Examples and Templates for EHR Incentive Program Security Risk Assessments

You can streamline EHR Incentive Program compliance by pairing clear examples with ready-to-use templates. This guide walks you through the security risk assessment requirement, practical tools and templates, and documentation models that support HIPAA Security Rule implementation and protected health information security.

Use the sections below to scope, execute, document, and mitigate risks systematically, ensuring complete security risk assessment documentation and efficient risk mitigation planning.

Security Risk Assessment Requirement

For EHR Incentive Program compliance, you must perform a security risk analysis of electronic protected health information across your environment. This includes administrative, physical, and technical safeguards, and extends to hosted systems, connected devices, and business associates handling ePHI.

Regulators expect a thorough administrative safeguards risk analysis, implementation of security updates, and timely correction of identified deficiencies. “Periodic” reviews are required; best practice is to reassess at least annually and whenever you introduce significant changes such as a new EHR module, cloud migration, or mergers.

Scope and evidence

• Systems in scope: EHR, patient portals, HIE connections, backups, endpoints, and integration engines.
• Data flows: intake, storage, transmission, and disposal of ePHI.
• Evidence: policies, system configurations, audit logs, training records, and risk registers.

Minimum deliverables

• Documented methodology aligned to HIPAA Security Rule implementation.
• Asset and data-flow inventory covering protected health information security.
• Risk register with likelihood, impact, existing controls, and residual risk.
• Plan of Action and Milestones (POA&M) for remediation and risk mitigation planning.
• Executive summary suitable for EHR Incentive Program attestation.

ONC Security Risk Assessment Tool

The ONC Security Risk Assessment Tool helps small to midsize providers structure a complete analysis. It guides you through questionnaire-based checks, aggregates results, and produces exportable reports that support security risk assessment documentation.

How to use it effectively

1. Prepare scope: list systems, vendors, and locations handling ePHI.
2. Complete sections: administrative, physical, and technical controls; policies; workforce training.
3. Rate responses: mark “implemented,” “partially,” or “not implemented,” and capture notes and evidence.
4. Review the summary: prioritize items with higher potential impact on protected health information security.
5. Export results: attach outputs to your risk register and POA&M.

Tips and examples

• Map each question to your policy or control. Example: “Unique user IDs” → Access Control Policy; verify EHR audit trails and identity governance records.
• Treat the output as input to your own templates; ONC certified tools apply to EHR functionality, while the ONC SRA Tool is a structured aid for analysis.
• Record decisions immediately: owner, due date, and acceptance criteria for each finding.

HIPAA Risk Assessment Template

Use this template to record consistent, actionable findings. It standardizes administrative safeguards risk analysis while keeping entries concise and auditable.

Template fields

• Asset/Process: system, workflow, or vendor handling ePHI.
• Threat–Vulnerability Pair: what could go wrong and why.
• Likelihood (1–5) and Impact (1–5): define your scoring rubric.
• Inherent Risk Score: likelihood × impact.
• Existing Controls: policies, technical safeguards, monitoring.
• Residual Risk: after existing controls.
• Recommended Mitigation: control enhancement or compensating measure.
• Owner, Due Date, Status, Evidence Link/Location.

Sample entry

• Asset/Process: EHR user access management.
• Threat–Vulnerability: credential sharing due to weak authentication.
• Likelihood: 3; Impact: 4; Inherent Risk: 12 (High).
• Existing Controls: unique IDs, password policy; no MFA for remote access.
• Residual Risk: Medium.
• Mitigation: implement MFA and quarterly access reviews; update workforce training.
• Owner/Due: IT Security, 60 days; Evidence: access review report and MFA rollout plan.

HIPAA Security Risk Analysis Template Suite

A template suite accelerates documentation and ensures traceability from findings to remediation. Assemble the following components to cover HIPAA Security Rule implementation comprehensively.

Core documents

• Policy and Procedure Index: mapped to administrative, physical, and technical safeguards.
• Asset and Data-Flow Inventory: systems, data stores, interfaces, and transmission paths.
• ePHI Systems Register: purpose, location, encryption, backup, and recovery details.
• Business Associate Inventory: BAAs, services in scope, and oversight activities.
• Risk Register: master list of findings with scoring and status.
• Gap Analysis Crosswalk: requirement-by-requirement compliance narrative and evidence.
• Training and Awareness Plan: frequency, audience, and completion metrics.
• Incident Response and Contingency Plans: roles, contact trees, and test dates.
• POA&M: prioritized tasks, budget, and milestones for risk mitigation planning.
• Metrics Dashboard: key risk indicators and remediation progress.

Usage pattern

• Start with the crosswalk to identify mandatory controls and current coverage.
• Populate the asset inventory, then trace ePHI flows to confirm scope.
• Log gaps in the risk register and link evidence locations for audit readiness.
• Publish the POA&M and update metrics monthly until closure.

Security Risk Assessment Tip Sheet

Apply these field-tested practices to strengthen protected health information security and keep documentation defensible.

• Right-size the scope: include hosted platforms, shadow IT, and connected medical devices.
• Engage a cross-functional team: compliance, privacy, IT, clinical operations, and vendors.
• Define a scoring rubric up front and use it consistently across findings.
• Treat “partially implemented” as a tracked risk with a clear owner and deadline.
• Validate controls with evidence: screenshots, config exports, and sampled audit logs.
• Prioritize encryption at rest and in transit, MFA for remote access, and patch cadence.
• Test backups and disaster recovery; document results in the contingency plan.
• Review BAAs and vendor SOC reports; track third-party risks explicitly.
• Document residual risk and the rationale behind any risk acceptance decision.
• Schedule a post-mitigation review to confirm risk reduction and update training.

Sample Security Risk Assessment Report

Use the outline below to produce clear, concise security risk assessment documentation that leadership can act on.

Executive summary

• Scope and period covered, methodology, and key results (for example, 3 Critical, 8 High, 14 Medium).
• Top themes: access control, data loss prevention, vendor oversight.
• POA&M highlights: 30/60/90-day milestones and expected risk reduction.

Methodology

• Standards referenced and scoring model (likelihood, impact, risk matrix).
• Data sources: interviews, architecture diagrams, control testing, and log reviews.
• Assumptions and limitations.

Findings and risk register excerpt

• CR-01: Unencrypted database snapshot backups in legacy environment; risk: Critical; mitigation: enable encryption, rotate keys, and restrict snapshot access.
• HI-02: Incomplete termination procedures for workforce changes; risk: High; mitigation: automate HR–IAM feed and run monthly orphaned-account reviews.
• ME-07: Missing quarterly vulnerability scans on radiology workstations; risk: Medium; mitigation: add to scanning scope and remediate within SLA.

Recommendations

• Technical: MFA expansion, encryption coverage, EDR deployment tuning.
• Administrative: policy updates, workforce training refreshers, vendor due diligence.
• Operational: change-management gates tied to ePHI impact and rollback planning.

Appendices

• Asset inventory and data flows.
• Evidence register with locations for auditors.
• Glossary and acronyms.

Security Risk Assessment and Mitigation Plan

Translate findings into a prioritized, budget-aware plan that drives measurable risk reduction. This is the core of risk mitigation planning and the artifact most often requested during EHR Incentive Program compliance reviews.

POA&M structure

• Task ID and Finding ID linkage.
• Mitigation Action: what will change and where.
• Owner and Stakeholders: accountable and consulted roles.
• Milestones: 30/60/90-day checkpoints with acceptance criteria.
• Resources and Budget: tooling, services, and staff effort.
• Risk After Mitigation: target score and validation method.
• Status and Evidence: closure notes and evidence locations.

Example plan items

• MFA-01: Enforce MFA for all external access to EHR and VPN; Owner: IT Security; Milestones: pilot (30 days), full rollout (60 days), validation (90 days); Target: residual risk Low.
• ENC-02: Encrypt backup snapshots and implement key rotation; Owner: Infrastructure; Milestones: design (30), deploy (60), test restore (90); Target: residual risk Low.
• VND-05: Update BAA terms and add quarterly security reporting; Owner: Compliance; Milestones: negotiate (45), execute (75), first report (90); Target: residual risk Medium→Low.

FAQs

What is required for an EHR Incentive Program security risk assessment?

You must analyze risks to ePHI across administrative, physical, and technical safeguards; document findings and evidence; implement security updates; correct deficiencies; and maintain a POA&M. Your assessment should be comprehensive, cover all systems and vendors handling ePHI, and be reviewed periodically and after significant changes.

How does the ONC Security Risk Assessment Tool assist providers?

It structures the assessment through guided questions, helps rate control effectiveness, and summarizes gaps for prioritization. You can export outputs to populate your risk register and POA&M, strengthening security risk assessment documentation and supporting consistent follow-through.

What are the key components of a HIPAA Security Risk Analysis Template?

Core elements include asset/process, threat–vulnerability pair, likelihood and impact scores, inherent and residual risk, existing controls, recommended mitigation, ownership, due dates, status, and evidence references. Using these fields ensures traceability and alignment with HIPAA Security Rule implementation.

How can providers use mitigation plans to address identified risks?

Convert each finding into a POA&M task with a named owner, milestones, budget, and success criteria. Track progress at 30/60/90-day intervals, validate control effectiveness, update residual risk scores, and capture evidence so you can demonstrate risk mitigation planning and sustained compliance.