My EHR system makes me HIPAA compliant, right?

July 16, 2020

Let’s face it, in today’s digital age, it’s tough to find a medical practice that doesn’t utilize an Electronic Health Records (EHR) system. Even if you were late to the game and just recently made the switch, the use of EHRs in doctor’s offices nearly doubled between 2009 and 2017, to almost 86% of providers. One of the biggest qualifications for any EHR system is that it meets all HIPAA compliance requirements to protect the sensitive patient data held within it.

But is that where HIPAA compliance begins and ends? 

A common misconception many providers have, however, is that implementing a HIPAA compliant EHR ensures their practice is in compliance with all standards  – instead, it’s just one piece of the much larger puzzle.

Make no mistake, having a HIPAA compliant EHR is essential. There are a number of safeguards that should be implemented to protect your EHR’s electronic data, such as: 

  • Having the proper technical safeguards in place to secure your online databases
  • Having access controls such as unique logins for your EHR system limiting access to authorized individuals
  • Encrypting all stored information within your EHR
  • Having access logs to your EHR system in case of any breaches or audits

While these safeguards are key, there are other HIPAA requirements that go beyond the security of your EHR software and impact your practice’s operations, physical accessibility, and all technology used within the organization – including IT networks and other applications not included in your EHR software. That’s why the Security Risk Analysis’ three sections – administrative, physical, and technical safeguards – are so essential to ensure every aspect of your business’ risk is assessed.

  1. First, let’s look at HIPAA compliant operations and administrative safeguards. Much of HIPAA law applies to having the proper policies and procedures in place. This means documenting things like how your practice releases protected health information (PHI), how you complete required annual HIPAA training, how you review employee access to PHI, how you’ll apply sanctions to workforce members if violating privacy laws, and more. Most of these will address how the ‘business’ side of your practice operates. What’s more, your policies must reflect your actual practice operations – they can’t simply be templates downloaded off the internet to meet HIPAA requirements. Administrative safeguards should also include having all contracts in place to protect your PHI, such as Business Associate Agreements with all required vendors – including your EHR provider. 
  2. Second, your physical safeguards encompass both obvious and not so obvious ways to protect your practice from harm. This means determining if you have locks on your doors (we hope this one is covered) but also how often access codes are changed, when your last fire marshal inspection was, if you use privacy screens to prevent seeing PHI on computers in use, and if your PHI is physically separated from patients to prevent unauthorized access – just to name a few.  Physical security is key to showing your practice’s efforts to prevent loss or theft of PHI and goes well beyond your EHR system.
  3. Lastly, beyond your EHR, your practice has likely implemented a number of different technology systems and applications.  These technologies carry the same risks as your EHR and need technical safeguards to ensure the privacy of PHI they store or access. From your office wifi to your cloud storage solution or server, each system must have controls to prevent unauthorized access to your PHI. In fact, the more technology you rely on, the more accessible PHI is to the wrong people. Cyberattacks in healthcare are expected to increase by 400% in 2020, making your electronic data protection critical. It’s not just data at rest either – sending emails containing PHI requires encryption, as does instant messaging or text messaging when it includes PHI. All of these systems are gateways to your practice’s data and are essential to protect just like your EHR solution.

Even non-HIPAA experts can conclude that having a HIPAA compliant EHR system is a no brainer. But missing all, or even just some, of the other pieces to the puzzle puts your practice and your patients at high risk. In fact, within  Abyde’s Security Risk Analysis, only 10% of the questions pertain to your EHR system. Whether with Abyde, internally, or with another vendor – it’s essential to review the other 90% of your necessary safeguards before getting slammed with a HIPAA violation. 

RECENT POSTS

Related posts

OSF Healthcare HIPAA Settlement
Abyde News, Fines, HIPAA

What OSF Healthcare’s Ransomware Fine Teaches Every Practice About SRAs

August 5, 2026 No comments yet

August 5, 2026 The latest HIPAA fine is another clear reminder that ransomware attacks are, unfortunately, here to stay in the healthcare industry. A settlement involving the OSF Healthcare System was recently announced by the Office for Civil Rights (OCR). As an enterprise healthcare provider in the midwest, the organization serves 174 locations, including 16 hospitals – a prime target for a ransomware attack.    So, what happened?  In April 2021, OSF discovered that they joined the unlucky club of ransomware victims when a malicious actor deployed Nephilim, a ransomware strain made to target larger organizations. Once the ransomware infected OSF systems, the hacker demanded payment or patient Protected Health Information (PHI) would be leaked online. In this attack, sensitive information like financial account information, driver’s license numbers, medical record numbers, and more, were all exposed. Over 53,000 patient records were exposed in this attack.  When ransomware attacks in healthcare have soared 278% in recent years, it’s more of a when then an if your organization doesn’t have the right safeguards in place.  While the breach was discovered in April, OSF healthcare reported the breach to the OCR in October. The OCR took it from there, digging into what precautions (or lack thereof) let this happen.  What did the OCR discover? If you’ve read any of our other fine breakdowns, you already know where this is going: another missing Security Risk Analysis (SRA).  The SRA is a required document every HIPAA-regulated entity (ie: every practice and their Business Associates that handle patient information) needs to complete. The SRA is a thorough review of the physical, technical, and administrative safeguards in place to prevent PHI ending up in the wrong hands. While the OCR didn’t specify exactly how the ransomware got into OSF’s system, a technical safeguard vulnerability was very likely the entry point. A proactive SRA could have flagged that gap before it turned into a major breach. In addition to missing this required documentation, OSF also took too long to report the breach to the OCR and notify affected patients. This is a direct violation of the Breach Notification Rule, which requires organizations to notify patients within 60 days of a discovered breach. Moreover, since the breach impacted more than 500 patients, OSF was also required to report this breach to the OCR within 2 months as well. Time is of the essence in every component of a breach, from securing systems to ensuring affected parties are aware to protect themselves and an over five month delay was unacceptable in the eyes of the OCR.    What was the result?  OSF’s settlement tops the list as the largest fine of the year, coming in at $552,250, plus government monitoring for the next two years.  It’s very important to note that this breach occurred in 2021, meaning that over five years were spent from the initial breach, to investigations, to the public press releases. Also, the average cost of a healthcare breach is over 7 million dollars –  from implementing secure systems, notifying patients, legal fees, and more. The Takeaway While the settlement payment and Corrective Action Plan (CAP) are just the cherries on top, this experience was a tremendous cost of time, money, and resources, highlighting the importance of making sure everything is secure before a situation occurs.  So, when was the last time you looked at your SRA? It’s time to seriously analyze your current compliance posture. Ransomware groups don’t check whether you’re a small dental office or a 16-hospital health system before they attack, they check whether the door was left open. Time and again, OCR’s findings come back to the same root cause: organizations can’t secure what they haven’t even identified as a problem. Looking to review your current compliance standings? Meet with our team of experts for a complimentary educational consultation. 

Spencer Gifts HIPAA Fine
Abyde News, Fines, HIPAA

Spencer Gifts HIPAA Settlement: Ransomware, Risk Analysis, and What Comes Next

June 19, 2026 No comments yet

June 19, 2026   Quick Guide:  The Office for Civil Rights issued a major fine towards Spencer Gifts benefits plan. This fine reinforces that all HIPAA-regulated entities must have a thorough compliance program.    The Stats You Need to Know 76%: The percentage of large healthcare breaches now caused by hacking/IT incidents. $450,000: Financial settlement of this enforcement. 10,023: The number of individuals were impacted in this breach.  264%: The increase in ransomware-related breaches reported to the OCR since 2018.   When you think about Spencer’s, you likely picture the staple mall store with pop culture novelty gifts, not the latest HIPAA settlement enforcement headline.  Spencer Gifts LLC Flexible Benefits and Welfare Benefit Plans, or their employee benefits plan, reached a settlement with the Office for Civil Rights for $450,000 and a 2 year Corrective Action Plan (CAP).  This fine is a reminder that Covered Entities include all parties that create and utilize patient data, including health care plans. While they might not see patients traditionally, they still are responsible for keeping Protected Health Information (PHI) secure.    What Happened?   In response to employee complaints regarding access to their employee benefits portal, Spencer Gifts Health Plan discovered their systems were infiltrated with ransomware in November 2021. Malicious actors encrypted over 10,000 individuals’ PHI and demanded a ransom. The exposed data included names, phone numbers, social security numbers, and more, putting employees at risk.  The breach was reported in January 2022. After years of investigation, it was settled that the plan failed to meet basic HIPAA Security Rule requirements proactively.    The Compliance Gaps A common misconception is that an organization faces a financial penalty due to a breach. While the breach serves as the catalyst for the investigation, the OCR is looking to see if an organization has a thorough compliance program in place and made a genuine effort to protect patient data.  For instance, the health plan did not complete a Security Risk Analysis (SRA). This required assessment identifies all technical, administrative, and physical safeguards (and vulnerabilities) across your organization. By completing this document, your organization can address concerns before they become an issue. There’s no way to know where risks are unless they are properly reviewed.  Additionally, the plan did not have sufficient policies and procedures, nor trained staff adequately. Without sufficient policies and training, staff are left without the tools to recognize and respond to HIPAA threats before they escalate. As a result, Spencer Gifts now faces $450,000 in penalties and two years of government monitoring to ensure those missing requirements are finally implemented. And that figure doesn’t account for the years of investigation, legal fees, breach notification costs, and operational disruption that preceded the settlement.   The Biggest Takeaway This case isn’t only a lesson for retail organizations’ health plans, but it’s a warning for every HIPAA-regulated entity. The OCR can and will investigate any organization exposed for failing to meet HIPAA requirements, including small medical practices To be prepared before a cyberattack occurs, make sure your organization has: A completed and current Security Risk Analysis. A trained workforce that knows how to handle PHI Accessible policies and procedures staff can actually reference. An up-to-date compliance program.  Ready to strengthen your compliance program? Schedule a free educational consultation with our team today.

OCR Ransomware Settlements
Abyde News, Fines, HIPAA

OCR Ransomware Settlements: 4 Massive HIPAA Fines from April 2026 & How to Avoid Them

May 4, 2026 No comments yet

May 4, 2026   Quick Guide:  The Office for Civil Rights (OCR) just issued a massive wake-up call, announcing four simultaneous settlements totaling $1,165,000. The Stats You Need to Know 76%: The percentage of large healthcare breaches now caused by hacking/IT incidents. 427,000+: Total number of patients impacted across these four recent settlements. 264%: The increase in ransomware-related breaches reported to the OCR since 2018. The Office for Civil Rights (OCR) just announced a flurry of investigation settlements. At the root of the four that were announced: ransomware. Ransomware attacks continue to target healthcare facilities. As of last year, the OCR discovered that 76% of large breaches are due to hacking and IT shortcomings. Unfortunately, healthcare information is a goldmine for hackers, exposing sensitive data that can lead to identity theft, financial fraud, and compromised patient care. Breakdown & Lessons Learned Regional Women’s Health Group (Axia) The first settlement was regarding the Regional Women’s Health Group (Axia), an OBGYN network across five states. In this case, the organization submitted a breach report following a cyberattack that exposed over 37,000 patients. The settlement resulted in a $320,000 fine and a 2-year Corrective Action Plan (CAP). The Lesson: The OCR didn’t just fine them for being hacked; they reached a settlement because the healthcare organization failed to conduct a “thorough and accurate” Security Risk Analysis (SRA). If you don’t know where your vulnerabilities are, you can’t patch them. Unfortunately, hackers counted on this negligence and exploited it.  Assured Imaging This was the largest of the four fines, affecting a staggering 244,813 individuals. When a ransomware infection hit their servers, Assured Imaging, a medical imaging enterprise, reported a breach to the OCR. After a long investigation (the initial cyberattack occurred in 2020), and resulted in a $375,000 settlement and a 2-year CAP.  The Lesson: Beyond the initial ransomware attack, it was discovered that Assured had never completed an SRA. Additionally, the organization did not notify patients within 60 days of discovery of the breach. This is a direct violation of the Breach Notification Rule, which aims to allow patients to take control and mitigate risks as quickly as possible.  Consociate Health Consciate Health is the only Business Associate (BA) fine in the four. BAs continue to be under the OCR’s microscope, such as potentially needing to follow stricter requirements when handling patient data. Their breach started with a phishing attack that eventually led to the encryption of systems holding data for over 136,000 people. The BA discovered the ransomware six months after the initial phishing attack. Upon the OCR’s further investigation, the SRA was found to be insufficient. The organization paid a $225,000 settlement and entered into a 2-year CAP.  The Lesson: Human error (phishing) is the most common entry point for ransomware. Constant employee training is just as important as a strong firewall. Additionally, just because a BA doesn’t directly work with patients doesn’t mean it isn’t their responsibility to keep patient data secure.  SG Health Plan Even employee benefit plans are regulated under the Health Insurance Portability and Accountability Act (HIPAA). SG Health Plan, associated with a Connecticut energy provider, reported that the data of 9,316 members were exposed following a ransomware attack. It was discovered that the organization did not complete an extensive SRA. The benefit plan entered a settlement with the OCR for $245,000 and a 2-year CAP.  The Lesson: This settlement highlights that HIPAA applies to corporate health plans just as much as it does to traditional healthcare providers. Additionally, every organization that handles Protected Health Information (PHI) must complete an SRA.  The Bottom Line The OCR isn’t fining practices for ransomware attacks, but for being ill-prepared.  However, it is easier said than done to ensure your organization is secure in protecting patient data and complying with HIPAA.  Proactively implementing the HIPAA Security Rule is your opportunity to mitigate the impacts of a cyberattack. Waiting until the ransom note appears on your screen is a million-dollar mistake. Want to see what you might be missing?  Run a 5-Minute HIPAA Gap Assessment and protect your practice today!