HIPAA compliance safeguards Protected Health Information (PHI) with privacy, security, and breach notification rules that healthcare providers and partners must follow. Achieving compliance requires strong identity, access, and data security measures. Netwrix solutions help enforce least privilege, detect insider threats, secure endpoints, and simplify compliance reporting to strengthen trust and reduce risks.
HIPAA is a federal law created to protect sensitive patient information in healthcare, including medical records, personal details, and other identifying data. It primarily serves as a privacy safeguard to prevent unauthorized access to personal information, while also fostering trust between patients, healthcare providers, and other entities that handle this data. Therefore, the law applies to primary care organizations like hospitals and healthcare providers, as well as to insurance companies, data handlers, and other parties with access to patient information.
Why HIPAA Compliance Matters
In the current healthcare industry, HIPAA is essential for protecting patient data and ensuring compliant IT operations, providing safeguards in line with industry-standard cybersecurity protocols. Achieving and maintaining HIPAA compliance is therefore important not only to meet regulations but also as a key aspect of digital security.
This guide explores the details of HIPAA compliance regulations, what it takes for a covered entity to meet HIPAA standards, and how HIPAA works alongside other protections to improve security. At Netwrix, we help organizations safeguard sensitive data with identity-first security because HIPAA compliance is both a regulatory requirement and a data security challenge. Netwrix solutions provide visibility with auditing and DSPM, enforce control with identity and privileged access management, and automate compliance with directory and identity governance. These capabilities help healthcare organizations stay compliant and secure.
What Is HIPAA Compliance?
Established in 1996, the Health Insurance Portability and Accountability Act (HIPAA) is a US law that sets federal standards for safeguarding personal or sensitive healthcare information, particularly regarding the disclosure of that information without patient consent. This law is backed by five additional rules, including the HIPAA Privacy Rule, established by the US Department of Health and Human Services (HHS) to enforce HIPAA requirements, and the HIPAA Security Rule, which oversees the protection of any health information created, stored, or transmitted digitally.
HIPAA regulates any entity that manages or handles patients’ data, such as healthcare providers, insurance companies, or IT vendors processing this data, setting expectations for protecting this information from leaks or breaches. The law also guarantees patients the right to confidentiality over their personal information while enabling them to share healthcare details with trusted parties.
In practice, HIPAA compliance policy includes any efforts to protect patients’ personal data, such as encrypting information, auditing systems, enforcing security rules, appointing a privacy officer, or training employees on security best practices.
The Core HIPAA Rules and Standards
As noted earlier, HIPAA is primarily supported by five additional rules that specify protections for patients’ Protected Health Information (PHI).
The first is the Privacy Rule, which regulates how PHI is used and shared. Specifically, it states that only authorized healthcare workers and the individuals involved can access PHI, and that PHI should only be used for healthcare or payment reasons. Sharing this information in any other case is only allowed with the patient’s clear written permission.
The second rule, the Security Rule, supports the Privacy Rule by setting standards for protecting PHI stored or processed electronically. These standards are divided into three categories: administrative safeguards, technical safeguards, and physical safeguards. (More details on these safeguards will be provided later.)
Third is the Breach Notification Rule. As the name indicates, this rule governs how regulated entities should report and respond to PHI breaches, setting requirements to report such incidents quickly to all covered entities, the media, and the US Department of Health and Human Services (HHS).
Next, there’s the Omnibus Rule, an addition to HIPAA in 2013 that strengthens protections for digitally stored PHI. Specifically, the rule expands HIPAA’s definition of regulated entities to include any organization that creates, maintains, sends, or receives PHI as part of its operations.
Last is the Enforcement Rule. This fifth regulation covers the penalties that covered entities might face for any violations of patient privacy, including the use of PHI for marketing or sales.
To comply with HIPAA regulations, organizations typically focus on protecting PHI by following the best practices outlined in the Security Rule. Many aspects of these practices can be more effectively implemented using specialized IT security software. In particular:
- HIPAA Access Controls are best enforced with Netwrix Privileged Access Management, which eliminates standing admin rights, enforces MFA, and records sessions for full audit readiness.
- Audit controls can be strengthened with Netwrix Data Security Posture Management (DSPM) and auditing solutions. Netwrix Auditor provides HIPAA-ready reports and unified audit trails, while Netwrix Access Analyzer enables continuous access reviews, identifies PHI exposure, and supports DSAR responses with proof of compliance.
- Integrity controls can be verified with Netwrix Change Tracker, part of the Endpoint Management solution, which monitors unauthorized configuration modifications, validates file integrity, and ensures systems remain hardened against HIPAA violations.
- Transmission Security and the overall security of communications can be strengthened with endpoint protection software like Netwrix Endpoint Protector, which enforces encryption, blocks unapproved transfers, and prevents PHI leakage through email, USB, and cloud uploads.
- Risk Monitoring should be strengthened with Netwrix ITDR, which detects credential abuse, insider threats, and AD/Entra ID privilege escalation attempts in real time. Together with Netwrix DSPM and Threat Manager, healthcare organizations can spot PHI exposure, shadow data, ransomware, and lateral movement before it turns into a HIPAA breach.
While a security stack should include these elements for comprehensive protection, it is especially important for healthcare providers and partnering entities to deploy these tools to remain legally compliant.
HIPAA Compliance Requirements
Achieving and maintaining HIPAA compliance requires an ongoing culture of security and privacy guided by clear, communicable security measures. More than just establishing expected protections, the best practices for HIPAA compliance involve properly aligning internal standards with HIPAA regulations and frameworks, while also implementing measures for consistent application throughout your organization.
Therefore, a HIPAA compliance program must include comprehensive policies and plans to protect all confidential information. Many of these will align with general IT security best practices, such as establishing rules for secure passwords, managing access effectively, using encryption, securing networks, and responding to incidents. Additionally, healthcare-specific security practices are incorporated into these policies. Netwrix Directory Management automates group and user management to enforce accurate access rights and reduce risks from stale or orphaned accounts. Netwrix Identity Management governs joiner/mover/leaver processes, enforces least-privilege access, and automates attestation campaigns to support HIPAA compliance.
Protected Health Information (PHI) and Data Security
“PHI” is defined in HIPAA as any information that is sufficiently identifiable to be linked to a specific patient. This includes individuals’ names, street addresses, telephone numbers, email addresses, Social Security numbers, or any other data that clearly identifies the patient in question.
In effect, this requires organizations to implement practical, meaningful protections commonly used in general cybersecurity strategies, such as risk analysis and management, facility access controls, encryption methods, access and identity management, audit controls, and ongoing employee training. The Security Rule also provides specific standards for implementing these protections. Protecting PHI from unauthorized access is at the core of HIPAA, and fostering a culture of confidentiality is essential for compliance.
HIPAA Compliance in Healthcare Operations
As established by the HIPAA Security Rule, any PHI stored or transmitted digitally must be protected with effective administrative, technical, and physical safeguards. According to the HHS, these protections must adequately:
- Ensure the confidentiality, integrity, and availability of all electronic PHI (ePHI) that the organization creates, receives, maintains, or transmits.
- Protect against known threats to the information or its integrity.
- Protect against reasonably anticipated, impermissible use or disclosure.
- Ensure security with the support of a trained, compliant workforce.
Meeting many of these requirements can be as straightforward as implementing strong IT protections, because solid defenses against breaches, leaks, or cyberattacks are best built using cybersecurity best practices.
These standards define HIPAA IT compliance, which is distinct from healthcare HIPAA compliance. While general HIPAA compliance covers the broad principles of what information an organization must protect and the overall safeguards to implement, HIPAA IT compliance focuses on the specific measures taken to secure relevant systems.
An example of healthcare HIPAA compliance would be requiring all patient data to be stored securely in a protected database. On the other hand, examples of HIPAA IT compliance include enforcing strong data access controls, encrypting data properly, and creating detailed sharing policies to prevent PHI from being shared with unauthorized individuals.
Programs, Frameworks, and Governance
Any HIPAA compliance program should include thorough technical, administrative, and physical safeguards to effectively prevent unauthorized access to PHI in any form, whether physical or digital. While this should naturally involve comprehensive cybersecurity measures following best IT security practices, the program should also incorporate frameworks specifically aligned with regulatory standards.
First, it’s crucial to approach HIPAA compliance with a clear plan of action that is outlined by written policies, procedures, and standards for conduct. Naturally, all these parts of your HIPAA compliance plan should align with regulatory requirements, such as by following a certified framework for HIPAA like the NIST Cybersecurity Framework.
To uphold HIPAA compliance, organizations must also implement strategies for audits, system assessments, and data and traffic reporting. These steps are crucial not only for demonstrating ongoing compliance but also for identifying vulnerabilities or policy drift that could compromise systems.
The implementation of any HIPAA compliance plan should be overseen by a dedicated compliance officer or compliance committee with a thorough understanding of HIPAA requirements and how to best apply them within your organization. Compliance officers should work closely with IT professionals to ensure confidentiality measures are reliably integrated throughout your organization, enabling both departments to support each other in advising and implementing effective protections.
HIPAA Compliance Audits: How to Be Ready
Preparing for audits is an essential part of HIPAA compliance because any regulated organization will be regularly inspected to ensure PHI is effectively protected. This process should include appointing a designated HIPAA privacy officer (if one is not already in place), clearly defining PHI and specifying when it can be disclosed, and establishing procedures for handling requests related to privacy protection, access, correction, or transfer.
Furthermore, your organization must be able to provide a detailed history of data demonstrating ongoing compliance with HIPAA. Automated reporting tools are vital because solutions like Netwrix Auditor or Access Analyzer significantly simplify the data collection process by continuously monitoring and recording network activity, including data access attempts. These logs should also reflect a long-standing policy of least privilege access rules to verify a commitment to patient confidentiality.
Because HIPAA audits specifically target confidentiality, it is especially important to use the previously mentioned reporting tools to monitor access to databases containing PHI. These audits aim to verify that your organization’s PHI has not been improperly accessed, not just to confirm that it is being effectively protected, making continuous access monitoring essential for these purposes.
Best Practices for Ensuring HIPAA Compliance
Like many security standards, the first step toward HIPAA privacy compliance is to conduct initial risk assessments to find gaps in policy. However, this monitoring should also be an ongoing part of your security efforts. Becoming HIPAA compliant is a continuous process, not an instant change, and efforts to meet compliance must include regularly assessing and monitoring systems for policy changes, vulnerabilities, or other irregularities.
An effective HIPAA policy will feature reliable safeguards in three key areas:
- Technical safeguards protect digital assets, such as encryption methods, identity and access management, and device management.
- Physical safeguards protect hardware and other physical systems, such as automatic workstation logout policies, facility access controls, and device and media controls.
- Administrative safeguards enforce consistent security policies throughout the organization, train staff effectively, and establish security incident procedures and contingency plans in case of an attack.
To better ensure all team members respect and uphold these safeguards, it’s crucial to continually educate employees about the importance of HIPAA compliance to foster a stronger culture of security.
HIPAA Compliance Benefits
Achieving HIPAA compliance is crucial for safeguarding your clients’ interests as much as it is for meeting legal requirements. With clear and definitive protections in place for patients’ personal information, the public can trust that their health data will stay confidential and their privacy rights will be upheld.
By establishing greater trust, healthcare providers and partner organizations can strengthen their reputation in the market. With HIPAA security compliance supported by Netwrix solutions, organizations not only reduce cyberattack risks but also simplify compliance reporting, cut audit prep time by up to 85%, and continuously validate least-privilege access across sensitive PHI environments. Even if a HIPAA-compliant organization experiences an attack, it typically avoids legal penalties as long as it can prove PHI was protected according to HIPAA regulations and the incident was not due to negligence.
Generally, HIPAA compliance also ensures your organization follows broader best practices for healthcare operations and data management. This helps build trust not only with your organization but also across the healthcare industry, reflecting the original goals of HIPAA.
Challenges and Common Issues
One of the biggest challenges to HIPAA compliance is a lack of understanding of its purpose or how to apply it. Even if effective security policies are already in place at your organization, employees might not consistently follow them during their work, which can lead to improper protections for PHI or even accidental disclosures. Continuous staff education is essential to prevent the misuse of PHI across all levels of your organization.
Many organizations also struggle to achieve compliance because healthcare IT security frameworks are complex. With numerous steps in healthcare supply chains and large amounts of data, protections can be hard to apply uniformly. Without proper preparation and the right tools, HIPAA protections might not cover all system parts needed to secure PHI.
Furthermore, any organization seeking HIPAA compliance will encounter additional costs, staff training downtime, and operational challenges as systems and policies are adjusted to comply with federal rules. Although legally necessary, these changes will still cause business disruptions that organizations need to consider before starting their compliance efforts.
Consequences of Non-Compliance
HIPAA violations are discovered and punished quite reliably, as the HHS Office for Civil Rights (OCR) boasts a 99% resolution rate for all HIPAA complaints received. In cases where covered entities are found to be non-compliant as a result of neglect or unfamiliarity with HIPAA, penalties can range from $100 to $50,000 in fines per violation, depending on the degree of non-compliance.
In cases where entities are found to have willfully obtained or disclosed PHI, meanwhile, punishments are more severe, including fines of up to $50,000 and up to 1 year of imprisonment. Attempts to sell or otherwise utilize PHI for commercial advantage, personal gain, or malicious intent face up to $250,000 in fines and up to 10 years of imprisonment.
Even simple negligence can result in substantial penalties for organizations. In one case example, the Children’s Medical Center of Dallas experienced a breach of ePHI for 3,800 patients when an employee’s unencrypted, non-password-protected mobile device was stolen. After litigation, the Center faced a $3.2 million fine due to insufficient policies as well as the breach itself. Similarly, when the Alaska Department of Health and Human Services was found to not have conducted a risk analysis of its systems or implemented sufficient risk management policies, it was fined $1.7 million in damages.
Strengthening Compliance Through Technology
As previously shown, modern compliance programs rely heavily on technology to enforce HIPAA safeguards because of the increasingly digital healthcare industry. Therefore, deploying effective IT security solutions aligned with current data security frameworks is a crucial part of HIPAA security compliance.
Solutions like Netwrix Data Security Posture Management (DSPM) identify and classify PHI, reduce shadow data risks, and enforce encryption. Privileged Access Management (PAM) removes persistent admin privileges and records sessions for audits. Identity Management and ITDR solutions prevent unauthorized access and detect insider threats in real time. Directory and Endpoint Management help maintain AD hygiene and prevent data leaks at endpoints. Lastly, Netwrix Auditor and Access Analyzer simplify HIPAA compliance reporting with ready-made templates and ongoing access reviews.
Enhancing Healthcare Team Outcomes
Beyond its role in regulatory compliance, however, HIPAA promotes a framework for more efficient operations in the healthcare industry through a more interconnected organization.
Just like general IT security practices, enforcing HIPAA compliance is a team effort, not solely the responsibility of your IT department and compliance committee. All staff should receive ongoing training about the importance of HIPAA requirements and how to uphold them in daily tasks, whether they involve directly protecting PHI or simply ensuring PHI is transmitted only to authorized parties. Any team member with access to patient data can be a potential vulnerability for PHI confidentiality, so all employees must understand and consistently follow HIPAA best practices to keep your organization both compliant and secure.
While emphasizing this shared responsibility may require additional training or cultural shifts within the company, a unified approach to HIPAA compliance is essential not only for meeting regulations but also for improving workplace efficiency. When all staff understand which security protocols are crucial and why, work can proceed more reliably and consistently under effective security measures. This reduces redundancies caused by inconsistent or insecure practices and strengthens the organization’s overall security posture.
HIPAA Compliance Software from Netwrix
Netwrix HIPAA compliance software helps healthcare providers and their partners address privacy and security challenges by ensuring visibility into sensitive data, enforcing least privilege, and automating compliance reporting. With built-in HIPAA-ready reports, continuous auditing, and data risk assessment tools, organizations can streamline compliance efforts, reduce the risk of breaches, and demonstrate adherence to HIPAA standards during audits
Conclusion
Following security best practices and complying with federal law, HIPAA is essential for all healthcare organizations to protect patients’ personal data. Beyond legal compliance, HIPAA is vital for regulated organizations to maintain trust with clients and the public. The better your organization demonstrates its commitment to privacy standards, the more confident consumers will be in entrusting their PHI to your systems.
Since the modern healthcare industry relies heavily on digital systems and information, however, HIPAA compliance should be seen as just one part of the organization’s broader security strategy. By integrating healthcare-specific protections with IT security best practices, regulated entities can go beyond mere compliance to develop reliable, versatile security measures that lead to a stronger, more efficient, and overall more secure organization.
FAQs
What does HIPAA mean?
“HIPAA” refers to the US Health Insurance Portability and Accountability Act of 1996, a federal law designed to protect patients’ sensitive information, known as Protected Health Information (PHI). The law sets requirements for how healthcare providers and other entities that handle or process PHI must store this sensitive data to prevent breaches or cyberattacks.
What are the five rules of HIPAA?
The five rules of HIPAA are:
- The Privacy Rule establishes that PHI may be accessed only by authorized entities for healthcare or payment processing.
- The Security Rule provides regulations on the administrative, technical, and physical protections necessary to safeguard PHI that is stored or processed digitally.
- The Breach Notification Rule requires regulated entities to promptly inform affected patients, the media, and HHS of a breach of PHI.
- The Omnibus Rule expands and clarifies HIPAA regulations around digitally stored PHI.
- The Enforcement Rule describes what penalties may be issued to entities that improperly disclose PHI or experience a breach that exposes PHI.
While organizations should understand all these rules to achieve and maintain HIPAA compliance, the Security Rule and Omnibus Rule provide the most specific regulations to follow when developing IT security for a system that stores or transmits PHI.
What is a HIPAA violation?
A HIPAA violation occurs when PHI is disclosed to an unauthorized entity. Examples include everything from a system breach to accidentally emailing a message containing PHI to a non-healthcare entity.
What is the main purpose of HIPAA regulations?
HIPAA regulations are designed to safeguard patients’ privacy and build trust within the healthcare industry. With legal protections for patients’ privacy rights, consumers can approach healthcare providers expecting their sensitive data to be secure and that any privacy breaches will be addressed.
What are the three important rules for HIPAA compliance?
For healthcare providers and related entities, the three most important rules for HIPAA compliance are the Privacy Rule, the Security Rule, and the Breach Notification Rule. The Privacy Rule sets standards for protecting PHI and related patient rights, and the Security Rule supports these regulations by defining specific expectations for physical, technical, and administrative safeguards needed to secure PHI. Meanwhile, the Breach Notification Rule mandates that regulated organizations promptly notify affected patients, the media, and the US Department of Health and Human Services of any breaches involving PHI to ensure the public is informed.
While it is important that organizations also understand the two additional HIPAA rules (the Omnibus Rule and the Enforcement Rule), these feature far less in ongoing efforts to achieve HIPAA compliance.
What is an example of HIPAA compliance?
Examples of HIPAA compliance can be found in any effort made to effectively safeguard sensitive patient information. One of the most practical examples would be establishing a privacy plan to protect patients’ personal data, such as by encrypting data, managing user roles and permissions according to the Least Privilege principle, and regularly auditing systems to maintain optimal security.
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