Protecting patient data is at the core of HIPAA Security compliance. Every organization handling protected health information (PHI), whether directly in healthcare or as a business associate, must regularly test for risks and address vulnerabilities. Conducting a thorough HIPAA Security Risk Assessment helps reduce exposure to threats by carefully defining scope, minimizing attack surfaces, and leveraging available tools and resources.

Is your organization prepared for a HIPAA assessment? Schedule a consultation to find out!

Optimize Your HIPAA Security Risk Assessments

The Health Insurance Portability and Accountability Act (HIPAA), enforced by the U.S. Department of Health and Human Services (HHS), is one of the most comprehensive data protection laws in the country. A key requirement under the HIPAA Security Rule is conducting ongoing risk assessments to identify and mitigate potential threats to protected health information (PHI).

To make your HIPAA Security Risk Assessments more effective, follow these best practices:

• Prioritize critical risks: Focus on vulnerabilities most likely to impact HIPAA compliance and PHI security.
• Reduce the attack surface: Limit unnecessary data storage, access points, and systems that increase risk exposure.
• Leverage trusted resources: Use HHS guidelines and tools from other federal agencies to guide risk reporting.
• Align with multiple regulations: Streamline assessments by mapping HIPAA requirements to other applicable frameworks.
  

Most importantly, avoid going at it alone. Partnering with an experienced HIPAA security advisor can help your organization implement, assess, and optimize compliance strategies effectively.

Understanding Risks to PHI

Under the HIPAA Security Rule, organizations must conduct regular risk assessments to safeguard protected health information (PHI). These risks often overlap with definitions in the HIPAA Privacy Rule, which outlines who can access PHI and under what circumstances.

Covered entities such as healthcare providers, plan administrators, clearinghouses, their business associates (including lawyers, contractors, and third-party vendors) must monitor for threats of unauthorized access to PHI. According to the Privacy Rule, PHI includes any identifiable health records, such as medical histories, treatment details, conditions, or billing information.

To stay compliant, PHI must be:

• Accessible to patients and law enforcement when legally required.
• Kept secure from all other unauthorized access.
• Protected against breaches that compromise confidentiality, integrity, or availability.
  

In addition to preventing unauthorized disclosures, HIPAA risk analyses should also account for:

• Compliance gaps with administrative, physical, and technical safeguards required by the Security Rule
• Operational weaknesses in visibility or communication systems that may impact the HIPAA Breach Notification Rule
  

By proactively identifying and addressing these risks, organizations strengthen their HIPAA Security posture and reduce the likelihood of costly violations. 

Minimizing Your Attack Surface

A core principle of HIPAA Security is reducing the attack surface limiting the assets, systems, and data that could be exposed to cyber threats. For organizations handling protected health information (PHI), this means two things:

1. Reducing the amount of PHI retained
2. Minimizing the pathways cybercriminals could exploit to access PHI De Identifying PHI

The Department of Health and Human Services (HHS) recommends two methods for de-identifying PHI so that patient identities cannot be traced:

• Expert Determination Method:  A qualified expert applies scientific principles to ensure the risk of re-identification is negligible.
• Safe Harbor Method: PHI is stripped of specific identifiers, including:
  • Names and numerical identifiers (e.g., Social Security numbers, license numbers)
  • Addresses smaller than a state of residence
  • Dates related to age (except for the year, for patients 90 and younger)
  • Phone numbers and other unique numbers tied to devices, vehicles, etc.
  • Electronic identifiers such as email addresses, IP addresses, and URLs
  • Photographs, biometric data, or other personal likenesses
    

Retention and Access Controls

Beyond de-identification, organizations should limit how much PHI is stored and where it is stored. The HIPAA Privacy Rule defines two Required Disclosures—providing PHI to the individual upon request and to HHS. All other uses, including Permitted Disclosures (e.g., for research or law enforcement), must follow the “minimum necessary” principle.

Best Practice

Keep only the least amount of PHI possible, in the fewest number of systems, and under strict access controls. This makes HIPAA Security risk assessments easier while reducing the chances of unauthorized disclosure.

Utilizing Available Resources

Several government agencies, including the Department of Health and Human Services (HHS) and the National Institute of Standards and Technology (NIST), provide tools and frameworks to help organizations meet HIPAA Security risk assessment requirements. These resources can streamline compliance efforts and strengthen security practices:

• Security Content Automation Protocol (SCAP):  Developed by NIST, SCAP helps organizations test and evaluate their Security Rule protections dynamically and automatically, including risk assessments.
• Security Risk Assessment (SRA) Tool: Created by the Office of the National Coordinator for Health Information Technology (ONC) and HHS’s Office for Civil Rights (OCR), this tool is tailored to small and mid-sized covered entities and business associates. It tracks vulnerabilities, responses, and general compliance guidance.
• NIST Special Publications (SPs): Additional guidance includes:
  • SP 800-115: Technical methods for conducting security assessments
  • SP 800-100: Managerial considerations for security and risk management
  • SP 800-66: Practical implementation guidance for the HIPAA Security Rule
  • SP 800-39: Broader information systems risk management framework

While these resources provide a strong foundation, they can be complex to navigate without expert guidance. Partnering with a HIPAA compliance advisor ensures that your risk assessment processes not only align with HHS expectations but also strengthen your organization’s overall HIPAA Security posture.

Streamlining Compliance Requirements

Meeting HIPAA Security risk assessment obligations is often just one part of a larger compliance strategy. Many organizations must also align with additional regulations, such as PCI DSS, NIST standards, or SOC 2. One of the most effective ways to streamline these overlapping requirements is by adopting the HITRUST CSF (Common Security Framework).

The HITRUST CSF is a comprehensive cybersecurity and compliance framework built originally for the healthcare industry. It now includes controls that address multiple industries and regulatory environments, including:

• PCI DSS (Payment Card Industry Data Security Standards)
• NIST Special Publications such as SP 800-171, critical for government contractors
• AICPA SOC frameworks, including SOC 2 for service organizations

By implementing HITRUST, organizations can take advantage of its “assess once, report many” approach. This means a single HITRUST assessment can demonstrate compliance across multiple frameworks, minimizing duplication and effort.

HITRUST also offers flexible certification paths:

• Essentials or Implemented Assessment: Valid for one year
• Risk-based Assessment: Valid for two years

For organizations balancing HIPAA with other requirements, HITRUST is one of the most efficient ways to ensure security, compliance, and scalability.

Rethink Your HIPAA Compliance

For many organizations, especially those preparing for HIPAA compliance for the first time, the HIPAA Security Rule risk assessment can feel complex and difficult to interpret. Covered entities and business associates must take proactive steps to protect PHI, continuously monitoring for threats, addressing vulnerabilities, and closing compliance gaps before they become violations.

At RSI Security, we’ve guided healthcare providers, business associates, and adjacent industries through every stage of HIPAA compliance. Our team understands that investing in discipline up front not only ensures compliance but also enables your organization to grow securely in today’s evolving healthcare landscape.

Ready to strengthen your HIPAA Security posture? 

To get started on your HIPAA security risk assessment prep, contact RSI Security today!

Download HIPAA Checklist