Question 1

What is the difference between the HIPAA Security Rule and Privacy Rule?

Accepted Answer

The Security Rule focuses specifically on electronic protected health information (ePHI) and requires administrative, physical, and technical safeguards to ensure its confidentiality, integrity, and availability. The Privacy Rule is broader and governs the use and disclosure of all PHI (electronic, paper, and oral), establishes patient rights, and defines permitted uses. Most technology-focused compliance work centers on the Security Rule, but organizations must comply with both.

Question 2

What is a HIPAA risk analysis and why is it required?

Accepted Answer

A risk analysis is an assessment of potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI held by your organization. It is explicitly required by 45 CFR 164.308(a)(1)(ii)(A) and is the foundation of your entire HIPAA compliance program. OCR has cited failure to conduct a thorough risk analysis as the most common finding in enforcement actions and breach investigations. We conduct risk analyses that satisfy OCR expectations and provide actionable remediation roadmaps.

Question 3

Do we need a Business Associate Agreement for every vendor that touches PHI?

Accepted Answer

Yes. Under HIPAA, you must have a BAA in place with every business associate that creates, receives, maintains, or transmits PHI on your behalf. This includes cloud hosting providers, EHR vendors, billing services, IT support companies, shredding services, and any other vendor with access to PHI. We review your vendor relationships, identify gaps in BAA coverage, and help you implement agreements that meet regulatory requirements.

Question 4

How does HIPAA relate to HITRUST?

Accepted Answer

HITRUST CSF incorporates all HIPAA Security Rule requirements into its control framework, so achieving HITRUST certification demonstrates HIPAA compliance alignment. However, HITRUST certification is not legally equivalent to HIPAA compliance; only HHS/OCR makes that determination. Many organizations use HITRUST as a structured approach to satisfying HIPAA requirements because it provides a certifiable framework with third-party validation. We help organizations with both standalone HIPAA compliance programs and HITRUST-based approaches.

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