Note: this blog was published on March 19, 2025. A few days ago, the Trump administration announced an upcoming reorganization of the Department of Health and Human Services (HHS). Depending on how this plays out, the information in this blog as well as other HIPAA compliance and regulatory guidance could change. Stay tuned!
When a new HIPAA update or final rule comes out, everything starts to feel like a fire drill.
The reason? HIPAA—short for the Health Information Portability and Accountability Act—directly impacts every aspect of release of information, and the consequences of non-compliance can make you liable for fines, legal repercussions and long-lasting reputational damage.
As we discussed in a previous blog post, even small, well-intentioned mistakes can have lasting impacts. But that begs the question: What can you do proactively to make sure your staff stays HIPAA-compliant?
In this blog, we share seven tips to help you and your team navigate the rough waters of HIPAA compliance, regulations and requirements!
5 Key Rules of HIPAA Compliance
HIPAA sets the standard for how patient information can be compliantly stored and shared. These requirements exist to reduce the risk of unauthorized access while still ensuring patients, providers and approved third parties can access the health information they need, when they need it.
Five of the most notable rules under HIPAA include:
- The Privacy Rule, which controls how patient information is used and shared. It also gives patients rights over their health records, including the ability to access them and request changes.
- The Security Rule, which focuses on protecting electronic health records (EHRs). It requires safeguards like passwords, encryption and other security measures to keep digital patient information safe.
- The Enforcement Rule, which holds healthcare organizations accountable for protecting patient information. It allows the Office for Civil Rights (OCR) to investigate violations, issue fines (ranging from $100 to $50,000 per violation…and violations can stack up). If what OCR finds is really egregious, they can refer it to the Department of Justice for a broader inquiry which can even include criminal charges..
- The Omnibus Rule, which implemented provisions from the HITECH Act to strengthen privacy protections by holding business associates accountable for patient data, just like healthcare providers. It also gives patients more control over their health information and requires quicker notification if a data breach occurs.
- The Breach Notification Rule, which requires organizations to notify affected individuals if patient information is accessed or shared without permission, ensuring transparency and accountability in case of a data breach.
Of course, there’s more to HIPAA than just these areas, the guidance is pretty sprawling. Having a firm understanding of these five key rules is a great place to start for everyone in HIM.
7 HIPAA Compliance Tips for Your Team
HIPAA compliance isn’t just a box to check—it’s an ongoing responsibility that protects both your patients and your organization.
It can be a daunting act to juggle evolving compliance requirements with managing best practices across large (and even small!) teams. Unfortunately, there’s no magic button to guarantee HIPAA compliance 100% of the time.
The good news? Even without magic, there are high-impact strategies you can incorporate into your release of information processes to make compliance worries a thing of the past.
1. Training and Re-training Your Staff is a Top Priority
Keeping your staff trained on HIPAA rules isn’t just a one-time task; it’s an ongoing priority. New and experienced HIM staff alike need thorough annual training on proper PHI handling, patient authorization requirements and security protocols.
Interactive learning methods like role-playing scenarios, real-world case studies and hands-on e-learning modules help employees apply HIPAA rules to real situations. A well-trained team is a key line of defense against compliance risks, and investing in ongoing, role-specific training helps everyone on your team learn how to best protect patient information while keeping operations running smoothly.
2. Getting Leadership Buy-In Sets an Early Precedence
HIPAA compliance starts at the top. If leadership takes compliance seriously by staying informed, reinforcing HIPAA standards and following protocols, staff are more likely to do the same.
Setting clear policies and providing easy access to resources helps your team understand your expectations around compliance. When leaders prioritize HIPAA, it becomes second nature for everyone else, too!
3. Incorporate HIPAA Compliance into Your Workflows
Understanding HIPAA compliance means very little if we don’t use this information to inform our best practices and processes. When you build out workflows with HIPAA compliance in mind, you’re taking the most proactive step right from the beginning.
Every team has a workflow that best suits them, but here are some aspects you can implement into any release of information process:
- Defining a designated record set (DRS) that is specific to your systems, your business and your clinical practices
- Ensuring requests follow a structured process, and thinking though how that process will vary based on different systems and different request types
- Incorporating quality control checks throughout the lifecycle of a request
4. Revisit Your Internal Processes at Regular Intervals
As HIPAA evolves, so should your internal workflows. Here are a few ways you can make sure your HIM processes are current and up to date:
- Schedule and conduct regular internal audits to identify any compliance gaps with new regulations
- Perform spot checks to ensure staff are consistently following proper procedures
- Review standards and penalties for non-compliance
- Keep everything documented so all steps are easy to follow and monitor
5. Use Technology to Your Advantage—And Keep it Secure
With cybersecurity attacks on the rise, taking extra steps to keep your data protected is more crucial now than ever before. Some security steps you should be following right now are:
- Securing electronic devices with password protection, encryption and two-factor authentication
- Ensuring your information storage software is secure and compliant
- Being mindful of PHI handling in all scenarios
- Using secure email systems to discuss requests instead of personal devices
Along with these steps, we also recommend keeping all software up to date, which makes your devices less vulnerable to malware or other bad actors—consider this your reminder to restart your laptop and install those updates!
6. Keep an Eye Out for Changes and Updates
If you had more hours in your workday, how many of them would you spend keeping track of regulatory updates? Unfortunately, we can’t give you more hours, but we can offer you some tips to weave HIPAA updates into your schedule more seamlessly! This could look like:
- Subscribing to regulatory newsletters
- Turning on notifications for news alerts
- Performing policy reviews
- Attending HIPAA compliance workshops and seminars
- Set a standing time every week to review the U.S. Department of Health and Human Services website for any articles, announcements or updates
7. Have an Immediate Response Plan in Place
Accidents happen, especially in the realm of release of information where teams are handling hundreds—if not thousands—of patient records at a time. That’s why it’s important to have a plan in place when a privacy incident or unintentional violation occurs.
Here are some processes your team can begin to implement today to play a more proactive role in privacy incident resolution:
- Create an incident response plan
- Prepare a breach notification process for government agencies, patients, the media and other relevant parties
- Ensure you have post-breach training available for employees to mitigate future incidents
- Conduct evaluations at a regular cadence to ensure nothing falls between the cracks
Set Your Staff Up for Success
Being HIPAA compliant is a cornerstone of health information management, and everyone from healthcare providers and health plans to business associates has an obligation to protect patients’ health data. With changing regulations, new technologies and increasing demands on healthcare organizations, having a trusted compliance partner can make all the difference.
The easiest way to stay up to date on all things HIPAA compliance? Subscribe to receive HealthMark’s blog alerts! We use this platform to keep you in-the-know when new rules are proposed and finalized.
In the meantime, you can also review our HIM Compliance page, where we highlight key areas of compliance most relevant to HIM teams and answer some of our clients’ most frequently asked questions.