5 Critical HIPAA Compliance Steps for IT Systems in 2025

Ensure your healthcare organization meets HIPAA compliance in 2025 with these essential steps to protect ePHI and avoid penalties.

•

April 18, 2025

HIPAA compliance in 2025 requires a proactive approach to secure electronic protected health information (ePHI). With stricter regulations like mandatory encryption, multi-factor authentication (MFA), and regular security risk assessments, healthcare organizations must adapt to avoid penalties and data breaches. Here's a quick overview of the five steps to meet these updated standards:

Maintain Security Documentation: Keep detailed records of IT assets, policies, and changes to ensure transparency and compliance.
Perform Regular Risk Assessments: Identify vulnerabilities, prioritize risks, and continuously monitor for improvements.
Implement Encryption and Access Controls: Use strong encryption and MFA to protect ePHI both in storage and transit.
Leverage Compliance Software: Automate security controls, risk assessments, and audit preparations.
Develop Testing and Incident Response Plans: Conduct regular security tests and create clear protocols to address breaches effectively.

These steps are essential for safeguarding patient data and aligning with the latest HIPAA requirements. Start implementing them now to stay compliant and secure.

Master HIPAA Compliance: The Ultimate 2025 Checklist for ...

Step 1: Create and Maintain HIPAA Security Documentation

The HIPAA Security Rule mandates that covered entities and business associates document their security needs and safeguards for electronic protected health information (ePHI).

Track IT Assets and Data Flow

Keep detailed records, including policies, user access logs, audit trails, and incident reports. These documents are essential for conducting thorough risk analyses.

Keep Security Policies Updated

To stay compliant:

Set a routine schedule to review and update security measures and documentation.
Record any changes to systems or processes that impact ePHI security.
Develop and adapt a security awareness and training program as conditions change.

Thorough documentation does more than guide your security program - it also provides proof of compliance during audits. Be sure to keep detailed records of decisions, risk analyses, and the reasoning behind your security measures.

These records will be crucial for Step 2: Performing regular risk assessments.

Step 2: Perform Regular Risk Assessments

The Office for Civil Rights (OCR) has made Security Risk Analyses (SRAs) a mandatory requirement starting in 2025, with penalties for those who fail to comply. Use the security documentation from Step 1 to trace how electronic protected health information (ePHI) moves through your systems during the SRA process.

Identify and Address Security Weaknesses

Skipping an SRA can leave ePHI vulnerable to ransomware and other cyber threats, according to OCR. To minimize risks, follow these steps:

Map ePHI access points: Identify where ePHI is accessed, stored, or transmitted.
Evaluate existing controls: Check if current security measures are effective.
Prioritize vulnerabilities: Rank risks based on severity and create a plan to address them.
Monitor progress: Keep track of remediation efforts to ensure completion.
Account for human error: Recognize that phishing remains a major issue, causing over 90% of healthcare breaches.

Establish a Risk Assessment Routine

Security Risk Analyses should be an ongoing effort, not a one-time project. Here’s when to conduct them:

Initial SRA: Perform when deploying an electronic health record (EHR) system or introducing new certified EHR technology.
Annual review: Conduct at least once per year or whenever systems or policies change.
Special assessments: Carry out after security incidents or when new threats emerge.

Once you've mapped risks and set a schedule for regular assessments, you're ready to move on to Step 3, which focuses on implementing encryption and access controls.

sbb-itb-f3ffd9f

Step 3: Set Up Strong Encryption and Access Rules

After completing your risk assessment, it's time to implement encryption and access controls to protect ePHI (electronic protected health information). HIPAA considers encryption "addressable", meaning it's required based on your risk analysis.

Follow Updated Encryption Standards

HIPAA doesn’t specify exact encryption methods but encourages alignment with National Institute of Standards and Technology (NIST) guidelines. To secure ePHI:

Encrypt data at rest and in backups using full-disk or file-level encryption.
Encrypt data in transit with protocols like TLS.

These steps ensure sensitive information remains protected, whether stored or transmitted.

Unique user IDs and identity verification are essential for controlling ePHI access. Here’s how to improve login security:

Require strong passwords, multi-factor authentication, and session timeouts.
Document emergency access procedures and enable audit tracking to monitor activity.

These measures help limit access to authorized users and reduce the risk of unauthorized access.

Step 4: Use HIPAA Compliance Software

HIPAA compliance software helps you automate security controls and keep track of ePHI across your IT systems. It ensures encryption standards and access rules are applied consistently.

Key Features to Look For

When selecting HIPAA compliance software, make sure it includes:

Continuous risk assessment and breach detection
Automated encryption monitoring
Built-in backup systems with quick recovery options
Automated enforcement of access permissions

Streamline Audit Preparation

The right software can simplify audits by:

Automatically generating audit trails and access logs
Offering built-in templates to align tasks with HIPAA requirements

How to Get Started

Schedule a demo to confirm the software integrates with your current systems.
Use vendor-provided templates and support to set up your policies effectively.

Step 5: Create Security Testing and Emergency Response Plans

Once encryption and compliance tools are in place, the next step is to ensure your defenses hold up and you're prepared for potential breaches. This involves regular security testing and having a clear incident response plan (IRP) in place.

Regular Security Testing

Set up a consistent schedule for testing your systems:

Annual penetration tests: These help uncover vulnerabilities that attackers could exploit.
Biannual vulnerability scans: These scans identify potential weak points in your security setup.

After each test, perform a gap analysis to pinpoint areas that need improvement. As Scott Mattila notes, staying ahead with proactive testing strengthens your defenses over time.

Establishing an Incident Response Plan (IRP)

An IRP outlines how to handle security incidents step by step, including containment, investigation, remediation, communication, reporting, and post-incident analysis.

"The purpose of an incident response plan is to enable an organization to respond quickly and effectively to an incident, minimize the damage caused by the incident, and return to normal operations as quickly as possible."

To keep your team prepared:

Conduct quarterly tabletop exercises with the core team.
Hold semiannual drills for all IT staff.
Run additional exercises after major system changes or real incidents.

Make sure to document the results of these exercises to improve and fine-tune your IRP procedures.

Conclusion: Meeting HIPAA Requirements in 2025

Taking these five steps lays the groundwork for a solid HIPAA compliance framework. These steps are crucial for navigating the shifting cybersecurity challenges of today.

The Change Healthcare breach highlights the importance of staying ahead of threats to protect patient data and maintain trust. As Scott Mattila notes, "cybersecurity demands regular maintenance and proactive planning".

The revised HIPAA regulations emphasize the need for automating compliance controls and reporting. To align with these changes, organizations should focus on: