number, full-face photos, and device identifiers.
• Use vs. Disclosure: Use is internal handling of PHI; disclosure is sharing PHI outside your organization.
• Authorization: A signed permission from the individual for uses/disclosures not otherwise permitted by the HIPAA Privacy Rule.
• De-identification: Removal of identifiers so data can no longer identify an individual. Methods include expert determination or removal of specified identifiers (Safe Harbor).
• Limited Data Set (LDS): PHI stripped of most direct identifiers, shared under a data use agreement for research, public health, or health care operations.
• Psychotherapy Notes: Notes kept separate from the medical record with special protections; most uses require authorization.
• Treatment, Payment, and Health Care Operations (TPO): Core purposes that allow many uses/disclosures without authorization under the HIPAA Privacy Rule.

Covered Entity Responsibilities

Covered entities must build and maintain a privacy and security program suited to their risks and operations. Your obligations span policy, technical controls, training, and incident response.

• Privacy Program: Publish and distribute an NPP, apply the minimum necessary standard, manage authorizations, and handle restrictions and confidential communications.
• Security Rule Compliance: Implement administrative, physical, and technical safeguards appropriate to your environment to protect ePHI.
• Risk Assessment Procedures: Perform ongoing risk analysis and risk management to identify threats, vulnerabilities, and reasonable controls.
• Workforce Training Requirements: Train all workforce members on policies, procedures, and safeguards; document completion and refreshers.
• Access Control Policies: Define role-based access, approve access requests, review access regularly, and remove access promptly upon role changes.
• Individual Rights: Provide timely access to records, allow amendments, and offer an accounting of certain disclosures.
• Data Breach Notification: Investigate incidents, conduct a breach risk assessment, mitigate harm, and notify affected parties and regulators when required.
• Business Associate Oversight: Execute Business Associate Agreements, monitor BA performance as appropriate, and address known BA noncompliance.
• Documentation and Retention: Maintain policies, procedures, and required documentation for at least six years and update them as operations evolve.

Business Associate Agreement Essentials

A Business Associate Agreement (BAA) is the contract that enables a CE to disclose PHI to a BA while protecting individuals’ privacy and security. It spells out what a BA may do with PHI and how the BA will safeguard it.

• Permitted Uses and Disclosures: Define specific purposes and prohibit uses not authorized by the BAA or law.
• Safeguards: Require administrative, physical, and technical protections for ePHI consistent with Security Rule Compliance.
• Subcontractors: Mandate that subcontractors who handle PHI agree to the same restrictions and safeguards.
• Breach and Security Incident Reporting: Oblige prompt reporting of incidents to support timely Data Breach Notification by the CE.
• Individual Rights Support: Ensure the BA helps the CE with access, amendment, and accounting requests when PHI is held by the BA.
• Return/Destruction of PHI: Require PHI to be returned or destroyed at contract end where feasible, with continued protections if not feasible.
• Audit and Termination: Allow oversight of BA compliance and termination for material breaches.

Administrative Safeguards Implementation

Administrative safeguards are your organizational policies and processes that reduce risk to ePHI. They translate governance into daily practice.

• Security Management Process: Conduct Risk Assessment Procedures, prioritize risks, and implement a risk management plan with measurable controls.
• Workforce Security: Screen workforce members, define job-based access, and remove access promptly when roles change.
• Information Access Management: Enforce least privilege and document Access Control Policies and approval workflows.
• Security Awareness and Training: Provide initial and periodic Workforce Training Requirements, including phishing awareness and device handling.
• Security Incident Procedures: Detect, report, triage, and document incidents; escalate potential breaches for assessment and response.
• Contingency Planning: Maintain data backup, disaster recovery, and emergency mode operations procedures; test and revise plans regularly.
• Evaluation and Documentation: Review safeguards periodically and update policies, procedures, and risk analyses as systems and threats change.

Physical Safeguards Practices

Physical safeguards protect facilities, people, and hardware that store or access ePHI. They limit opportunities for unauthorized viewing, loss, or theft.

• Facility Access Controls: Manage entry with keys or badges, maintain visitor logs, and protect server/network rooms and on-site storage.
• Workstation Use and Security: Define appropriate workstation use, apply privacy screens, and position monitors to reduce shoulder-surfing.
• Device and Media Controls: Track laptops, mobile devices, and removable media; encrypt devices; sanitize or destroy media before reuse or disposal.
• Environmental Protections: Use secure cabinets, anchored hardware, and protections against fire, water, or power disruptions where ePHI is stored.

Technical Safeguards Technologies

Technical safeguards are the systems and tools that enforce your policies for ePHI. They implement Access Control Policies, monitor activity, and protect data in motion and at rest.

• Access Controls: Assign unique user IDs, enforce role-based access, enable automatic logoff, and maintain emergency access procedures.
• Authentication: Verify users and devices with strong passwords, multifactor authentication, and, where appropriate, single sign-on.
• Encryption: Protect ePHI in transit (TLS, secure messaging) and at rest (full-disk or file-level encryption) to reduce breach risk.
• Audit Controls: Log system and application activity, centralize logs, and review alerts for anomalous access or exfiltration.
• Integrity Controls: Use hashing, checksums, and change monitoring to ensure ePHI is not altered or destroyed improperly.
• Transmission Security: Secure email, APIs, and file transfers; restrict insecure protocols; segment networks handling ePHI.
• Endpoint and Application Security: Apply patching, configuration baselines, mobile device management, vulnerability scanning, and secure development practices.
• Data Loss Prevention and Backup: Detect and block unauthorized sharing, and maintain encrypted, tested backups aligned with recovery objectives.

A practical approach to HIPAA compliance ties policy to execution: understand PHI concepts, document processes, train your workforce, implement layered safeguards, and continually reassess risk. Doing so strengthens privacy, achieves Security Rule Compliance, and improves your readiness for Data Breach Notification and audits.

FAQs.

What is the definition of Protected Health Information?

Protected Health Information (PHI) is individually identifiable health information related to health status, care, or payment for care that is created or received by a covered entity or business associate. When stored or transmitted electronically, the same information is ePHI.

How do Business Associate Agreements safeguard PHI?

Business Associate Agreements contractually require vendors to use and disclose PHI only for defined purposes, implement administrative, physical, and technical safeguards, flow down protections to subcontractors, report incidents promptly, support individual rights, and return or destroy PHI at contract end—thereby extending HIPAA protections beyond the covered entity.

What are the main types of HIPAA safeguards?

HIPAA groups safeguards into three categories: administrative (policies, workforce oversight, Risk Assessment Procedures), physical (facility, workstation, and device protections), and technical (Access Control Policies, authentication, encryption, audit and integrity controls) to ensure comprehensive Security Rule Compliance.

When is Breach Notification required under HIPAA?

Breach Notification is required when unsecured PHI is compromised and a risk assessment indicates a significant probability that the PHI was acquired, viewed, or used in an impermissible way. You must mitigate harm and, when required, notify affected individuals and regulators without unreasonable delay.