Guide: What is HIPAA Compliance?

Are you familiar with HIPAA compliance?

Is your organization doing all that it is required to protect patient records?

The Health Insurance Portability and Accountability Act (HIPAA) has become very important in recent years. This is because so many healthcare organizations are making use of technology to operate more efficiently.

With the addition of new technology and electronic medical records (EMR), HIPAA compliance has become a hot topic. Failure to comply with the standards and requirements set by the HIPAA can come with serious consequences and fines.

So what is HIPAA compliance? If you don’t what HIPAA compliance is, it’s time that you learn. Below we’ll give you a thorough overview of everything you need to know about HIPAA compliance.

What is HIPAA Compliance?

The HIPAA sets the standard for protecting patient data. These standards apply to any organization that manages protected health information (PHI).

There are several main points that these organizations, as well as any individuals with access to this information, need to be aware of. They need to follow these when managing patient information to be compliant.

The act is composed of these three main rules, and it’s impossible to answer the question of “What is HIPAA compliance?” without giving an overview of these. We’ll discuss these rules in more detail below:

  • HIPAA Privacy Rule
  • HIPAA Security Rule
  • HIPAA Breach Notification Rule

In addition to these three rules, there are others that have been added in recent years as well. The Final Omnibus Rule and the Enforcement Rule have supplemented the original requirements of HIPAA. These have added requirements to the above rules.

It’s also important to be aware of the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH was created to increase the adoption of electronic health records. It also added higher penalties for not being HIPAA compliant and committing a HIPAA violation.

Who Needs to Be HIPAA Compliant?

It’s important to note which organizations need to be compliant with the HIPAA regulations. Essentially any organization that will have access to PHI must follow HIPAA rules and guidelines. No matter how often or how briefly it may be, anyone who comes into contact with PHI will need to comply.

Here are a few of the main organizations and individuals that will need to follow HIPAA rules:

  • Healthcare Organizations
  • Medical Offices
  • Physicians
  • Business Associates
  • Medical Staff
  • Subcontractors

Why HIPAA Compliance is Important

The truth is technology has brought a lot of changes to how organizations manage and access patient data. These changes have added a lot of conveniences. They have changed how organizations operate. Yet, it has also brought increased risks to the industry.

New methods of managing patient information come with more security risks. With the addition of technology, there are more security and privacy threats than before.

The HIPAA seeks to ensure that every organization is protecting patient information. At the same time, the rules do allow for flexibility.

The HIPAA acknowledge the increased efficiency of using electronic data and other methods. Yet, the act ensures that patients and their information are always well-protected.

Privacy, Security and Breach Notification Rules

As mentioned above, the HIPAA consists of three distinct “rules.” These rules ensure that organizations are taking the right steps to protect PHI. Below we’ll take a deeper look at these rules.

The HIPAA Privacy Rule

The HIPAA Privacy Rule exists to set conditions and limits to what is allowed when it comes to the permissible use of PHI and disclosures.

It’s a common misconception that HIPAA only applies to electronic medical records. However, this is not the case. These rules also apply to physical records and other formats as well.

For one thing, the HIPAA Privacy Rule designates what it considers PHI. The rule also designates whose responsibility it is to protect PHI. It sets guidelines for when PHI can and can’t be disclosed without consent by a patient.

This rule also sets parameters on a patient’s rights in regards to their own health or payment information.

The HIPAA Security Rule

While the HIPAA Privacy rule sets guidelines for all formats of PHI, the HIPAA Security Rule focuses on only electronic PHI.

This rule sets guidelines and safeguards for physical, technical, and administrative areas. It outlines how organizations can be HIPAA compliant. The rule discusses what should be done to protect patient information and avoid unauthorized disclosures of PHI.

The rule outlines how to deal with building security, device security, access controls, and encryption. This rule also emphasizes contingency planning. The rule discusses the creation of data backup plans, disaster recovery plans, and other contingency tasks.

The HIPAA Breach Notification Rule

An organization should follow every measure outlined in the rules mentioned above. Yet, there are still cases where a data breach may occur.

The HIPAA Breach Notification Rule acknowledges these issues. It outlines the steps an organization should follow in the case of a data breach.

One of the major requirements discussed is the need for the organization to report a breach. A breach should be reported to the affected patients, the media, and the Department of Health & Human Services. The only exception is if there is proof that PHI wasn’t compromised in the breach.

How to Get Started With HIPAA Compliance

How do you get started with HIPAA compliance? The very first step you’ll need to take is to appoint both a Privacy Officer and a Security Officer.

These officers will work to make sure your organization is maintaining HIPAA compliance at all times.

Below are a few tasks that fall under these two roles:

  • Conducts risk assessments to find vulnerabilities and risks to PHI.
  • Develops policies and procedures to address risks and vulnerabilities.
  • Trains employees and policies, procedures, and HIPAA guidelines. Each employee should be able to answer the question, “What is HIPAA compliance?”
  • Ensures the privacy and security of PHI when shared third parties and business associates.
  • Investigates, reports on and notifies applicable parties in the event of a breach.

There are various options you’ll have for adding these two roles to your organization. You may choose to have the same individual function as both the Privacy Officer and the Security Officer, for example.

You may also choose to outsource these roles to a third-party consultant, either temporarily or permanently.

Final Thoughts

So what is HIPAA compliance? By now you should have a pretty good idea of what it’s all about but there is a lot more to understand. Spend some time learning what you can about HIPAA and hopefully you’ll avoid some of the most common HIPAA violations.

Believe it or not, it doesn’t have to be hard to make sure your organization is HIPAA compliant and that your PHI is well-protected.

If you’re ready to get started with HIPAA compliance, HIPAA Security Suite can help. Learn more about our HIPAA compliance solutions to get started.

HIPAA Security Reminders


HIPAA Security Suite has developed a weekly HIPAA Security Reminder series that’s FREE for all of us who are responsible for, or engaged in, the use and protection of PHI.

Pursuant to Section 164.308(a)(5) of the HIPAA Security Rule, the Standard states: Implement a security awareness and training program for all members of its workforce (including management).

This standard is part of our Best Practices Recommendations for HIPAA Security Suite users, but it’s available for FREE to anyone who wants to comply with HIPAA using the easiest, best tools available.

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