HIPAA Security Rule


The HIPAA Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information. (ePHI).  It requires entities to evaluate risks and vulnerabilities in their environments and to implement reasonable and appropriate security measures to protect against reasonably anticipated threats or hazards to the security or integrity of ePHI.  A Security Risk Analysis is the first step in that process.

Please note that the HIPAA Security Rule does not prescribe a specific risk analysis methodology, recognizing that methods will vary dependent on the size, complexity, and capabilities of the organization.  Instead, the Rule identifies risk analysis as the foundational element in the process of achieving compliance, and it establishes several objective that any methodology adopted must achieve.

Risk Analysis Requirements under the HIPAA Security Rule

The Security Management Process standard in the Security Rule requires organizations to “[i]mplement policies and procedures to prevent, detect, contain, and correct security violations.” (45 C.F.R. § 164.308(a)(1).) Risk analysis is one of four required implementation specifications that provide instructions to implement the Security Management Process standard. Section 164.308(a)(1)(ii)(A) states:

Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the [organization].

The following questions adapted from NIST Special Publication (SP) 800-665 are examples organizations could consider as part of a risk analysis. These sample questions are not prescriptive and merely identify issues an organization may wish to consider in implementing the HIPAA Security Rule:

  • Have you identified the e-PHI within your organization? This includes e-PHI that you create, receive, maintain or transmit.
  • What are the external sources of e-PHI? For example, do vendors or consultants create, receive, maintain or transmit e-PHI?
  • What are the human, natural, and environmental threats to information systems that contain e-PHI?

In addition to an express requirement to conduct a risk analysis, the Rule indicates that risk analysis is a necessary tool in reaching substantial compliance with many other standards and implementation specifications.