HIPAA

HIPAA was created to improve the accountability of healthcare providers, insurers, and their partners, ensuring PHI is kept secure and confidential to prevent fraud and abuse. Under the provisions of the act, healthcare organizations are held accountable for the PHI they store, handle, access, and transfer.

The HITECH Act of 2009 later strengthened HIPAA by expanding enforcement, introducing tougher penalties, and encouraging the adoption of electronic health records.

 The standards established under HIPAA must be followed by all:

• Healthcare providers

• Health plans

• Healthcare clearinghouses

• Business associates of HIPAA-covered entities
  
  

HIPAA is a U.S. law, but it can apply internationally if a foreign business works with companies that handle the health information of U.S. residents. In such cases, foreign vendors must comply through Business Associate Agreements (BAAs).

To comply with HIPAA, covered entities must implement safeguards to secure and protect PHI. Five main HIPAA rules provide specific guidelines:

• The Privacy Rule Sets standards for how PHI can be used and disclosed, and grants patients the right to access and control their health information.

• Security Rule: Requires administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of electronic PHI (ePHI).

• Breach Notification Rule: Requires covered entities to notify affected individuals, the Department of Health and Human Services (HHS), and in some cases the media, if a breach of unsecured PHI occurs.

• Enforcement Rule: Outlines how HHS, through its Office for Civil Rights (OCR), enforces HIPAA compliance.

• Omnibus Rule: Strengthened requirements for business associates, clarified patient rights (such as requesting electronic copies of records), and updated privacy/security provisions.

 HIPAA gives patients several important rights, including the ability to:

• Access and request copies of their health information

• Request corrections to their records

• Request restrictions on certain disclosures

• Receive an accounting of disclosures

• Obtain their information in an electronic format

The OCR within HHS enforces HIPAA. Organizations can face financial penalties and other sanctions for avoidable breaches of PHI or ePHI. The penalty structure is tiered, based on the level of knowledge the covered entity had about the violation—from fines that vary by severity to potential criminal prosecution.

Enforcement ensures that organizations are held accountable for safeguarding patient privacy, maintaining the confidentiality of health data, and providing patients with access to their records.

Covered entities should be aware of common violations, including:

• Unauthorized access to patient records

• Failure to secure ePHI

• Insufficient employee training on HIPAA regulations

• Mishandling the disposal of medical records

• Improper encryption of electronic data

• Lost or stolen devices containing PHI

• Disclosing health information without patient consent

• Lack of Business Associate Agreements (BAAs) with vendors
  
  

Awareness of these common pitfalls helps organizations proactively prevent violations that could lead to penalties and reputational damage.

To remain compliant, covered entities and business associates should:

• Establish a comprehensive compliance framework with regular audits and risk assessments

• Regularly review and update policies and procedures

• Provide ongoing staff training on HIPAA requirements and emerging cybersecurity risks

• Ensure PHI is properly de-identified when shared, unless disclosure is authorized

• Maintain clear Business Associate Agreements with vendors handling PHI

HIPAA compliance doesn’t end at the organizational level—patients and clients also play a role in safeguarding their information. Covered entities should educate patients on best practices, such as using secure patient portals instead of email for communication, enabling multifactor authentication when available, safeguarding login credentials, and promptly reporting suspicious activity. Encouraging client-side protection enhances overall HIPAA compliance by mitigating risks such as phishing, credential theft, and unauthorized access to patient portals.

By fostering an environment of accountability, continuous improvement, and strong data protection—including organizational safeguards and client-side awareness—organizations can maintain HIPAA compliance and protect patient rights.