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Protect ePHI Data: 5-Step ePHI Data Security Plan

Securing valuable (and lucrative) ePHI data can be challenging. Here is a practical 5-step plan to secure your ePHI data
Protect ePHI data
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If you’re a healthcare organization 2021 was a pretty bad year, and that’s not just pandemic-speak. It was the worst year to date for healthcare breaches. 45 million records were exposed or stolen in 713 major breaches. 2022 is on a mission to break the record. The Department of Human & Health Services’ (HHS) infamous Wall of Shame notes that 20 million patient records have been exposed in healthcare breaches in 2022. Healthcare records are so lucrative that they account for 95% of all identity theft cases and are worth 25 times as much as a credit card. With hackers at your heel, it is increasingly difficult (and imperative), to secure your valuable Electronic Protected Health Information (ePHI). In this blog, we lay out 5 aspects to comprehensively protect your ePHI both from a breach and after a breach. A 5-Step ePHI data security plan. Protect EPHI data!

5 Steps to Protect your ePHI Data

Step #1 ePHI Data Security Plan => Assess: Risk Assessment and Incident Planning

The Health Insurance Portability and Accountability Act (HIPAA) Security Rule mandates that all “covered entities” aka health care providers conduct a periodic risk analysis to assess the ePHI their organization creates, transmits, or stores. The first step to protecting your ePHI data is assessing the risks and setting up an incident response plan.

  • Risk Assessment: A thorough, yearly risk assessment will give you a clear picture of your IT infrastructure, data landscape, corporate changes, staff turnover, the latest vulnerabilities and malware/ransomware types. You’ll want to consider everything from technical risks like system or software vulnerabilities to non-technical risks like user error or social engineering. It should also outline the movement of your ePHI and its transitions between providers, payers and patients. A good start to formulate your risk assessment plan is HHS’ security risk assessment tool.
  • Incident Response Planning: With a clear overview of flow of data, you can then work on creating an Incident Response Plan that outlines the steps to take should a breach occur (Check out a 5-Step Ransomware Response Plan). This plan should be reviewed and updated regularly to ensure it’s up-to-date with the latest threats.

Step #2 ePHI Data Security Plan => Protect: Encrypt, Secure, Train, Audit

Now that you know where your ePHI is and how it flows, you can start to put security controls in place to protect your ePHI data.

  • Robust Encryption: The first step is encryption which renders data unreadable and unusable to unauthorized individuals. This is the most effective way to protect PHI as even if a hacker manages to gain access to your systems, they won’t be able to make sense of the data. All ePHI in-transit and at-rest should be encrypted, whether it’s stored on servers, laptops, mobile devices or backups.
  • Secure Data and Endpoints: Create a culture where ePHI is respected and data security is seen as an organizational responsibility. Get buy-in from a cross-functional team on a set of security objectives so that everyone understands the importance of critical applications and securing sensitive data sets. Build a software ethos of “data privacy by design”. Protect your data with a reliable backup that utilizes offsite/cloud-based storage. Conduct regular backup and recovery testing of both your backup application and processes. You’ll also want to secure remote access to your systems with a Virtual Private Network (VPN) which creates a protected, encrypted tunnel between an authorized user and your network. Multi-factor authentication (MFA) is another strong measure to take as it requires users to provide additional proof of identity before being granted access, making it much harder for hackers to gain entry.
  • Train Employees and Users: As cybercriminals are becoming more sophisticated, employee/user error is one of the leading causes of healthcare data breaches. You’ll want to train your staff on best practices for handling ePHI. This includes ensuring they understand the importance of keeping data secure, how to spot phishing emails and what to do if they suspect a breach has occurred. Run email/messaging campaigns to regularly train your users on cybersecurity best practices such as not sharing passwords, not opening attachments from unknown senders and being vigilant about social engineering attacks. Cybersecurity training should be an ongoing process as threats are constantly evolving.
  • Audit to Ensure Compliance with Regulatory Laws: As a covered entity, you’re required to comply with HIPAA regulations which set out strict guidelines on the handling of PHI.  An audit is extremely helpful to review security controls and measures, uncover red flags before they spiral out of control, and to identify gaps and opportunities to strengthen your organization’s cybersecurity. This includes ensuring all your staff members have received adequate training on the legal and regulatory implications of processing ePHI as well as putting in place physical, technical and administrative safeguards.

Step #3 ePHI Data Security Plan => Detect: Intrusion Detection and Prevention Systems

An Intrusion Detection System (IDS) is a network security tool that monitors for suspicious activity and raises alerts when something suspicious is detected. This allows you to quickly identify and investigate any potential threats. A Prevention System (IPS) takes things one step further by blocking suspicious traffic before it has a chance to reach your systems.

When choosing an IDS/IPS solution, you’ll want to make sure it offers the following features:

  • Round-clock monitoring and Real-time alerts: To rapidly identify suspicious activities, use round-the-clock monitoring and real-time notification. The system should be able to detect and raise alerts for suspicious activity in real-time.
  • Customizable rules: You should be able to customize the rules and thresholds for raising alerts to fit your organization’s specific needs.
  • Integration with SIEM: The system should integrate with your Security Information and Event Management (SIEM) platform to provide a centralized view of all security events.
  • Auto-updates: Ensure firewall, intrusion detection and protection system, antivirus, and associated security technologies are auto-updated, wherever possible.
  • Timely Reporting: The system should offer comprehensive reporting capabilities to help you quickly identify and investigate potential threats.

Step #4 ePHI Data Security Plan => Respond: Contain, Eradicate, Recover

Struck by a breach! Fear not, simply reach out for the comforting hand of your Incident Response Plan that you outlined in Step #1 above. Follow the steps to contain the breach, eradicate the threat and recover from the incident with your ePHI intact.

  • Contain the Breach: The first step is to contain the breach and prevent it from spreading further. This may involve disconnecting affected systems from the network, shutting down servers or blocking specific IP addresses.
  • Eradicate the Threat: Once you’ve contained the breach, you can start working on eradicating the threat. This can include running malware scans, deleting malicious files or restoring clean backups.
  • Recover from the Incident: The final step is to recover from the incident and get your systems up and running again. This would mean rebuilding servers, restoring data from a backup, or reconfiguring applications.

Following these steps will help you minimize the impact of a breach and get your systems back up and running as quickly as possible. Thus ensuring minimal downtime and business continuity

Step #5 ePHI Data Security Plan => Retrospect and Improvise

After a breach has been successfully contained, eradicated and your systems have been recovered, it’s time to take a step back and reflect on what happened. Review your Incident Response Plan and see if there are any areas that can be improved. Are there any steps that could be added or removed? Are there any tools or technologies that could make the process more efficient?

This reflection is an important part of the process as it helps you continuously improve your Incident Response Plan and ensures that you’re always prepared for the next breach.

Cybersecurity training should be an ongoing process as threats are constantly evolving. Review your Incident Response Plan regularly and make sure all staff are trained on best practices. By following these steps, you can protect your organization from the devastating effects of a data breach.

It’s Worth It! The Cost-Benefit of a Robust ePHI Data Security Plan

According to the IBM Security Cost of a Data Breach Report, the average cost of a data breach is $4.24 million. This does not include regulatory fines, damage to your brand, and loss of customer base. For a healthcare organization, the added cost of a regulatory compliance breach can be substantial. HIPAA settlement fines, on average, amount to about $1.1 million, and this figure is only increasing as the HSS becomes more assertive in enforcing HIPAA regulations. The cost-benefit of implementing a robust ePHI data security plan will not only cost-effectively protect your ePHI data, but also ensure that you can quickly recover from a breach with minimal downtime and impact to business continuity.

Kickstart ePHI Data Protection With Backup and Recovery

The covered entity (you), must securely back up retrievable exact copies of electronic protected health information and restore any loss of data. Backups should be frequent, encrypted, tested and stored offsite.


CloudAlly’s HIPAA-compliant Healthcare backup and recovery secures your ePHI across multiple SaaS platforms Microsoft 365Google WorkspaceSalesforce, Dropbox, and Box. CloudAlly’s secure cloud backup stores your data on robustly encrypted AWS S3 storage with MFA,  ISO 27001 certification, intrusion detection, and 99/9% uptime. Protect your ePHI data – Start a free trial or schedule a demo, now!

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