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What Is the HIPAA Security Rule?

The HIPAA Security Rule is a set of legal standards for maintaining the confidentiality, integrity, and availability of electronic protected health information (ePHI) in the United States. It requires healthcare entities and their business associates to implement administrative, physical, and technical measures to secure patient data and mitigate the risk of data breaches. Noncompliance can result in significant financial and legal sanctions.

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Why Is the HIPAA Security Rule Important?

The HIPAA Security Rule’s compliance requirements establish a framework that helps healthcare organizations mitigate the risk of data breaches and unauthorized access to patients’ ePHI. The healthcare industry remains a favorite target among cybercriminals, and compliance with HIPAA rules is an essential step in fending off their attacks to uphold patient privacy, maintain trust, and prevent identity theft.

Ransomware attacks on healthcare organizations rose more than 165% in 2023 compared to 2022, according to Zscaler findings.

Overview of the HIPAA Security Rule

 Part of the Health Insurance Portability and Accountability Act of 2003, the Security Rule sets forth standards to which healthcare organizations and their business associates must adhere in order to address potential risks to ePHI.

These standards fall into three main categories:

  • Administrative safeguards lay out policies and procedures for security measures, including how to conduct security risk assessments, define roles and responsibilities, and create emergency plans.
  • Physical safeguards cover standards for device security, including workstation usage, physical access to health information technology and its infrastructure, and more.
  • Technical safeguards define the technologies required to secure ePHI against unauthorized access, disclosure, and alteration, including access controls, encryption, authentication, and secure transmission.

In addition, the Security Rule requires covered entities to have detection and response measures in place in the event unauthorized access or a data breach does occur. Exactly what these and other security measures look like can vary from one entity to another.

Main Objectives of HIPAA

  • Protect patient privacy by ensuring the confidentiality of, and preventing unauthorized access to, individuals’ personal health information.
  • Improve health insurance portability, making it easier for patients to keep their health coverage when changing insurance plans or employers.
  • Simplify healthcare administration with standards for electronic transactions like billing and claims to speed up processes and cut down on paperwork.
  • Strengthen the security and integrity of ePHI by establishing standards for the handling, transmission, disclosure, and protection of patient data.
  • Reduce healthcare fraud and abuse by supporting standards for detecting and preventing fraudulent practices and other criminal misuse of PHI.
  • Standardize electronic health information transactions to improve the interoperability of health information systems.
  • Enforce compliance among HIPAA covered entities by imposing penalties for noncompliance. 

As of early 2024, the Office for Civil Rights (OCR) has imposed 138 HIPAA noncompliance fines, totaling more than US$137 million (according to HHS).

  Data Protected Under HIPAA

HIPAA covers data relating to an individual’s health or condition, or the provision of healthcare and related payments, that could reasonably be used to identify that individual. The HIPAA Privacy Rule refers to this as “individually identifiable health information” or protected health information (PHI). By extension, ePHI is any PHI transmitted by or maintained in electronic media, such as electronic health records (EHRs).

Examples of PHI include:

  • Common personal identifiers such as name, address, birth date, and Social Security number
  • Records of health and medical history, diagnoses, treatments, prescriptions, and test results
  • Billing records and payment details related to the provision of healthcare services
  • Health plan information, including enrollment data, insurer, coverage details, and claims
  • Healthcare provider details, including doctors and sites that provided care or treatment
  • Business associate information related to entities that perform functions or services on behalf of covered entities and involve the use or disclosure of PHI

HIPAA does not regulate the use of anonymized information that does not identify and could not reasonably be used to help identify an individual, referred to as “de-identified health information.”

Breach Notification Rule

Covered entities must report breaches affecting fewer than 500 individuals to the OCR and those affected, no more than 60 days after the calendar year in which the breach is discovered. In case of a larger breach, the entity must also notify prominent media.

Notice must include a description of the breach and the data involved, guidance on how affected individuals can protect themselves, and an explanation of investigation and resolution efforts, among other details.  

HIPAA in Cybersecurity

HIPAA security requirements are a central force in the protection of ePHI, especially as attacks on the industry become more frequent and devious. In this landscape, maintaining HIPAA-compliant security and networking technology, data integrity controls, and audit controls is crucial for healthcare organizations to protect themselves and their patients.

The healthcare industry was the fourth most popular target of encrypted cyberattacks worldwide in 2023, with 29% more attacks compared to 2022. Learn more in the ThreatLabz 2023 State of Encrypted Attacks Report.

HIPAA Security Rule Requirements

The HIPAA Security Rule outlines numerous safeguards for the protection of ePHI. However, these safeguards don’t prescribe specific security measures, giving organizations the flexibility to determine which technologies to use, how often to conduct reviews, and so on.

Put another way, HIPAA’s requirements chiefly concern the outcome—that the data is successfully protected—not the particular means by which organizations achieve it.

Click below to expand the categories of key HIPAA requirements.

Administrative Safeguards

  • Conduct regular risk assessments to identify potential vulnerabilities

  • Develop and implement effective security policies and procedures

  • Designate a security officer to implement and oversee security measures

  • Train staff on proper data handling and compliance practices

Physical Safeguards

  • Control physical access to facilities and systems that house ePHI

  • Implement policies for security and the use of workstations with access to ePHI

  • Safeguard electronic media that contains ePHI

Technical Safeguards

  • Implement access controls based on user roles to limit access to ePHI

  • Utilize data encryption and decryption to protect ePHI at rest and in motion

  • Maintain mechanisms to authenticate users and verify the integrity of ePHI

Organizational Requirements

  • Ensure business associates with which you share ePHI are also Security Rule compliant

  • Establish contingency plans for data backup and recovery in case of a security incident

  • Periodically evaluate your security measures to adapt to changes in technology and risks

Policies and Procedures

  • Develop and maintain written policies and procedures for HIPAA Security Rule compliance

  • Regularly review and update policies as your organization's environment changes

Best Practices for HIPAA Compliance

HIPAA gives covered entities the flexibility to determine their own ideal approaches to compliance, based on their unique needs. With that in mind, some essential considerations in each of the Administrative, Physical, and Technical safeguard areas will help you ensure compliance.

Administrative Safeguards

  • Security management process: Identify and analyze potential risks to ePHI and implement measures that reduce risks and vulnerabilities to a reasonable level.
  • Information access management: Implement policies and procedures to enforce strict role-based access to ePHI, consistent with the Privacy Rule’s “Minimum Necessary Rule” for use or disclosure.

Physical Safeguards

  • Workstation and device security: Implement policies and procedures that specify proper use of and access to workstations and electronic media as well as the transfer, removal, disposal, and reuse of electronic media.

Technical Safeguards

  • Access control: Implement policies and procedures that allow only authorized persons to access ePHI.
  • Audit control: Implement mechanisms to record and examine access and other activity in information systems that contain or use ePHI.
  • Integrity controls: Implement policies, procedures, and electronic measures to ensure that ePHI is not improperly altered or destroyed.
  • Transmission security: Implement measures that guard against unauthorized access to ePHI being transmitted over a network.

HIPAA Compliance Checklist

With the aforementioned requirements and best practices in mind, the HHS Office of Information Security’s Top 10 checklist is a simple way to see if your organization is moving in the right direction for HIPAA compliance:

unchecked Use a cloud service provider that encrypts

unchecked Conduct compliance audits

unchecked Implement a zero trust model

unchecked Set up your privacy settings

unchecked Use two-factor authentication

unchecked Establish and enforce security policies

unchecked Maintain cloud visibility

unchecked Understand cloud compliance, requirements, and regulations

unchecked Install updates to your operating system

unchecked Avoid using public Wi-Fi

The Future of the HIPAA Security Rule

 The OCR has updated the HIPAA Privacy Rule, Enforcement Rule, and some administrative requirements, but as of this writing, the Security Rule hasn’t changed (except for some small error corrections) since 2013. However, planned cyber resiliency updates by the US Department of Health and Human Services are considered likely to lead to three important changes in 2024:

  1. New security requirements for covered entities that participate in Medicare or Medicaid
  2. New security standards in the HIPAA Security Rule to better support accountability
  3. A greater capacity for the OCR to investigate and penalize HIPAA noncompliance

These updates are essential to protect patient data in the evolving technological and cyberthreat landscapes. The proliferation of IoT devices, cloud adoption, advanced threats like double extortion ransomware, and the persistent complexity of legacy healthcare networks all make security more important than ever, and HIPAA remains one of the strongest forces in strengthening that security while reinforcing patient trust. 

How Zscaler Supports HIPAA Security Rule Compliance

Zscaler zero trust architecture offers progressive healthcare organizations HIPAA-compliant threat protection, data loss prevention (DLP), SSL inspection, sandboxing, and much more. Our cloud native security platform, the Zscaler Zero Trust Exchange, connects users to applications, not IP networks, enabling organizations to seamlessly leverage their existing IT infrastructure concurrent with any phase of cloud and digital transformation.

As cloud adoption continues to accelerate, selecting the right cloud security platform is key. The Zscaler platform reduces cloud security risk and misconfiguration, improves compliance, provides shadow IT visibility, delivers actionable threat intelligence, and enforces HHS OIC best practices for securing healthcare data in the cloud, enabling your organization to:

  • Preserve the confidentiality and integrity of patient data
  • Maintain compliance with HIPAA, HITECH, and other regulations
  • Protect patients and data from cyberattacks by eliminating the attack surface
  • Inspect 100% of TLS/SSL traffic to stop hidden threats and reduce data loss 

To learn more about how Zscaler helps secure modern healthcare and ensure HIPAA compliancevisit Zscaler for Healthcare.

Suggested Resources

FAQs

How Does Cybersecurity Impact the HIPAA Security Rule?

Cybersecurity is the most crucial piece of HIPAA Security Rule compliance. Measures such as risk assessments, access controls, encryption, and incident response help ensure an organization can effectively secure ePHI against the dangers of unauthorized access and data breaches, and maintain the resilience of healthcare systems against evolving cyberthreats.

What Is the Best Cybersecurity Solution for HIPAA Security Rule Compliance?

The best cybersecurity solution for HIPAA compliance involves a holistic, layered approach. While HIPAA doesn’t require specific technologies or tools, your organization needs to employ robust access controls, encryption, risk assessments, advanced threat detection and prevention, and more to protect ePHI. It’s crucial to find a proven technology partner that can deliver effective, compliant solutions that match your organization’s unique needs.

Is Cybersecurity Essential for HIPAA Compliance?

Cybersecurity is absolutely essential for HIPAA compliance. The HIPAA Security Rule mandates stringent measures to safeguard ePHI, and with the healthcare sector increasingly relying on digital technologies, health information is at greater risk from cyberthreats. Effective cybersecurity reduces the risk of data breaches and demonstrates a commitment to ensuring patient privacy.

What Does HIPAA Not Cover?

HIPAA doesn’t cover all entities or types of data. Covered entities include healthcare providers, health plans, and healthcare clearinghouses, as well as their business associates who handle ePHI. Entities not covered include employers, life insurers, and most schools and universities. HIPAA also doesn’t regulate data held by non-healthcare-related entities or unrelated to health conditions, treatments, or payments.