How to Protect PII, PHI, and ePHI: Controls, Examples, and Risks

PII and PHI Definitions

Personally Identifiable Information (PII) is data that can identify a person, such as a name, address, or Social Security number. Protected Health Information (PHI) is any individually identifiable health data held or transmitted by a covered entity or business associate. When PHI is created, stored, or transmitted electronically, it becomes electronic PHI (ePHI).

Under Protected Health Information regulations and HIPAA compliance standards, you must safeguard the confidentiality, integrity, and availability of PHI/ePHI. All PHI is PII, but not all PII is PHI; context and the holder of the data determine whether HIPAA applies.

• PII examples: full name, email address, phone number, driver's license, biometric identifiers.
• PHI/ePHI examples: medical record numbers, lab results, diagnoses, treatment plans, insurance member IDs, billing details tied to a patient.

Common risks include unauthorized access, data leakage through misdirected messages, lost devices without encryption, overbroad internal permissions, and re-identification when datasets are combined.

ePHI Encryption Techniques

Encryption is a core safeguard for ePHI. Apply strong electronic data encryption protocols for data at rest and in transit, and manage keys with rigor to prevent misuse or loss.

• Data at rest: Use AES-256 (or comparable strength) for databases, file systems, backups, and endpoint drives. Enable full-disk encryption on laptops and mobile devices, and consider field-level encryption for sensitive identifiers.
• Data in transit: Enforce TLS 1.2+ for all network connections, including APIs, portals, and telehealth tools. Use mutual TLS or IPsec for service-to-service traffic. For messaging, prefer secure portals or end-to-end email encryption when email is unavoidable.
• Key management: Generate keys with approved random sources, store them in HSMs or a hardened KMS, rotate and retire keys on a schedule, separate key and data access, and monitor all key use.
• Implementation tips: Inventory systems holding ePHI, classify data, encrypt by default, test recovery of encrypted backups, and document decisions to meet HIPAA compliance standards.

Implementing Access Controls

Limit who can see or alter PII/PHI using least privilege and role-based access control implementation. Map job functions to permissions, grant only what each role needs, and review access regularly.

• Identity and authentication: Enforce MFA for all workforce logins, use SSO to centralize control, and block legacy protocols. Apply conditional access for higher-risk scenarios.
• Authorization: Combine RBAC with attributes (location, device posture, time) for granular decisions. Use just-in-time access for privileged tasks and “break-glass” procedures with auditing.
• Lifecycle and oversight: Automate joiner–mover–leaver workflows, recertify high-risk access quarterly, disable dormant accounts, and alert on anomalous activity through centralized logging.

Key risks are excessive permissions, shared or orphaned accounts, inadequate session timeouts, and insufficient monitoring of administrative actions.

Secure Disposal Methods

Data you no longer need still creates risk. Establish secure data disposal policies that cover paper, removable media, endpoints, servers, and cloud services, and verify that disposal is complete and documented.

• Digital media: Follow sanitization practices such as cryptographic erase, secure overwrite, or verified destruction. For SSDs and mobile devices, prefer crypto-erase or vendor-provided secure wipe.
• Paper records: Use cross-cut shredding or pulping, and store sensitive documents in locked containers prior to destruction.
• Cloud and backups: Apply retention schedules, object locks where appropriate, and request certificates of destruction from providers. Track chain of custody from collection to final disposition.

Improper disposal risks include data recovery from discarded media, regulatory penalties, breach notification costs, and reputational damage.

Email Security Practices

Email is convenient but risky for PHI. Minimize use, and when you must send PHI, layer controls and verify the recipient before transmission.

• Protection: Use secure portals or end-to-end email encryption for messages containing PHI. Ensure TLS is enforced for server-to-server transport, not merely opportunistic.
• Content hygiene: Keep PHI out of subject lines, limit to the minimum necessary, and avoid open distribution lists. Use BCC to prevent reply-all exposure.
• DLP and prevention: Apply data loss prevention rules, banner warnings for external recipients, auto-scan attachments, and hold high-risk messages for review.
• Mailbox security: Require MFA, enable phishing defenses, and monitor for auto-forwarding rules and anomalous logins.

HIPAA-Compliant File Sharing

When sharing files with PHI, choose platforms designed for healthcare and aligned to HIPAA compliance standards. Confirm encryption at rest and in transit, strong identity controls, and comprehensive audit trails.

• Access controls: Restrict links to named users, require authentication, set expirations, and limit downloads or enable view-only where possible.
• Data minimization: Share only the necessary portions, redact identifiers when feasible, and watermark sensitive exports.
• Governance: Obtain a Business Associate Agreement, define retention and e-discovery procedures, and monitor access logs for anomalies under Protected Health Information regulations.

Conducting Risk Assessments

Perform a formal risk analysis to understand where ePHI lives, how it moves, and which threats matter most. Use recognized risk management frameworks to structure your approach and guide remediation.

• Scope and inventory: Catalog systems, data stores, user groups, vendors, and data flows touching PII/PHI/ePHI.
• Threats and vulnerabilities: Evaluate technical, physical, and administrative risks, including misconfiguration, social engineering, insider threats, and third-party exposure.
• Analysis and treatment: Rate likelihood and impact, record findings in a risk register, and track mitigations, acceptances, and target dates.
• Cadence: Reassess at least annually and after material changes such as EHR upgrades, cloud migrations, telehealth rollouts, or mergers.

Conclusion: Protecting PII, PHI, and ePHI requires layered encryption, disciplined access controls, secure disposal, careful email and file-sharing practices, and a repeatable risk assessment program. Embed these controls into daily operations to reduce breach likelihood and meet HIPAA compliance standards.

FAQs

What measures secure electronic Protected Health Information?

Secure ePHI with strong encryption at rest and in transit, rigorous key management, MFA-backed access controls, continuous logging and monitoring, and hardened endpoints and servers. Pair these technical safeguards with policies, training, and vendor oversight to align with Protected Health Information regulations.

How does role-based access control protect PHI?

Role-based access control limits data access to what each job function requires, reducing exposure from unnecessary permissions. By standardizing role definitions, reviewing entitlements regularly, and enforcing MFA, RBAC shrinks the attack surface and prevents privilege creep in day-to-day operations.

What are the risks of improper data disposal?

Improper disposal can allow recovery of sensitive records from discarded media, leading to reportable breaches, legal penalties, incident response costs, and reputational harm. Clear, purge, or destroy media per secure data disposal policies and maintain auditable destruction records.

How often should risk assessments be conducted?

Conduct a comprehensive risk assessment at least once per year and whenever significant changes occur, such as adopting new systems or engaging new vendors. This cadence keeps your controls aligned to evolving threats and supports ongoing compliance with risk management frameworks.