How to Handle PHI Securely and Avoid HIPAA Violations

What Is PHI and Why It Matters

Protected Health Information (PHI) includes any health-related data that can be linked to an individual and is created, received, stored, or transmitted by healthcare entities. Examples include names, Social Security numbers, diagnosis codes, lab results, treatment history, and physician notes.

PHI is distinct from personally identifiable information (PII) in that it is specifically governed by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA defines strict privacy and security rules for PHI. Breaching those rules—intentionally or inadvertently—can lead to HIPAA violations including fines, investigations, and reputational damage.

Common HIPAA violations frequently result from issues in data handling and vendor oversight. Some of the most common causes include:

• Unauthorized employee access to patient records
• Failure to encrypt PHI at rest or in transit
• Data exposure through third-party service providers
• Loss or theft of unprotected mobile devices
• Inadequate access controls or audit trails

What Organizations Must Do to Handle PHI Securely

Effective PHI protection requires a mix of technical safeguards, administrative policies, and physical security. Although not all-inclusive, here are several examples of steps to consider:

Encrypt PHI Everywhere

• Use AES-256 encryption or stronger for stored PHI
• Avoid using unencrypted email, fax, or SMS for PHI
• Enforce encryption policies on cloud storage, mobile devices, and backups

Apply Role-Based Access Control (RBAC)

• Limit PHI access to only those who need it for their role
• Regularly audit user access and adjust based on role changes
• Implement automatic revocation for terminated employees

Monitor for Insider and External Threats

• Use User Behavior Analytics (UBA) to detect unauthorized access patterns
• Deploy Data Loss Prevention (DLP) to control risky actions
• Monitor access logs for anomalies like rapid logins or impossible travel
• Set up real-time alerts for unauthorized file transfers or database queries

Enforce Secure Email Practices with SPF, DKIM, and DMARC

• Configure Sender Policy Framework (SPF) records on all email domains
• Implement DomainKeys Identified Mail (DKIM) for message integrity
• Require DMARC enforcement to block spoofed healthcare emails
• Monitor third-party email senders for compliance

Secure Remote and Mobile Access

• Deploy Mobile Device Management (MDM) with remote wipe and encryption enforcement
• Require multifactor authentication (MFA) for all external PHI access
• Define clear telehealth policies for PHI usage from home networks

Vendor Risk and Business Associate Compliance

Vendors that handle PHI—known as Business Associates (BAs)—are a leading source of HIPAA risk. Organizations working with third parties should pay attention to the following measures:

• Sign Business Associate Agreements (BAAs) with all third parties that store, process, or transmit PHI
• Require vendors to implement encryption, logging, and access control
• Conduct periodic audits or assessments to verify HIPAA compliance

How to Continuously Monitor Third-Party Compliance

• Gain visibility into your third-party ecosystem
• Assess vendor security postures
• Scan for cloud service misconfigurations and outdated systems
• Flag anomalies, such as a drop in security ratings or new IP exposure
• Integrate vendor risk monitoring into onboarding and renewal workflows

Mapping to the HIPAA Security Rule

The HIPAA Security Rule outlines specific safeguards to protect electronic PHI (ePHI). Organizations should consider the following safeguards:

Administrative Safeguards:

• Conduct periodic risk assessments focused on PHI exposure
• Maintain an incident response and breach notification plan
• Designate a HIPAA privacy/security officer
• Train staff regularly on HIPAA-compliant data handling

Physical Safeguards:

• Secure physical access to servers and PHI endpoints
• Use badge systems and access logs for data rooms
• Implement screen protectors and idle logoff settings
• Prohibit PHI storage on removable media without encryption

Technical Safeguards:

• Enforce strong MFA
• Log all user interactions with PHI systems
• Use session timeout settings for idle systems
• Encrypt PHI during storage, transmission, and backup

Final Thoughts: Treat PHI as Critical Business Data

Protecting PHI is not just a regulatory requirement—it’s a core trust and reputational issue. Healthcare organizations that fail to protect PHI suffer not only fines and lawsuits but long-term damage to their credibility.

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