HIPAA Security Rule Guide: Guide & How to Comply

Keeping electronic Protected Health Information (ePHI) secure isn’t just a best practice—it’s a legal requirement under the HIPAA Security Rule. As healthcare continues to embrace digital transformation, staying compliant with HIPAA safeguards has never been more essential. This guide will help you understand the Security Rule, what it means for your organization, and how to achieve reliable ePHI protection.

The HIPAA Security Rule sets clear standards for securing electronic health data through a combination of administrative, physical, and technical safeguards. Whether you’re a covered entity or a business associate, the law expects you to implement effective policies, conduct a thorough risk assessment, and ensure your workforce is properly trained.

Our practical guide will walk you through each core requirement—from developing robust security policies to establishing business associate agreements and ongoing monitoring. We’ll break down complex rules into actionable steps, empowering you to achieve Security Rule compliance and protect patient privacy every step of the way. Let’s get started on making ePHI security a seamless part of your daily operations.

What is HIPAA Security Rule

The HIPAA Security Rule is a federal regulation designed to protect the confidentiality, integrity, and availability of electronic Protected Health Information (ePHI). It applies to any organization—covered entities and business associates—that manages, stores, transmits, or accesses ePHI. At its core, the Security Rule mandates the implementation of comprehensive HIPAA safeguards to defend sensitive health information from unauthorized access, alteration, or loss.

What sets the Security Rule apart is its focus on ePHI security through specific administrative, physical, and technical safeguards. These requirements are not just about technology but also about the people and policies behind the systems. By enforcing a layered approach to security, the rule helps organizations build a culture of compliance and risk awareness.

Key components of the HIPAA Security Rule include:

• Administrative safeguards HIPAA: These involve policies, procedures, and workforce training to manage ePHI security, oversee risk assessment HIPAA processes, and assign security responsibility within the organization.
• Physical safeguards HIPAA: These controls address the physical access to electronic systems, equipment, and the locations where ePHI is stored or accessed, ensuring only authorized personnel can reach sensitive areas.
• HIPAA technical safeguards: These rely on technology to restrict access to ePHI, monitor activity, and protect data during transmission—such as encryption, unique user identification, and audit controls.

Security standards HIPAA are intentionally flexible and scalable, recognizing that healthcare organizations vary widely in size, resources, and complexity. The rule allows each entity to evaluate its own risks and implement safeguards that are reasonable and appropriate for its environment.

To promote ongoing Security Rule compliance, organizations must regularly conduct risk assessments, documenting potential vulnerabilities and proactively addressing them. This process is vital for effective ePHI protection, ensuring that security controls adapt as threats and technologies evolve.

In short, the HIPAA Security Rule provides a framework to help healthcare organizations safeguard ePHI, reduce risks, and maintain trust with patients by prioritizing data privacy and security at every level.

Core Requirements: Ensuring ePHI

Core Requirements: Ensuring ePHI

To meet the HIPAA Security Rule’s expectations, organizations must address several core requirements designed to keep electronic Protected Health Information (ePHI) safe at every stage—creation, storage, transmission, and access. These requirements are not suggestions; they’re foundational steps every covered entity and business associate must take to demonstrate Security Rule compliance and protect patient trust.

Here’s what you need to prioritize for robust ePHI protection:

• Comprehensive Risk Assessment: Regularly conduct a risk assessment for HIPAA to identify threats, vulnerabilities, and the potential impact of unauthorized access or disclosure. This process is crucial for tailoring your safeguards to your actual risk profile and for meeting security standards HIPAA demands.
• Administrative Safeguards HIPAA: Develop and enforce policies and procedures that govern how ePHI is handled, who is authorized to access it, and how your workforce is trained. This includes ongoing staff awareness programs and clear incident response protocols.
• Physical Safeguards HIPAA: Secure physical access to workstations, servers, and devices that store or process ePHI. Implement controls such as locked doors, visitor management, and secure device disposal policies to prevent unauthorized physical access or theft.
• HIPAA Technical Safeguards: Deploy technical solutions to control digital access to ePHI. This includes user authentication, automatic logoff, data encryption, and audit controls for tracking access and activity within your systems.
• Continuous Monitoring and Improvement: HIPAA requires a dynamic approach. Regularly review and update your safeguards as technology, workforce roles, and threats evolve. Document all changes and decisions to demonstrate ongoing Security Rule compliance.
• Documentation and Accountability: Maintain thorough records of all risk assessments, policies, training, and security incidents. This documentation is essential for audits and proves your commitment to ePHI security.

By focusing on these core requirements, we can create a culture of security that not only meets regulatory demands but also strengthens patient trust and organizational resilience. Remember, effective ePHI security is an ongoing process—staying proactive is the key to HIPAA compliance and long-term data protection.

Administrative Safeguards Overview

Administrative safeguards are the backbone of HIPAA Security Rule compliance—they define the policies and processes that protect ePHI across the organization. These safeguards go beyond technical measures, focusing on the people and procedures that shape your approach to ePHI protection.

Under administrative safeguards HIPAA, covered entities and business associates must develop, implement, and maintain security standards that address both internal and external threats to ePHI security. The goal is to ensure that only authorized personnel access sensitive information, risks are regularly evaluated, and effective security management is in place at all times.

Key elements of administrative safeguards include:

• Security Management Process: This involves conducting a thorough risk assessment HIPAA requires, identifying potential threats and vulnerabilities, and implementing measures to reduce risks to an acceptable level. Regular reviews and updates to these assessments help maintain ongoing ePHI protection.
• Assigned Security Responsibility: Every organization must designate a security official who is responsible for developing and enforcing HIPAA safeguards. This ensures accountability and a clear point of contact for all ePHI security matters.
• Workforce Security: Policies must be in place to ensure only authorized staff can access ePHI. This includes procedures for hiring, transferring, and terminating employees, as well as ongoing monitoring of user access.
• Information Access Management: Access to ePHI should be based strictly on job roles—granting the minimum necessary access to perform job duties, in line with HIPAA technical safeguards and security standards HIPAA mandates.
• Security Awareness and Training: All employees should receive regular training on ePHI security, including recognizing phishing attempts, password best practices, and incident reporting procedures. Ongoing education is critical for effective Security Rule compliance.
• Security Incident Procedures: Organizations must be prepared to detect, respond to, and document security incidents involving ePHI. This includes clear protocols for reporting breaches and mitigating potential harm.
• Contingency Planning: Administrative safeguards require a plan for responding to emergencies—such as power outages or cyberattacks—to ensure ongoing ePHI protection. This includes data backup, disaster recovery, and emergency mode operations planning.
• Periodic Evaluation: Regularly review and update your administrative, physical safeguards HIPAA requires, and technical safeguards to adapt to new threats and changes in your organization or technology.

By prioritizing administrative safeguards, organizations lay a strong foundation for comprehensive ePHI security and demonstrate a proactive commitment to protecting patient data. Effective administrative safeguards not only support Security Rule compliance but also build trust with patients and partners, ensuring your healthcare operations can thrive in today’s digital landscape.

Physical Safeguards Overview

Physical safeguards under the HIPAA Security Rule play a critical role in protecting ePHI from unauthorized physical access, tampering, and theft. These security standards ensure that the physical environments housing electronic systems are as secure as the digital protections in place. Without robust physical safeguards, even the most advanced technical controls can be compromised.

Physical safeguards HIPAA requirements focus on controlling access to the actual locations and devices where ePHI is stored or processed. They are essential for any organization striving for Security Rule compliance and strong ePHI protection. Let’s break down the key areas:

• Facility Access Controls: Implement policies to limit physical access to buildings, rooms, or areas where information systems and ePHI are located. This includes procedures for visitor sign-in, badge access, and after-hours entry so only authorized personnel can reach sensitive areas.
• Workstation Use and Security: Define the proper functions and physical placement of workstations to minimize the risk of unauthorized viewing or tampering. This means positioning monitors away from public view, using screen privacy filters, and ensuring workstations are used appropriately for ePHI access.
• Device and Media Controls: Establish protocols for the disposal, re-use, and movement of electronic devices and media containing ePHI. This encompasses secure disposal of hard drives, proper data wiping before reassigning equipment, and tracking removable media such as USB drives or backup tapes.
• Environmental and Disaster Protection: Safeguard physical infrastructure against hazards (such as fire, flood, or power loss) that could threaten data integrity or availability. Use secure storage, uninterruptible power supplies, and climate controls where necessary.

Practical advice for Security Rule compliance: Start by conducting a thorough risk assessment HIPAA requires; identify where ePHI is physically stored or accessed, and evaluate your current safeguards. Train your staff to recognize and follow physical security protocols, and routinely review your procedures in light of evolving risks.

Remember, physical safeguards are just as important as technical and administrative safeguards HIPAA mandates. By addressing these standards, we reduce the risk of breaches and create a culture where ePHI security is everyone’s responsibility. Consistent review and improvement of physical safeguards are key to sustained compliance and peace of mind for both your organization and the patients you serve.

Technical Safeguards Overview

Technical safeguards are the heart of ePHI security under the HIPAA Security Rule. These controls define how healthcare organizations use technology to protect sensitive health data from unauthorized access, alteration, or disclosure. Getting technical safeguards right is crucial for Security Rule compliance and for creating a strong defense against today’s cyber threats.

HIPAA technical safeguards focus on controlling access, monitoring activity, and protecting data integrity. They set standards for the systems and procedures you use to manage and secure electronic Protected Health Information (ePHI). Let’s break down the core technical safeguards you’ll need to implement:

• Access Controls: Only authorized individuals should view or modify ePHI. This means setting up unique user IDs, strong passwords, automatic logoff features, and role-based permissions. Each user’s access to ePHI should be limited to what’s necessary for their job—no more, no less.
• Audit Controls: Your systems must log and monitor all access and activity involving ePHI. This includes tracking who accessed data, what actions they performed, and when it happened. Regularly reviewing these logs helps detect suspicious behavior and supports incident investigations.
• Integrity Controls: It’s essential to ensure that ePHI isn’t altered or destroyed in an unauthorized manner. Technical safeguards like data validation, checksums, and secure backups help maintain the accuracy and reliability of health information.
• Transmission Security: When ePHI is transmitted over networks—whether internally or externally—it must be protected from interception or tampering. Encryption and secure communication protocols (like TLS) are key tools for safeguarding data in transit.
• Authentication Controls: Verifying the identity of users and systems is a must. Multi-factor authentication (MFA) and digital certificates add layers of protection, ensuring only legitimate users can access sensitive data.

Implementing these technical safeguards involves both technology and process decisions. Choose solutions that fit your organization’s size and complexity, and make sure your IT team understands how to configure and maintain them. Regularly update software and systems to address vulnerabilities, and always document your technical choices and procedures for HIPAA audits.

Proactive risk assessment is central to technical safeguard success. Evaluate your current systems for gaps, test your controls, and adapt to new threats as they emerge. This ongoing vigilance not only helps maintain Security Rule compliance but also builds a culture of ePHI protection that patients and partners can trust.

The Mandate for Risk Analysis and Management

The Mandate for Risk Analysis and Management

To maintain strong ePHI security, the HIPAA Security Rule places a clear and non-negotiable responsibility on covered entities and business associates: they must perform ongoing risk assessment HIPAA activities. This is not a one-time event—it’s an ongoing process designed to identify, evaluate, and address potential threats to the confidentiality, integrity, and availability of electronic Protected Health Information.

Why is risk analysis so critical? Simply put, without understanding where your vulnerabilities lie, you can’t implement the right HIPAA safeguards—whether they’re administrative, physical, or technical. A well-executed risk analysis is the bedrock for all other security standards HIPAA requires. It shapes your security policies, guides your investments in technology, and ensures your workforce is prepared to respond to emerging threats.

Here’s what a compliant risk analysis and management process should include:

• Comprehensive Asset Inventory: Identify all systems, devices, and applications that store, transmit, or process ePHI.
• Threat and Vulnerability Identification: Assess both internal and external risks that could compromise ePHI, such as cyberattacks, unauthorized access, or human error.
• Likelihood and Impact Evaluation: Estimate how probable each risk is and the potential damage it could cause to your operations and patients.
• Current Safeguards Review: Analyze your existing administrative safeguards HIPAA, physical safeguards HIPAA, and HIPAA technical safeguards to determine if they are adequate.
• Remediation Planning: Prioritize risks and develop an actionable mitigation plan, assigning responsibilities and deadlines for each task.
• Continuous Monitoring and Review: Regularly revisit your risk analysis to adapt to new threats, changes in technology, or organizational updates.

Risk analysis is not just about checking a compliance box—it’s about proactive ePHI protection. A thorough process helps you detect gaps before they turn into breaches, ensuring reliable Security Rule compliance and safeguarding patient trust.

Remember, risk assessment HIPAA obligations are flexible and scalable. Whether you’re a solo practitioner or a large healthcare system, the expectation is that you’ll implement reasonable and appropriate safeguards for your unique environment. What matters most is that you document your process, decisions, and improvements, building a culture of security that stands up to scrutiny—and keeps your patients’ information safe.

Developing Security Policies and Procedures

Developing robust security policies and procedures is the cornerstone of achieving Security Rule compliance and effective ePHI protection. These documents translate the requirements of HIPAA safeguards into actionable steps for your organization, ensuring that everyone—from leadership to front-line staff—understands their responsibilities when it comes to ePHI security.

Where do we start? Begin by conducting a thorough risk assessment HIPAA requires. This assessment will identify potential threats and vulnerabilities to your electronic Protected Health Information. The findings set the foundation for your policies, ensuring they address real-world risks unique to your environment.

Key elements to address in your security policies and procedures include:

• Access Management: Define who is authorized to access ePHI, under what circumstances, and through which systems. Establish protocols for granting, modifying, and revoking access.
• Workforce Security: Outline security training requirements, ongoing awareness programs, and the process for reporting security incidents or violations. This supports the administrative safeguards HIPAA emphasizes.
• Physical Safeguards HIPAA: Document controls around facility access, device management, and workstation security. Make it clear how physical access to ePHI is prevented for unauthorized persons.
• Technical Safeguards: Describe the use of passwords, encryption, audit controls, and transmission security technologies. Specify how systems are monitored and how ePHI integrity is maintained.
• Incident Response: Create a step-by-step plan for responding to suspected or confirmed breaches, including notification procedures and corrective actions.
• Review and Update: Set schedules for periodic review of all policies and procedures, and outline the process for making updates as technology, regulations, or operations change.

For Security Rule compliance, policies must be clear, easy to understand, and tailored to your organization’s size and complexity. Avoid generic templates—customization ensures your HIPAA safeguards are practical and enforceable. Assign accountability for implementation and monitoring, and make sure all staff receive regular training on the policies relevant to their roles.

Finally, document everything. Keep records of your policy creation, updates, training sessions, and risk assessment HIPAA activities. This documentation not only strengthens ePHI security but also demonstrates your commitment to HIPAA technical, administrative, and physical safeguards in the event of an audit or investigation.

By investing the time and resources to develop and maintain strong security policies and procedures, we protect patient data, support trust, and ensure our organization meets every aspect of security standards HIPAA demands.

Workforce Training Requirements

Workforce Training Requirements

Comprehensive workforce training is a cornerstone of HIPAA Security Rule compliance—and a key element in safeguarding ePHI. While advanced security systems and policies are vital, it’s the people in your organization who put these HIPAA safeguards into action every day. Effective training empowers your team to recognize threats, handle sensitive data appropriately, and reduce the risk of breaches.

Under the administrative safeguards of HIPAA, all covered entities and business associates must provide ongoing security awareness and training programs for every member of the workforce, regardless of their level of access to ePHI. This isn’t just about ticking boxes for compliance; it’s about building a culture of ePHI security that protects your patients and your organization.

Key components of HIPAA workforce training include:

• Security Policies & Procedures: Employees must be trained to understand and follow your organization’s HIPAA technical safeguards, administrative safeguards, and physical safeguards. This includes how to use secure systems, report suspicious activity, and avoid risky behaviors.
• Recognizing and Reporting Threats: Staff should be able to identify phishing attempts, malware, unauthorized access, and other security risks—and know the correct channels for reporting incidents promptly.
• Password and Access Management: Training should stress the importance of strong passwords, regular password updates, and the principle of least privilege to ensure only those who need access to ePHI have it.
• Device and Media Controls: Employees should understand how to securely use, transfer, and dispose of devices or media that may contain ePHI, in accordance with physical safeguards HIPAA requires.
• Secure Communication: Guidance on sending ePHI only through approved, encrypted channels and never sharing sensitive information through unsecured methods.
• Incident Response: Training must cover what to do if a security incident or breach occurs, including immediate reporting and cooperation with investigation and mitigation efforts.

Training is not a one-time event. The Security Rule expects organizations to update training regularly—at least annually, or whenever there are changes in regulations, technology, or your security procedures. Regular refreshers help reinforce best practices and keep security top-of-mind.

Documentation is critical for Security Rule compliance. Keep clear records of who has completed training, what content was covered, and when. This not only demonstrates your commitment to HIPAA safeguards during audits, but also provides a foundation for continuous improvement.

Ultimately, well-designed workforce training is one of the most practical and effective ways to strengthen your ePHI protection strategy and reduce the risk of costly violations. By making HIPAA security standards an everyday priority, we can all contribute to a safer healthcare environment.

Business Associate Agreements and Security

Business Associate Agreements (BAAs) are a cornerstone of HIPAA Security Rule compliance and play a critical role in maintaining ePHI protection. Whenever a covered entity works with a third-party service provider—such as cloud storage vendors, billing companies, or IT support—that may access, process, or transmit electronic Protected Health Information, a BAA is legally required.

Why are BAAs so important for ePHI security? They ensure that every business associate understands their responsibilities and agrees to uphold the same HIPAA safeguards as the covered entity. Without a signed BAA, any disclosure of ePHI to a third party can be considered a serious violation, regardless of intent.

• Defining Responsibilities: BAAs outline each party’s obligations regarding administrative safeguards HIPAA, physical safeguards HIPAA, and HIPAA technical safeguards. This includes how ePHI is accessed, used, stored, and destroyed.
• Security Standards HIPAA: The agreement must specify the HIPAA security standards that the business associate will follow to prevent unauthorized access, ensure data integrity, and maintain ePHI availability.
• Breach Notification: BAAs require business associates to notify the covered entity of any security incidents or breaches involving ePHI, allowing for prompt risk assessment HIPAA and mitigation steps.
• Subcontractor Flow-Down: If a business associate uses subcontractors who will also handle ePHI, they must have similar BAAs in place, extending HIPAA safeguards throughout the entire supply chain.

We recommend regularly reviewing and updating your BAAs to reflect current workflows, new vendors, and evolving security standards HIPAA. Don’t forget—due diligence doesn’t end with a signature. Ongoing oversight, including periodic audits and risk assessments, ensures that your partners remain compliant and vigilant about ePHI protection.

In summary, a robust BAA is more than just paperwork—it’s a proactive tool for Security Rule compliance and a foundational step in your organization’s HIPAA safeguards strategy. By setting clear expectations, you’re not only protecting sensitive information but also building trust and accountability across every link in your data ecosystem.

Ongoing Monitoring and Evaluation

Ongoing Monitoring and Evaluation

To maintain Security Rule compliance, it's crucial that we treat HIPAA safeguards as an ongoing commitment—not a one-time checklist. Effective ePHI protection requires us to continuously monitor and evaluate our security posture, ensuring that HIPAA technical safeguards, administrative safeguards HIPAA, and physical safeguards HIPAA are not only in place but also functioning as intended.

Regular monitoring allows us to quickly spot potential vulnerabilities and respond to threats before they become breaches. Here’s how you can build an effective ongoing monitoring and evaluation process:

• Conduct Regular System Audits: Routinely audit systems that store or transmit ePHI. Use automated tools to monitor access logs, track failed login attempts, and detect unusual activity that could indicate a security incident.
• Review and Update Policies: Policies and procedures should be living documents. Revisit them periodically to ensure they align with evolving threats, new technologies, and updated security standards HIPAA requirements.
• Monitor User Activity: Keep a close eye on user access. Implement alerts for unauthorized attempts to access ePHI, and review permissions regularly to ensure only appropriate personnel have access.
• Evaluate Technical Controls: Test encryption, firewalls, and intrusion detection systems to verify they’re functioning correctly. This helps confirm that your HIPAA technical safeguards are providing robust ePHI security.
• Assess Physical Security Measures: Inspect facility access controls, workstation security, and device management practices. Ensure that physical safeguards HIPAA are effective at preventing unauthorized physical access to sensitive data.
• Perform Periodic Risk Assessments: Threats change, and so should your risk management plan. Schedule regular risk assessment HIPAA reviews to identify new vulnerabilities and update your mitigation strategies accordingly.
• Respond and Document: Whenever an incident or potential weakness is discovered, act quickly to investigate, resolve, and document it. This is not only a best practice, but also a compliance requirement.

By making ongoing monitoring and evaluation a standard part of your operations, you build a strong defense against data breaches and ensure your organization remains aligned with Security Rule compliance. Remember, effective ePHI protection is about anticipation and adaptation—staying vigilant is key to safeguarding patient trust and meeting regulatory demands.

Securing ePHI is a shared responsibility that requires commitment, vigilance, and ongoing education. By following the HIPAA Security Rule’s administrative, physical, and technical safeguards, we can reduce risks, protect patient privacy, and ensure the integrity of sensitive health information.

Regular risk assessments and a proactive approach to HIPAA safeguards are fundamental to Security Rule compliance. They help us identify vulnerabilities, implement the right controls, and adapt to evolving security threats. Remember, compliance isn’t a one-time task—it’s an ongoing process that should be woven into our daily operations.

Every organization, regardless of size, must tailor its ePHI protection strategy to its unique needs and resources. The flexibility of HIPAA’s security standards means we can find practical, scalable solutions that fit our circumstances, while still meeting the law’s requirements.

Staying compliant with the HIPAA Security Rule is not just about avoiding penalties—it’s about earning patient trust and safeguarding the future of healthcare. By prioritizing ePHI security and embracing best practices, we’re building a more secure, resilient healthcare environment for everyone.

FAQs

What are the three main categories of safeguards in the HIPAA Security Rule?

The HIPAA Security Rule establishes three main categories of safeguards to ensure the protection of electronic protected health information (ePHI): administrative safeguards, physical safeguards, and technical safeguards.

Administrative safeguards HIPAA refer to the policies, procedures, and actions that organizations implement to manage the selection, development, and enforcement of security measures. This includes workforce training, security management processes, and regular risk assessment HIPAA to identify and address potential threats to ePHI security.

Physical safeguards HIPAA involve the measures taken to secure the physical access to electronic information systems and the facilities where ePHI is stored. These controls help prevent unauthorized access, theft, or tampering with hardware and data, supporting overall ePHI protection.

HIPAA technical safeguards are the technology-based strategies and controls that protect ePHI and regulate who can access the information. These include access controls, audit controls, and encryption, all of which are crucial for Security Rule compliance and meeting security standards HIPAA requires.

Why is a risk analysis crucial for the Security Rule?

Risk analysis is the backbone of effective Security Rule compliance because it allows organizations to identify and address vulnerabilities that threaten ePHI security. By systematically evaluating where electronic protected health information (ePHI) is stored, accessed, and transmitted, a risk assessment HIPAA process uncovers potential threats—whether technical, administrative, or physical—that could compromise data integrity and confidentiality.

This assessment guides the implementation of HIPAA safeguards across all areas—administrative, physical, and technical. It ensures that security standards HIPAA requires are not just generic checkboxes, but targeted protections tailored to your unique environment. Without a thorough risk analysis, covered entities may overlook weaknesses, putting ePHI protection at risk and increasing the chance of costly data breaches.

Regular risk analysis also demonstrates ongoing diligence, which is critical for Security Rule compliance. It helps organizations adapt safeguards as technology and threats evolve, ensuring that ePHI security measures remain effective and appropriate for current risks. Ultimately, a proactive risk assessment supports patient trust and regulatory peace of mind.

What does the Security Rule specifically protect?

The HIPAA Security Rule specifically protects electronic Protected Health Information (ePHI). Its primary goal is to ensure the confidentiality, integrity, and availability of ePHI by requiring healthcare organizations and their business associates to implement a comprehensive set of HIPAA safeguards.

These safeguards are divided into three main categories: administrative safeguards HIPAA (such as workforce training and risk assessment HIPAA), physical safeguards HIPAA (like facility access controls), and HIPAA technical safeguards (including access controls and encryption). Each category addresses a different aspect of ePHI security, working together to provide a layered defense against unauthorized access, loss, or tampering.

By following these security standards HIPAA and maintaining Security Rule compliance, organizations are better equipped to provide robust ePHI protection, safeguarding patient data from evolving cyber threats and breaches.

How often should Security Rule compliance be reviewed?

Security Rule compliance should be reviewed at least annually, according to HIPAA administrative safeguards. Regular reviews ensure that all ePHI security measures remain effective and up-to-date, especially as technology and threats evolve.

Beyond the minimum annual review, HIPAA encourages ongoing risk assessment. This means you should also re-evaluate your HIPAA technical safeguards, physical safeguards, and policies whenever there are significant changes in your organization’s systems, procedures, or threats to ePHI protection.

By staying proactive with these reviews, we can maintain the highest standards of Security Rule compliance and ensure our patients’ information is always protected.