Security Risk Assessment Examples and Common Gaps in HIPAA Programs

Your HIPAA security program is only as strong as the risks you identify and remediate. This guide walks through security risk assessment examples and the most common gaps in HIPAA programs, showing how to prioritize ePHI sensitivity tiering, maintain airtight audit trails, and produce compliance documentation that stands up to scrutiny.

Identifying Common HIPAA Security Gaps

Where programs most often fall short

• No ePHI sensitivity tiering to separate high-impact systems (EHR, billing) from lower-risk tools, causing flat priorities and slow remediation.
• Incomplete asset and data-flow inventories, especially for cloud apps and shadow IT, which blinds you to where ePHI actually travels.
• Access reviews that happen ad hoc, leaving orphaned, shared, or privileged accounts active for months.
• Weak audit trails and log retention, preventing you from proving who accessed ePHI and when.
• Policies that exist on paper but lack control operation evidence (tickets, screenshots, configurations, sign‑offs).
• Vendor oversight that focuses on contracts but not on live security performance or Business Associate Agreements (BAAs) quality.

Quick diagnostic checks

• Can you show a current system list with risk ratings tied to ePHI sensitivity tiering?
• For a random control (e.g., MFA), can you retrieve control operation evidence within five minutes?
• Does every open risk have risk register linkage to an owner, target date, and treatment plan?
• Can you reconstruct access to a patient record using audit trails across apps and endpoints?

Conducting Regular Risk Analyses

A practical, repeatable approach

Perform risk analyses at least annually and whenever your environment changes materially (new EHR module, cloud migration, merger, major incident). Use a consistent method: identify assets and data flows, analyze threats and vulnerabilities, estimate likelihood and impact, and document treatment options with risk register linkage and clear acceptance criteria.

Steps you can implement now

• Inventory systems and data flows; tag with ePHI sensitivity tiering (Critical, High, Medium, Low).
• Map existing controls and note gaps; capture control operation evidence while you assess.
• Score risks, define mitigations, and enter items into a centralized risk register with owners and due dates.
• Align each mitigation to compliance documentation requirements so you can prove operation later.

Security risk assessment examples

• Phishing‑led mailbox breach: Threat actors exfiltrate ePHI from mailboxes lacking MFA. Mitigations: MFA, conditional access, secure email gateways, and mailbox audit trails; verify with control operation evidence (policy, config exports, alert history).
• Lost, unencrypted laptop: ePHI synced locally without full‑disk encryption. Mitigations: MDM‑enforced encryption, remote wipe, restricted local sync; evidence via MDM compliance reports.
• Third‑party billing portal: Vendor uses weak TLS and shared admin accounts. Mitigations: BAA with security addendum, MFA, named accounts, TLS 1.2+; maintain vendor audit trails and risk register linkage.
• Legacy imaging server: Unsupported OS with open SMB. Mitigations: Network segmentation, patch/upgrade, compensating IPS rules, encrypted backups; document change tickets and vulnerability closure.
• Backup media exposure: Offsite tapes not encrypted and chain of custody unclear. Mitigations: Media encryption, custody logs, periodic test restores; attach compliance documentation to the risk record.
• Over‑provisioned EHR roles: Broad access grants “view all” beyond job need. Mitigations: Role‑based access control, quarterly access recertification, break‑glass monitoring; keep sign‑off attestations.

From findings to action

Translate every finding into a remediation plan with owners, milestones, and evidence requirements. Close the loop by attaching proof (screenshots, change approvals, logs) to the risk record and verifying residual risk after control deployment.

Strengthening Access Controls

Design principles

• Least privilege with role‑based access control and just‑in‑time elevation for admins.
• MFA everywhere ePHI can be accessed (EHR, VPN/SSO, email, portals); no shared accounts.
• Quarterly access recertification, immediate deprovisioning on termination, and break‑glass procedures with heightened monitoring.
• Session timeouts, device trust checks, and geo/behavior‑based risk policies.

Evidence and monitoring

• Maintain audit trails for user, admin, and service activity; retain logs per policy.
• Store control operation evidence for access reviews (exported user lists, approval records, recertification attestations).
• Track metrics: number of privileged accounts, orphaned accounts found, MFA coverage, and time‑to‑deprovision.

Implementing Comprehensive Encryption

Data in transit

• Require TLS 1.2+ for apps, APIs, and portals; disable weak ciphers.
• Encrypt email with automatic policies for ePHI, using secure portals or S/MIME; log and review exceptions.
• Protect remote access with VPN or zero‑trust access plus MFA.

Data at rest

• Full‑disk encryption for laptops and mobile devices via MDM; prohibit removable media without encryption.
• Database and file‑level encryption for servers and cloud storage; enable server‑side encryption and key rotation.
• Encrypt backups and verify with periodic test restores; keep evidence of successful tests as compliance documentation.

Key management

• Centralize keys in a KMS or HSM, enforce separation of duties, and rotate on schedule or incident.
• Record key lifecycle events and attach logs as control operation evidence.

Enhancing Workforce Training

Make training role‑based and continuous

• Deliver onboarding plus annual refreshers; add micro‑modules after incidents or major changes.
• Target modules by role (clinical, billing, IT, executives) using ePHI sensitivity tiering to emphasize impact.
• Run phishing simulations and tabletop exercises tied to incident response plans; log outcomes and improvements.

Measure what matters

• Track completion rates, phishing failure trends, and time‑to‑report suspected incidents.
• Retain attendance, rosters, and scenario notes as compliance documentation and audit trails.

Updating Security Policies

Governance and versioning

• Maintain a living policy set with owners, review cadence, and explicit cross‑references to procedures and standards.
• Include exception handling with documented approvals, expirations, and compensating controls.

From paper to practice

• For each policy requirement, define expected control operation evidence (e.g., screenshots, logs, tickets, sign‑offs).
• Map policies to your risk register linkage so every rule has corresponding tests and controls.

Improving Business Associate Oversight

Risk‑based vendor management

• Inventory all vendors handling ePHI and tier them by inherent risk using ePHI sensitivity and data volume.
• Perform due diligence (security questionnaires, independent reports) and capture issues in your risk register.
• Define ongoing monitoring: security KPIs, incident notifications, penetration test summaries, and remediation tracking.

Strengthening Business Associate Agreements (BAAs)

• Specify security controls (encryption, MFA, logging), breach notification timelines, subcontractor flow‑downs, and right‑to‑audit.
• Require audit trails of control operation evidence upon request and outline acceptable compliance documentation.

Conclusion

Effective HIPAA programs blend rigorous risk analyses with proof of operation. By prioritizing high‑impact assets through ePHI sensitivity tiering, hardening access and encryption, training your workforce, enforcing policies, and tightening BAAs, you reduce breach likelihood and maintain defensible, evidence‑backed compliance.

FAQs.

What are common gaps in HIPAA security risk assessments?

Frequent gaps include missing ePHI sensitivity tiering, outdated asset inventories, weak MFA coverage, inconsistent access reviews, inadequate audit trails, and limited vendor oversight. Many programs also lack risk register linkage and control operation evidence to prove controls work, leaving compliance documentation incomplete.

How often should HIPAA risk assessments be conducted?

Perform a comprehensive risk analysis at least annually and whenever significant changes occur—such as new systems, migrations, mergers, or after security incidents. Update the risk register continuously as new findings arise and attach fresh evidence as mitigations are implemented.

What are effective controls to prevent unauthorized access?

Use MFA across all ePHI access points, enforce least privilege with role‑based access control, require just‑in‑time elevation for admins, and run quarterly access recertifications. Add session timeouts, device compliance checks, and continuous logging with audit trails to detect and contain misuse quickly.

How can organizations ensure their Business Associate Agreements comply with HIPAA?

Standardize BAAs with explicit security requirements (encryption, MFA, logging), breach notification windows, subcontractor obligations, and right‑to‑audit. Align each clause to measurable controls, collect control operation evidence during onboarding and periodically, and store all artifacts as compliance documentation linked in your risk register.