1. Administrative Safeguards (Policies & Procedures)

✅ Conduct a HIPAA Risk Assessment to identify vulnerabilities.
✅ Assign a Security & Privacy Officer responsible for compliance.
✅ Establish Access Control Policies (role-based access, least privilege).
✅ Develop an Incident Response Plan for security breaches.
✅ Implement a Business Continuity & Disaster Recovery Plan (data backups, failover testing).
✅ Require HIPAA Business Associate Agreements (BAAs) with IT vendors.
✅ Conduct regular HIPAA Security Awareness Training for employees.
✅ Maintain audit logs of system activity and access.

2. Physical Safeguards (Facility & Device Security)

✅ Restrict physical access to servers, networking equipment, and workstations.
✅ Implement workstation security policies (auto-lock screens, secure laptops).
✅ Encrypt removable media (USBs, external hard drives) or prohibit their use.
✅ Implement secure disposal policies for ePHI-containing hardware.
✅ Monitor and log physical access to critical IT infrastructure.

3. Technical Safeguards (IT & Cybersecurity Controls)

Access & Authentication Controls

✅ Implement role-based access control (RBAC) and least privilege.
✅ Enforce Multi-Factor Authentication (MFA) for all user logins.
✅ Require unique user IDs for system access (no shared logins).
✅ Implement automatic session timeouts for inactive workstations.

Data Security & Integrity

✅ Use end-to-end encryption for ePHI (both in transit and at rest).
✅ Ensure secure data backups with offsite storage and encryption.
✅ Deploy endpoint security (EDR/MDR solutions) to detect and prevent threats.
✅ Implement real-time integrity monitoring to detect unauthorized ePHI modifications.

Network Security

✅ Deploy firewalls, intrusion detection/prevention systems (IDS/IPS).
✅ Use VPNs for remote access to protect ePHI from unauthorized access.
✅ Segment networks to separate ePHI from public or less secure areas.
✅ Conduct regular vulnerability scanning & penetration testing.

Audit & Monitoring

✅ Enable detailed logging and monitoring for all access to ePHI.
✅ Retain audit logs for at least 6 years (as required by HIPAA).
✅ Set up automated alerts for unauthorized access attempts.

Email & Communication Security

✅ Use HIPAA-compliant email encryption for ePHI communication.
✅ Prohibit the use of personal email accounts for ePHI.
✅ Implement secure messaging platforms for internal communications.

Incident Response & Breach Notification

✅ Implement a 24/7 security monitoring solution (SOC, MDR).
✅ Have a Breach Response Plan to comply with HIPAA’s 60-day breach notification rule.
✅ Regularly test and update the Incident Response Plan.

4. Ongoing Compliance & Maintenance

✅ Conduct Annual HIPAA Risk Assessments.
✅ Perform Quarterly Security Audits (internal & external).
✅ Regularly update policies & procedures as regulations evolve.
✅ Ensure third-party vendors are HIPAA compliant (cloud providers, IT services).
✅ Stay updated on HIPAA cybersecurity best practices.

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