HIPAA Data Governance: What You Need to Know

Safeguarding patient data is more critical than ever as most patient data is now digitized. The Health Insurance Portability and Accountability Act (HIPAA) provides a comprehensive framework for protecting the privacy and security of health information.  

However, compliance with HIPAA is not just about following a set of rules; it’s about implementing robust healthcare data governance strategies to ensure that health information is managed, protected, and used responsibly. 

In this article, we’ll look at the types of organizations that are expected to comply with HIPAA regulations, the different ways HIPAA can be violated, the consequences for violating HIPAA, and the steps an organization can take to successfully implement HIPAA data governance. 

Who Needs to Follow HIPAA Guidelines?

HIPAA guidelines apply to a wide range of individuals, organizations, and businesses that handle Protected Health Information (PHI) in the United States. The following entities and individuals are required to follow HIPAA guidelines: 

• Covered entities: Organizations or individuals who directly handle PHI are subject to HIPAA regulations, including healthcare providers, health insurance companies, health maintenance organizations, employer health plans, and healthcare clearinghouses. 
• Business associates: Third-party vendors or contractors that work with covered entities and have access to PHI to perform services on their behalf are also subject to HIPAA regulations. These include data storage providers, IT and security vendors, billing and coding companies, and legal and accounting firms. 
• Healthcare workers and employees: All employees, contractors, or anyone working for a covered entity or business associate who has access to PHI must adhere to HIPAA regulations. This includes doctors and nurses, administrative staff, medical researchers, and support staff.  
• Individuals handling health information: Any individual who works with or has access to health data, even if not directly involved in providing healthcare, must follow HIPAA rules to protect patient information. This can include employees in various industries like law firms, insurance companies that handle medical information, and health technology.  
• State and local governments: Government agencies that manage or use PHI in healthcare-related programs like Medicaid, public health services, etc., also need to comply with HIPAA regulations to protect health data. 
• Healthcare apps and tech companies: As healthcare data is increasingly digitized, technology companies that develop or provide healthcare apps, patient portals, and telemedicine platforms may also be required to comply with HIPAA if they process or store PHI. 

What are HIPAA Violations?

HIPAA violations occur when an individual or organization fails to comply with the provisions set out by the Health Insurance Portability and Accountability Act (HIPAA). These violations can range from accidental breaches to intentional misconduct, and they typically involve the unauthorized access, disclosure, or mishandling of PHI. Violations can occur in various forms, whether due to negligence, poor security practices, or malicious intent.  

Types of HIPAA violations include: 

• Unauthorized access to PHI. 
• Failure to implement safeguards. 
• Improper disposal of PHI. 
• Failure to report data breaches. 
• Unauthorized disclosure of PHI. 
• Lack of Business Associate Agreements (BAAs). 
• Failure to implement proper access controls. 

What are the HIPAA Violation Penalties?

Violating HIPAA can result in serious consequences, including civil and criminal penalties, civil lawsuits, and reputation damage. 

Civil Penalties

The U.S. Department of Health and Human Services (HHS) may impose fines for violations. These penalties can range from $100 to $50,000 per violation, depending on the severity of the breach and whether the violation was due to willful neglect.  

The total penalty can be as high as $1.5 million per year for violations of the same provision. 

Criminal Penalties

For more severe violations, such as knowingly acquiring or disclosing PHI without authorization, criminal penalties can be imposed, including fines and imprisonment: 

• Up to $50,000 and up to 1 year in prison for offenses committed without malicious intent or for personal gain. 
• Up to $100,000 and up to 5 years in prison for offenses committed under false pretenses. 
• Up to $250,000 and up to 10 years in prison for offenses committed with the intent to sell or distribute PHI.  

Civil Lawsuits

In some cases, patients whose PHI has been improperly disclosed may file civil lawsuits against the violator. 

Reputation Damage

A HIPAA violation can cause significant damage to an organization’s reputation. Public disclosure of a breach can lead to a loss of trust among patients and clients, resulting in a decline in business.  

How to Implement HIPAA Data Governance

For a business or organization to Implement HIPAA data governance, it needs to create and enforce policies, procedures, and controls to ensure the protection, security, and privacy of Protected Health Information (PHI). Effective data governance helps safeguard sensitive health data, reduce the risk of data breaches, and ensure the organization meets legal and regulatory obligations. 

Here’s a step-by-step approach to implementing HIPAA data governance: 

1. Establish a Data Governance Framework

A solid framework is essential for defining how PHI will be managed, protected, and shared within the organization. The data governance framework should be aligned with HIPAA’s key principles: confidentiality, integrity, and availability of PHI. Organizations should define data ownership, designate data stewards, and develop data governance policies. 

2. Conduct a Data Inventory

Before implementing data governance practices, it’s necessary to understand the types of PHI an organization handles, where it’s stored, how it’s used, and who has access to it. Map out where PHI resides and who has access to it, and perform a risk assessment to identify vulnerabilities in the current system that could compromise PHI security.  

3. Implement Access Control Mechanisms

HIPAA requires that only authorized individuals can access PHI. Proper access controls are critical to data governance. Implement a system that grants access to PHI based on job roles and use multi-factor authentication and secure password policies to strengthen access controls. It’s also a good idea to make sure that employees and contractors only have access to the minimum amount of PHI necessary to perform their job duties. 

4. Establish Data Protection and Security Measures

Implement data security practices to protect PHI from unauthorized access, alteration, or destruction. It’s possible to do this by using encryption to protect PHI both in transit (such over the internet or through email) and at rest, when stored on servers or devices. Ensure that all critical PHI is regularly backed up and that there is a disaster recovery plan in place in case of system failures, natural disasters, or cyber-attacks.

Implement firewalls, anti-malware software, and intrusion detection systems to detect and prevent unauthorized access attempts. 

5. Monitor and Audit Access to PHI

Regular monitoring and auditing are essential to track access to PHI, identify potential breaches, and ensure compliance with HIPAA requirements. Maintain detailed audit trails that track who accessed PHI, what actions they performed, and when it occurred. This can help identify potential security threats or non-compliant behavior. 

Organizations should perform regular audits of system activity to detect any unauthorized access or misuse of PHI. These audits should be part of an ongoing compliance program and use tools that provide real-time monitoring of systems and alerts for suspicious activities involving PHI. 

6. Ensure Proper Data Retention and Disposal

HIPAA requires that PHI be retained for a certain period, and that it be securely disposed of when no longer needed. Failure to properly manage data retention and disposal can result in violations. 

Develop and enforce policies specifying how long different types of PHI should be retained. Retain records according to HIPAA’s minimum necessary retention periods or as required by law. When PHI is no longer needed, ensure it is securely deleted. This can involve securely wiping electronic devices or shredding physical records. 

7. Conduct Regular Staff Training and Awareness

Employees must understand the importance of HIPAA compliance and their role in protecting PHI. Provide initial and ongoing training to all employees, contractors, and business associates about HIPAA’s privacy and security requirements. Training should cover access control, data handling, and breach response protocols. 

Foster a culture of security and privacy within the organization by regularly reminding staff of their responsibility to safeguard PHI and encouraging them to report potential security incidents. 

8. Develop a Breach Response Plan

A breach response plan ensures that if PHI is compromised, the organization can respond quickly and in accordance with HIPAA’s notification requirements. 

Implement systems to detect and report breaches immediately. This includes monitoring for signs of unauthorized access or data loss. In the event of a breach, HIPAA requires covered entities to notify affected individuals, the Department of HHS, and in some cases, the media. Make sure the plan includes these requirements and timelines for notification (within 60 days of discovery of a breach). 

Designate an incident response team to handle breaches and mitigate potential damage. This team should be trained and ready to respond to any potential violation of PHI security. 

9. Create Business Associate Agreements (BAAs)

If an organization works with third-party vendors or contractors (business associates) who have access to PHI, it should ensure that there is a Business Associate Agreement (BAA) in place. 

The BAA should outline how the business associate will handle PHI and their responsibilities for maintaining security and compliance with HIPAA standards. Ensure that all existing BAAs are up-to-date and in compliance with HIPAA, especially if business associates change their practices or security measures. 

10. Continuous Improvement and Compliance Monitoring

HIPAA compliance is an ongoing process, so it’s important to continuously review and improve data governance practices. Regularly conduct internal audits and assessments to evaluate the effectiveness of the organization’s data governance policies and identify any potential gaps. 

HIPAA regulations can evolve, so it’s crucial to stay informed about any changes to HIPAA standards and incorporate them into the data governance strategy. Consider using third-party auditors or penetration testers to assess the data governance program and identify vulnerabilities that may need to be addressed. 

Implementing HIPAA data governance is a comprehensive process that requires a clear framework, access controls, data protection measures, training, and continuous monitoring. By following best practices and staying proactive about compliance, businesses and organizations can effectively protect PHI, mitigate risks, and ensure they meet HIPAA’s stringent privacy and security requirements. 

Partner With Actian for Data Discovery and Governance Needs

Actian provides advanced solutions for data discovery, governance, and lineage tracking. With powerful automation and integration capabilities, Actian’s platform helps businesses maintain accurate data lineage, ensure compliance, and optimize data management. By partnering with Actian, organizations can gain better control over their data assets and drive informed decision-making. 

About Actian Corporation

Actian makes data easy. Our data platform simplifies how people connect, manage, and analyze data across cloud, hybrid, and on-premises environments. With decades of experience in data management and analytics, Actian delivers high-performance solutions that empower businesses to make data-driven decisions. Actian is recognized by leading analysts and has received industry awards for performance and innovation. Our teams share proven use cases at conferences (e.g., Strata Data) and contribute to open-source projects. On the Actian blog, we cover topics ranging from real-time data ingestion, data analytics, data governance, data management, data quality, data intelligence to AI-driven analytics.