HIPAA Security & Privacy Compliance
HIPAA Security Rule and Privacy Rule compliance consulting, risk assessment, and audit preparation for healthcare organizations, life sciences, and business associates.
Bell Tower engineers HIPAA-compliant security programs aligned to the Security Rule, Privacy Rule, and Breach Notification Rule for healthcare organizations, life sciences companies, and business associates handling PHI.
What We Deliver
- Security Risk Assessment (SRA): OCR-acceptable risk analysis documenting threats, vulnerabilities, likelihood, and impact across all PHI storage locations
- Technical Safeguards Implementation: Access controls, audit controls, integrity controls, and transmission security engineered to 164.312 specifications
- Administrative Safeguards: Security management process, assigned security responsibilities, workforce training, and contingency planning per 164.308
- Business Associate Management: BA agreements, vendor risk assessments, and downstream compliance validation for PHI-sharing relationships
- Breach Notification Readiness: Risk assessment methodology for breach determination, notification workflows, and documentation for OCR investigations
HIPAA Security Rule Implementation
Bell Tower’s HIPAA consulting addresses the full administrative, physical, and technical safeguard requirements. We start with a comprehensive Security Risk Assessment that satisfies OCR expectations: identifying where PHI lives, what threats exist, how likely exploitation is, and what the impact would be. Most healthcare organizations struggle with complete asset inventory—particularly SaaS applications and employee mobile devices that touch PHI.
We engineer technical controls that satisfy 164.312 without over-engineering: encryption for data at rest and in transit, access controls with role-based permissions, audit logging that captures meaningful security events, and integrity controls that detect unauthorized modification. Our approach maps each technical control to specific implementation specifications (required vs. addressable) with documented rationale for addressable decisions.
For organizations already aligned to NIST CSF or ISO 27001, we provide crosswalk documentation showing how existing controls satisfy HIPAA requirements—avoiding redundant work while ensuring OCR audit readiness.
HIPAA to Framework Crosswalks
HIPAA Security Rule safeguards map directly to major security frameworks:
| HIPAA Safeguard | Implementation Spec | NIST CSF Mapping | ISO 27001 Mapping | Control Description |
|---|---|---|---|---|
| 164.308(a)(1) | Security mgmt process | ID.GV, ID.RM | A.5.1, A.5.2 | Risk analysis and management |
| 164.312(a) | Access controls | PR.AC | A.9.4 | Unique user IDs, emergency access, auto logoff |
| 164.312(b) | Audit controls | DE.CM | A.12.4 | Audit logs, audit review procedures |
| 164.312(c) | Integrity controls | PR.DS | A.12.2 | Mechanisms to authenticate ePHI |
| 164.312(d) | Person/auth | PR.AC | A.9.2 | Authentication for ePHI access |
| 164.312(e) | Transmission security | PR.DS | A.13.2 | Integrity controls, encryption |
| 164.310(d) | Device/media controls | PR.DS | A.8.1, A.8.2 | Disposal, media reuse, accountability |
We map your current security program to HIPAA requirements, identifying gaps between “addressable” decisions and OCR’s current enforcement posture.
Risk Assessment Examples
The Security Risk Assessment is where most HIPAA programs fail audit. We engineer assessments that satisfy OCR’s nine-element methodology:
Example: Threat-Vulnerability Pairing
Asset: EHR system containing PHI
Threat: Unauthorized access via compromised credentials
Vulnerability: Single-factor authentication, password reuse
Likelihood: High (based on incident data)
Impact: High (PHI exposure of 50,000+ records)
Risk Level: Critical
Remediation: Implement MFA, password policy enforcement, session management
Example: SaaS/Shadow IT Discovery
Finding: Marketing team uses unsanctioned cloud storage for patient testimonials
Risk: PHI stored outside BAA coverage, no audit logs, unknown encryption status
Remediation: Inventory sanctioned tools, implement CASB, execute BAAs or migrate data
Audit Evidence Library
OCR investigations and voluntary audits require proof of ongoing compliance. We build evidence libraries organized by safeguard:
| Safeguard Ref | Evidence Type | Source | Owner | Refresh Cadence |
|---|---|---|---|---|
| 164.308(a)(1) | Risk analysis document, risk register | Risk management | CISO/Privacy Officer | Annual |
| 164.308(a)(3) | Workforce authorization records, access reviews | HR/IAM | Security | Quarterly |
| 164.308(a)(5) | Training completion, sanction records | LMS/HR | Compliance | Annual |
| 164.312(a) | Access control policies, user provisioning logs | IAM systems | IT Security | Quarterly |
| 164.312(b) | Audit log samples, review documentation | SIEM/Logs | Security Operations | Monthly |
| 164.312(e) | Encryption assessments, transmission logs | Network security | Infrastructure | Annual |
From Automation to OCR
Compliance automation tools help, but OCR auditors require context and procedural documentation. We bridge the gap:
- Risk Analysis Documentation: Converting scan outputs into OCR-acceptable risk analysis format (threat + vulnerability + likelihood + impact)
- Addressable Decisions: Documented rationale for each addressable implementation specification (why encryption not feasible, what alternative implemented)
- Workforce Training: Evidence of security awareness training with HIPAA-specific content, not just generic cybersecurity
- Business Associate Tracking: Inventory of all BAs, current BAAs, and downstream compliance validation
Knowledge Transfer
HIPAA compliance requires ongoing operation, not just documentation. We ensure your team understands:
- How to update the SRA when new systems or threats emerge
- Workforce training requirements and documentation standards
- Business associate risk assessment methodology
- Breach notification decision trees and timelines (60-day rule, state law variations)
Your compliance program belongs to you. We engineer the controls, document the evidence, and ensure your team can operate it independently—prepared for OCR audits, business associate due diligence, and patient data requests.
Preparing for a HIPAA audit or OCR investigation? Contact us to discuss your current risk posture and evidence readiness.