Safeguard ePHI with Zero-Trust Controls, Clear Policies, and Audit-Grade Evidence
HIPAA (Privacy, Security, and Breach Notification Rules) requires you to protect ePHI, limit its use/disclosure, and prove you’re doing so.
SolveForce turns HIPAA into an operating system: risk assessment → Zero-Trust architecture → policies & BAAs → monitoring & drills — all wired to evidence you can hand to compliance, customers, and regulators.
Related pages:
🛡️ Cybersecurity → /cybersecurity • 🧭 NIST → /nist • 🏥 Healthcare Networks → /healthcare-networks • 🏢 Healthcare DCs → /healthcare-data-centers
☁️ Cloud → /cloud • 🔑 Keys/Secrets → /key-management / /secrets-management / /encryption
🚪 Access → /iam / /pam / /ztna / /nac • 🔏 DLP → /dlp
💾 Continuity → /cloud-backup / /backup-immutability / /draas
📊 Evidence/Automation → /siem-soar • 🧪 Exercises → /tabletop
🎯 Outcomes (Why SolveForce for HIPAA)
- Minimum necessary, always — access, flows, and disclosures constrained by role & purpose.
- Zero-Trust by default — ZTNA/SASE for users, NAC at ports, microsegmentation for clinical/biomed/administrative enclaves.
- Shared-responsibility clarity — BAAs with cloud/SaaS, controls mapped to who does what.
- Audit-ready — policies, logs, and control tests exported as evidence packs.
- Continuity with proof — immutable backups and tested DR with screenshots & checksums.
🧭 Scope (What We Build & Operate)
- Risk analysis & management — inventory systems & ePHI, assess threats, document mitigations & POA&M.
- Policies & BAAs — Privacy/Security/Breach policies, procedures, workforce training, vendor BAAs & responsibility matrices.
- Identity & access — SSO/MFA, RBAC/ABAC, JIT admin via PAM, session timeouts, automatic offboarding. → /iam • /pam
- Network & app controls — ZTNA per app, NAC 802.1X on campus, WAF/Bot & DDoS at portals/APIs; secure telehealth. → /ztna • /nac • /waf
- Data protection — labeling (ePHI), encryption in transit/at rest, CMEK/HSM, DLP, tokenization, secure messaging. → /encryption • /key-management • /dlp
- Logging, IR & ConMon — centralized audit logs (auth, access, admin), SIEM detections, SOAR playbooks, breach workflows & notification timelines. → /siem-soar • /incident-response
- Continuity — Object-Lock/WORM backups, cross-region/site DR, RTO/RPO aligned to clinical needs, tabletop drills. → /backup-immutability • /draas
🧱 HIPAA Rule Mapping (Selected)
- Security Rule (45 CFR 164.308/310/312)
- Administrative: risk analysis, workforce training, sanctions, contingency, evaluation.
- Physical: facility access, workstation & device/media controls.
- Technical: access control (unique ID, emergency access), audit controls, integrity, person/entity auth, transmission security (TLS/VPN).
- Privacy Rule (164.5xx) — minimum necessary, uses/disclosures, rights of individuals, notice of privacy practices.
- Breach Notification (164.400–414) — discovery, risk assessment, affected party & HHS notification within statutory timelines.
- 42 CFR Part 2 (overlay) — stricter controls for SUD data (labels, access, accounting of disclosures).
We align these with NIST 800-66 & 800-53 families to ease audits and reuse control evidence. → /nist
🧰 Reference Architectures (Choose Your Fit)
A) Cloud EHR & Patient Portals
Private Endpoints only • ZTNA for admins • WAF/Bot & DDoS at edge • CMEK/HSM • immutable logs/backups • BAA with CSP & EHR vendor.
B) Hospital Core + Imaging
EVPN/VXLAN core • NAC EAP-TLS • microseg for biomed & clinical • wavelength DCI for PACS/VNA • SAN/NVMe • PHI labeling & DLP. → /wavelength • /san
C) Telehealth / RPM
Media-optimized paths • ZTNA for clinicians • SASE for web/SaaS • DLP & encryption for transcripts • LTE/5G/satellite tertiary. → /sd-wan
D) Business Associates (BA) in Cloud
Landing zone with Org Policies • Private Service Endpoints • audit logs→SIEM • BAA in place • responsibility matrix • ConMon & DR evidence.
E) Research Enclave (HIPAA + 42 CFR Part 2)
Cited dataset lineage • tokenization/pseudonymization • ZTNA with step-up • HSM keys • immutable audit logs & approvals.
📐 SLO Guardrails (Operate HIPAA Like a Product)
| Domain | KPI / SLO | Target (Recommended) |
|---|---|---|
| Access | ePHI encryption (at rest / in transit) | = 100% |
| Joiner→productive access / Leaver revoke | ≤ 60 min / ≤ 15 min | |
| Logging | Audit log delivery to SIEM | ≤ 120 s |
| DLP | ePHI label coverage in ePHI systems | = 100% |
| BAAs | In-scope vendors with signed BAA | = 100% |
| Risk | Annual risk analysis & update | On time (≤ 12 mo) |
| Training | Workforce completion (regulated roles) | ≥ 99% |
| Continuity | Object-Lock on Tier-1 backups | = 100% |
| IR | Breach notification workflow tested | ≥ 1 / year with AAR |
SLO breaches open tickets and trigger SOAR actions (revoke, rekey, quarantine, rotate keys, force TLS, tighten ZTNA). → /siem-soar
📊 Evidence Pack (examples)
- Risk analysis & management plan; asset inventory; data flows.
- Policies & procedures (Privacy, Security, Breach, Contingency, Device/Media, Telework).
- BAAs & vendor due-diligence; responsibility matrices.
- Access lists, quarterly certifications, PAM recordings, ZTNA policies.
- Encryption configs (CMEK/HSM), DLP events, WAF/Bot logs.
- SIEM alerts/cases; incident & breach runbooks; TTX AARs.
- Backup/DR artifacts (screenshots, checksums, timings).
All exportable from SIEM/SOAR on demand. → /siem-soar
🛠️ Implementation Blueprint (No-Surprise Compliance)
1) Scope & inventory — systems, ePHI data stores/flows, roles; map Privacy/Security Rule applicability.
2) Risk analysis — threats/vulns/likelihood/impact; mitigation plan & POA&M.
3) Policies & BAAs — publish procedures; execute BAAs; define shared responsibility.
4) Build controls — ZTNA/NAC, keys/secrets (HSM), encryption, WAF/DLP, logging, least-privilege & JIT admin.
5) Training & awareness — baseline + role-based (clinical, billing, IT, vendor).
6) ConMon & IR — SIEM/SOAR wiring, detections, monthly scans; breach workflows and table-tops.
7) Continuity — Object-Lock backups; DR runbooks; drills with artifacts.
8) Assess & improve — internal audit; fix gaps; evidence pack; annual risk analysis refresh.
✅ Pre-Engagement Checklist
- 🗂️ Systems & ePHI inventory; data-flow diagrams; telehealth/RPM scope.
- 🧭 Current policies, risk analysis date, POA&M, training posture.
- 🤝 BAAs list (cloud, EHR, billing, CCaaS/IVR, analytics) & renewals.
- 🔐 IdP/SSO/MFA, PAM, ZTNA/NAC status; device posture (MDM/UEM + EDR).
- 🔑 KMS/HSM and vault posture; TLS enforcement; key rotation cadence.
- 🔏 DLP labels/policies; retention & deletion workflows; subject rights.
- 📊 SIEM destination; ConMon tooling; breach notification contacts; drill calendar.
- 🧩 42 CFR Part 2 / state privacy overlays (if applicable).
🔄 Where HIPAA Fits (Recursive View)
1) Grammar — clinical traffic rides /connectivity & /networks-and-data-centers.
2) Syntax — delivered via /cloud patterns with private endpoints.
3) Semantics — /cybersecurity + /dlp enforce minimum necessary & integrity.
4) Pragmatics — /siem-soar proves control effectiveness; /tabletop validates response.