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How to Implement a HIPAA Cybersecurity Framework: A Guide for Compliance Leaders

Richard P. Kusserow | November 2025

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The connection between HIPAA compliance and cybersecurity has never been stronger—from increased OCR enforcement action to national news coverage of cyber incidents like the Change Healthcare attack. But with multiple complex requirements, many compliance leaders are still unsure exactly how to ensure their cybersecurity program meets the OCR’s expectations.

This article provides a clear roadmap to robust and HIPAA-compliant cybersecurity measures. We explore a proven framework for protecting electronic personal health information (ePHI), along with clear steps to implement each “pillar.”

HIPAA and Cybersecurity: Why Urgent Action is Required in Today’s Compliance Landscape

The HIPAA Security Rule mandates robust measures to protect healthcare patients’ ePHI through physical, administrative, and technical safeguards. These requirements were introduced in 2003 due to the rising use of digital technology within healthcare. But over two decades later, digital technology has transformed healthcare—and the Security Rule has become a cornerstone of HIPAA compliance. 

The Office for Civil Rights (OCR) recently launched its “Risk Analysis Initiatives”—an effort to increase compliance with the risk analysis and risk management requirements under the HIPAA Security Rule’s administrative safeguards. This signals a clear shift in enforcement priorities—the initiative has already led to seven enforcement actions—likely driven by:

• Growing Frequency: Cyberattacks are growing more frequent, with the average organization experiencing 43 attacks per year.  The number of ransomware attacks alone has grown by 264 percent since 2018.
• Increased Prevalence: The number of organizations that face cyberattacks has also increased, with large and small institutions facing significant threats. Surveys show that 90 percent of healthcare organizations experienced a cybersecurity attack in the last 12 months, with nearly three-quarters saying the attacks disrupted patient care.
• Spiralling Costs: Not only have recent cyberattacks driven significantly higher costs—with the Change Healthcare’s ransomware attack resulting in nearly $2.5 billion in victim payouts and restorative measures—the OCR has also begun to enforce harsher penalties for failed cybersecurity or risk assessment measures.
  

The takeaway is simple: stronger cybersecurity measures are not just essential for HIPAA compliance—they are vital to protect your patients, reputation, and bottom line. But how can you actually improve your cyber posture?

Foundation First: Assessing Your Existing Cybersecurity Posture

The first step to improve your cybersecurity posture is to assess your existing program. Not only does this help you identify and prioritize risks, it also helps to map the entire cybersecurity program and provide a “blueprint” that can be leveraged when introducing new measures or revising old processes. 

However, while HIPAA mandates annual security risk assessments (SRAs), many organizations do not complete them. In fact, just 50 percent of organizations ever conduct cybersecurity audits—leaving many without clear visibility of their existing program or core vulnerabilities.

Our experts suggest four key steps to evaluate your existing cybersecurity posture:

1. Conduct Internal Security Risk Assessments (SRAs): Leverage resources like the NIST Cybersecurity Framework (CSF) or HITRUST Common Security Framework (CSF) to benchmark your cybersecurity controls and identify gaps or weaknesses.
2. Evaluate Emerging Threats: Compile a research report to understand how changing cybersecurity risks—such as AI-driven attacks and ransomware-as-a-service (RaaS)—could impact your security program.
3. Identify High-Risk Areas: Pinpoint the areas of your digital infrastructure that are most vulnerable or contain the most sensitive or unsecured PHI.
4. Run Third-Party Assessments: Work with external experts to either audit your cybersecurity program or run penetration tests that reveal exactly how your system will respond during real cyberattacks.
   

These steps should provide you with the data and information required to upgrade cybersecurity measures and ensure HIPAA compliance—but you’ll need to use the right framework.

The 5-Pillar HIPAA Cybersecurity Framework

A comprehensive HIPAA cybersecurity program requires an integrated framework that addresses every dimension of ePHI protection. The following five pillars provide that structure, translating regulatory requirements into operational security:

1. Robust Access Controls That Go Beyond Basic Password Requirements

Access controls form the first line of defense against both external attacks and insider threats. They determine who can access ePHI, what they can do with it, and when they can access it. Basic password requirements—while necessary—are insufficient for protecting ePHI in today’s threat environment.

Credential theft remains one of the most common attack vectors in healthcare breaches. When attackers gain legitimate user credentials, they can access systems undetected, moving laterally through networks and exfiltrating data over extended periods. Strong access controls prevent these attacks by requiring multiple verification methods, limiting permissions to only what’s necessary, and creating detailed audit trails that reveal suspicious activity.

Action Steps:

• Implement multi-factor authentication (MFA) for all systems containing ePHI
• Establish role-based access controls (RBAC) that grant users only the minimum necessary permissions
• Conduct access reviews at least quarterly to ensure permissions remain appropriate as roles change
• Deploy automated alerts for anomalous access patterns (unusual locations, bulk downloads, after-hours access)
• Maintain comprehensive audit logs for both incident response and OCR compliance evidence

2. Comprehensive Encryption Strategies for Data at Rest and in Transit

Encryption transforms readable ePHI into unintelligible code, rendering stolen data useless without the decryption key. While HIPAA does not mandate encryption in all circumstances, the OCR views it as a critical addressable safeguard—one that organizations must implement or document why an alternative provides equivalent protection.

Without encryption, lost laptops, stolen backup drives, and intercepted network traffic become immediate HIPAA breaches requiring full notification. With proper encryption, these same incidents may not constitute breaches at all, saving organizations from regulatory penalties and reputational damage. This protection is why encryption appears consistently in the OCR’s enforcement actions—its absence represents a fundamental security gap that exacerbates every other vulnerability.

Action Steps:

• Encrypt all ePHI at rest using strong standards such as AES-256 (servers, workstations, laptops, mobile devices, removable media)
• Encrypt all ePHI in transit using secure protocols such as TLS 1.2 or higher (email, file transfers, remote access, cloud connections)
• Implement full-disk encryption to protect against lost or stolen hardware
• Establish key management procedures that store keys separately from encrypted data and rotate them regularly
• Document encryption policies and any justified exceptions where alternative safeguards are used

3. Network Security Approaches That Protect Against Modern Cyber Threats

Network security creates layers of defense that prevent unauthorized access and contain breaches when they occur. In an environment where attackers constantly probe for vulnerabilities, relying on a single security control is insufficient—multiple defensive layers ensure that if one fails, others remain in place to protect ePHI.

The threat landscape demands this layered approach. Most successful cyberattacks exploit the weaknesses of legacy healthcare IT, such as unpatched vulnerabilities, weak network segmentation, and inadequate monitoring. Comprehensive network security addresses these vulnerabilities before attackers can exploit them.

Action Steps:

• Deploy next-generation firewalls configured to deny all traffic by default, explicitly permitting only necessary communications
• Implement network segmentation that isolates ePHI in restricted zones separate from clinical systems, administrative functions, and guest access
• Deploy intrusion detection and prevention systems (IDS/IPS) that provide real-time threat detection and alerts
• Establish rigorous patch management processes that prioritize systems with external exposure or the most sensitive ePHI
• Conduct regular vulnerability scans to identify and address security gaps before attackers discover them

4. Incident Response Planning That Meets the OCR’s Strict Reporting Requirements

Even robust security measures cannot prevent every incident. Effective incident response planning ensures that when breaches occur, you contain damage quickly, preserve evidence properly, and meet all regulatory obligations. Organizations without formal response plans waste critical time determining who should do what, often making costly mistakes in the process.

OCR’s breach notification requirements leave no room for improvisation. Breaches affecting 500 or more individuals must be reported within 60 days, with notifications extending to affected individuals and, in large breaches, to media outlets. Failure to report appropriately compounds the original violation—OCR’s enforcement actions consistently penalize both the security gaps that enabled breaches and the notification failures that followed. A tested incident response plan prevents these cascading violations.

Action Steps:

• Develop a formal incident response plan that defines roles, procedures, and decision-making authority before crises strike
• Establish detection mechanisms combining automated monitoring tools and staff training that encourage reporting suspicious activity
• Define specific response procedures for different incident types, including containment actions, forensic protocols, and evidence preservation
• Practice procedures through tabletop exercises that test your team’s readiness and reveal gaps in your plan
• Ensure your plan addresses OCR’s breach notification timelines and requirements for individuals, OCR, and media

5. Employee Training Methods That Create Lasting Security Awareness

Technology alone cannot secure ePHI—human behavior determines whether security controls succeed or fail. Employees represent both your greatest vulnerability and your most valuable defense, depending on whether they can recognize and respond appropriately to security threats. Every access control, encryption system, and network safeguard can be undermined by a single employee who falls for a phishing email or mishandles sensitive data.

The statistics underscore this reality: 34 percent of healthcare cyberattacks in 2024 involved compromised credentials, while 19  percent originated from malicious emails and 9 percent from phishing. Yet many healthcare employees lack proper knowledge of these threats.. The gap between threat prevalence and training coverage creates exploitable vulnerabilities. Comprehensive security awareness training transforms your workforce from a liability into an active defensive layer that can identify and report threats before they cause damage.

Action Steps:

• Conduct initial security training for all new employees before they access ePHI, covering HIPAA requirements, security policies, and common threats
• Provide ongoing annual training updated to reflect evolving threats and recent incidents, tailored to different roles
• Implement simulated phishing exercises that test employee recognition and use failures as educational opportunities rather than disciplinary actions
• Foster a security-conscious culture by recognizing positive behaviors, creating blame-free reporting channels, and ensuring leadership models appropriate practices
• Track training completion rates and phishing simulation results to identify individuals requiring additional coaching

Gain Expert Support to Improve HIPAA Cybersecurity Measures

The HIPAA cybersecurity framework delivers robust protection for ePHI, but it can be overwhelming for many organizations. From limited internal expertise to insufficient budgets, cybersecurity is a constant headache for many compliance leaders—which is why so many rely on Strategic Management Services.

Our healthcare compliance experts can help audit, plan, and implement your HIPAA program to meet the OCR’s expectations, protect patients’ ePHI, and make compliance simple and cost-effective for your organization. 

Want to explore how we can help you improve HIPAA compliance?

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