HIPAA Risk Assessment Examples Explained: Requirements, Best Practices, and Common Gaps

HIPAA Risk Assessment Requirements

A HIPAA risk assessment identifies how electronic protected health information (ePHI) is created, received, maintained, processed, and transmitted across your environment. You evaluate threats, vulnerabilities, likelihood, and impact to determine risk levels and required safeguards.

Scope your review to all locations where ePHI resides: EHR platforms, billing systems, patient portals, email, cloud storage, mobile devices, backups, medical devices, and third-party connections under business associate agreements (BAAs). Include people, processes, and technology.

Regulatory expectations, distilled

• Inventory assets and data flows that touch ePHI.
• Identify threats and vulnerabilities for each asset and workflow.
• Assess likelihood and impact, then assign risk ratings.
• Document existing security controls and gaps.
• Create and track a risk mitigation action plan to reduce risk to a reasonable and appropriate level.

Examples that clarify scope

• Small clinic: Unencrypted laptops with downloaded claims files, shared front-desk logins, and fax-to-email workflows storing ePHI in inbox archives.
• Telehealth startup: Cloud video platform, API integrations with a scheduling app, and BAAs with a cloud host and transcription vendor.
• Hospital department: Legacy radiology workstation storing images locally without centralized logging or multi-factor authentication.

Best Practices for HIPAA Risk Assessments

Use a repeatable method that blends technical depth with operational practicality. Start with a data flow diagram to visualize where ePHI moves and who can access it, then map controls to each step.

A practical step-by-step approach

• Build an asset inventory tied to data classifications and owners.
• Model threats for each asset and interface, including vendors under BAAs.
• Score risks using a simple, documented matrix for consistency.
• Select layered security controls: encryption, MFA, endpoint protection, network segmentation, secure configuration, backup and recovery, and least-privilege access.
• Validate controls through testing: phishing simulations, restore drills, patching checks, and log review.
• Adopt continuous monitoring to track drift, new systems, and emerging threats between annual assessments.

Make remediation actionable

Translate findings into a time-bound risk mitigation action plan with owners, budgets, and acceptance criteria. Use healthcare compliance software or a centralized tracker to update status, attach evidence, and link tasks to risks.

Common Gaps in HIPAA Compliance

Recurring issues tend to concentrate around identity, endpoints, vendors, and documentation. Target these early to materially lower risk.

• Stale or missing BAAs with cloud and billing vendors handling ePHI.
• Unencrypted laptops and mobile devices; weak or absent MFA for remote access.
• Shadow IT: unsanctioned file-sharing or messaging apps storing ePHI.
• Insufficient logging and alerting; no centralized review of access logs.
• Incomplete backups or untested restores for systems hosting ePHI.
• Patch management delays and unsupported legacy systems.
• Gaps in workforce training and role-based access reviews.
• Risk register not maintained; mitigation tasks lack owners or deadlines.

Examples to watch for

• Patient reports emailed to personal accounts to “work from home.”
• Vendor portal exposes ePHI due to default credentials and no audit trail.
• Disposal of old copiers with hard drives retaining PHI images.

Importance of Regular Risk Assessments

Environments change faster than static policies. New apps, integrations, and staff roles create fresh exposures, so a one-time review quickly becomes outdated.

Conduct assessments at least annually and whenever you introduce major changes, such as a new EHR, telehealth workflows, mergers, or significant vendor shifts. Regular reviews support compliance audits, cyber insurance controls, and executive risk reporting.

Business value, not just compliance

• Fewer incidents through earlier detection and hardening.
• Lower recovery costs by validating backup and recovery plans and response playbooks.
• Improved patient trust and partner confidence.

Documentation and Audits

Strong documentation demonstrates due diligence and accelerates audits. Maintain a clear narrative from risk identification to remediation and verification.

What to keep current

• Methodology, data flow diagrams, and asset inventory.
• Risk register with scores, owners, and target dates.
• Evidence of security controls: configurations, encryption keys management, MFA policies, logs, and test results.
• BAAs, workforce training records, access reviews, and incident response procedures.
• Continuous monitoring outputs and change management tickets.

Preparing for compliance audits

Map each risk and control to documented evidence you can produce quickly. Use healthcare compliance software to link policies, procedures, and proof, reducing audit-cycle friction.

Addressing Identified Gaps

Prioritize by risk reduction per unit effort. Tackle high-impact, low-effort items first while planning larger initiatives in phases.

From finding to fix

• Quick wins: enable MFA, encrypt portable devices, disable unused accounts, and tighten email forwarding rules.
• Planned projects: migrate legacy systems, implement centralized logging and SIEM, and standardize endpoint management.
• Vendor risk: update BAAs, require minimum controls, and request regular attestations and test results.
• Sustainment: define metrics, perform control health checks, and verify closure before marking risks as reduced or accepted.

Overcoming Challenges in Risk Assessments

Common hurdles include limited resources, legacy technology, and resistance to change. Address them with governance, automation, and clear ownership.

Pragmatic solutions

• Right-size the methodology so teams can execute consistently.
• Automate discovery, patch status, and access reviews where possible.
• Stand up a cross-functional risk council to unblock decisions and align budgets.
• Phase legacy remediation with compensating security controls while planning modernization.
• Reinforce culture through concise training and leadership reporting tied to business outcomes.

Conclusion

When you pair clear requirements with practical best practices, you turn HIPAA risk assessment examples into a repeatable program. Prioritize high-value security controls, document thoroughly for compliance audits, and drive a living risk mitigation action plan supported by continuous monitoring.

FAQs.

What are the key components of a HIPAA risk assessment?

Start with an inventory of systems and data flows containing ePHI, then identify threats and vulnerabilities for each asset. Score likelihood and impact, document current security controls, and record residual risk. Finish with a risk mitigation action plan assigning owners, timelines, and verification steps.

How often should HIPAA risk assessments be conducted?

Perform a comprehensive assessment at least annually and whenever significant changes occur, such as new systems handling ePHI, major vendor additions, mergers, or material process updates. Use continuous monitoring to catch drift and new risks between formal assessments.

What are common gaps found during HIPAA risk assessments?

Frequent findings include missing or outdated BAAs, lack of MFA, unencrypted devices, incomplete logging and monitoring, delayed patching, untested backups, and insufficient documentation of the risk register and remediation evidence.

How can organizations remediate identified HIPAA compliance gaps?

Prioritize high-risk items, implement layered security controls, and track remediation through a risk mitigation action plan. Update BAAs, harden endpoints and access, validate backups, and formalize documentation. healthcare compliance software can centralize evidence, automate reviews, and improve audit readiness.