A HIPAA assessment is a structured evaluation that measures how well an organization aligns with the Privacy Rule, Security Rule and Breach Notification Rule. It identifies gaps in policies, controls and operational practices that may expose protected health information to unauthorized access or loss.
Below is a detailed view of what a proper HIPAA assessment should include.
1. Comprehensive Security Risk Analysis
The Security Rule requires a detailed risk analysis covering every system and workflow that touches electronic PHI. This includes:
- Asset inventory for all systems storing or transmitting ePHI
- Threat and vulnerability identification for network, endpoint and cloud environments
- Review of identity and access controls, including MFA and least privilege
- Encryption status for data at rest and in transit
- Audit logging, log retention and monitoring processes
- Business continuity and disaster recovery readiness
- Gaps in patch management and configuration hardening
A risk analysis is the core of any HIPAA assessment and forms the foundation for remediation planning.
2. Privacy Rule Compliance Review
This portion focuses on how PHI is used, disclosed and protected during daily operations. Key elements include:
- Verification of Notice of Privacy Practices
- Evaluation of minimum necessary access rules
- PHI lifecycle management from creation to disposal
- Workforce training effectiveness and documentation
- Review of incident response workflow for unauthorized disclosures
- Procedures for patient rights such as access, correction and restrictions
The goal is to ensure PHI is handled in a lawful and controlled manner.
3. Administrative, Physical and Technical Safeguards Review
A HIPAA assessment measures safeguards across all three categories defined in the Security Rule.
Administrative Safeguards
- Risk management program maturity
- Workforce security and role based access
- Security awareness training, phishing simulations
- Third party risk management practices
- Policies for device, media and system management
Physical Safeguards
- Facility access controls and visitor management
- Server room protections
- Workstation security and acceptable use rules
- Secure disposal of hardware and media
Technical Safeguards
- Access control mechanisms, MFA and privilege audits
- Endpoint and network protection technologies
- Encryption and key management
- Intrusion detection and SIEM monitoring
- Integrity controls and data loss prevention
4. Business Associate Oversight
A HIPAA assessment also verifies whether covered entities maintain proper controls over vendors handling PHI.
This includes:
- Valid Business Associate Agreements
- Verification of vendor security posture
- Monitoring of vendor data handling practices
- Review of subcontractor compliance tracking
5. Gap Identification and Remediation Roadmap
Once all controls are reviewed, findings are consolidated into a technical remediation plan that prioritizes actions based on risk severity. Typical outputs include:
- Risk register with likelihood, impact and mitigation steps
- Policy updates for missing or outdated requirements
- Required security tool implementation or configuration improvements
- Workforce training improvements
- A compliance attestation package for audits or executive reporting
Why a HIPAA Assessment Matters
A well executed HIPAA assessment helps organizations reduce regulatory exposure, strengthen cybersecurity maturity and maintain trust with patients and partners. It ensures that PHI is protected with the right mix of policies, controls and monitoring.