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Contact Compliance TeamLast Updated: March 1, 2025
HIPAA Overview
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law that established national standards for protecting sensitive patient health information from being disclosed without the patient's consent or knowledge. The U.S. Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA.
Privacy Rule
Establishes national standards for the protection of certain health information. It addresses the use and disclosure of individuals' health information (Protected Health Information).
Core ComponentSecurity Rule
Establishes national standards for protecting electronic protected health information (ePHI) that is created, received, used, or maintained by a covered entity.
Core ComponentBreach Notification Rule
Requires covered entities to notify affected individuals, HHS, and in some cases, the media of a breach of unsecured protected health information.
Core ComponentOmnibus Rule
Expands the responsibilities of business associates, strengthens the limitations on the use of PHI for marketing and fundraising, and prohibits the sale of PHI without authorization.
Core ComponentUnderstanding Protected Health Information (PHI)
Protected Health Information (PHI) includes any individually identifiable health information that relates to:
- A person's past, present, or future physical or mental health condition
- Healthcare services provided to the individual
- Payment information related to healthcare services
- Any information that could reasonably be used to identify the individual
Our Commitment to HIPAA Compliance
At Astute Medic, we are committed to maintaining the highest standards of privacy and security for our clients' protected health information. We recognize our obligation as a Business Associate under HIPAA and have implemented comprehensive measures to ensure compliance throughout our organization.
Dedicated Compliance Team
Our dedicated compliance team oversees our HIPAA program, conducts regular assessments, and ensures our policies and procedures are up-to-date with regulatory changes.
Regular Risk Assessments
We conduct regular risk assessments to identify potential vulnerabilities and implement appropriate safeguards to protect PHI from threats.
Employee Training
All employees receive comprehensive HIPAA training during onboarding and ongoing education throughout their employment to ensure awareness of their responsibilities.
Vendor Management
We carefully evaluate and monitor our vendors and subcontractors to ensure they maintain appropriate safeguards for PHI that they may access.
Independent Audits
Our HIPAA compliance program undergoes regular independent audits to verify effectiveness and identify areas for improvement.
Documentation & Reporting
We maintain comprehensive documentation of our compliance efforts and offer transparent reporting to our clients about our security posture.
Technical Safeguards
Astute Medic implements comprehensive technical safeguards to protect electronic protected health information (ePHI) throughout our systems and applications. Our approach addresses the technical requirements of the HIPAA Security Rule while implementing industry best practices for data security.
Encryption
We employ robust encryption methods to protect ePHI:
- End-to-end encryption of all data transmitted between client systems and our platforms using TLS 1.3
- AES-256 encryption of all data at rest, including databases, file storage, and backups
- Secure key management systems to protect encryption keys
Access Controls
Our multi-layered access control system includes:
- Role-based access controls (RBAC) ensuring users have only the minimum necessary access
- Multi-factor authentication (MFA) required for all access to sensitive systems
- Automatic session timeouts after periods of inactivity
- Unique identification and authentication for all users
Audit Controls
Our comprehensive audit controls include:
- Detailed audit logging of all system activities, including access to PHI
- Tamper-proof audit trails that cannot be altered or deleted
- Regular audit log reviews and automated alerts for suspicious activities
- Long-term retention of audit logs for compliance and investigative purposes
Authentication
Our authentication mechanisms ensure proper identification:
- Strong password policies enforcing complexity, rotation, and history requirements
- Biometric authentication options where appropriate
- Integration with enterprise identity management systems (SSO, SAML, OAuth)
- Secure credential storage with one-way hashing algorithms
Transmission Security
We ensure secure transmission of ePHI through:
- Secure API connections with authenticated endpoints
- VPN tunnels for administrative access to production systems
- Protocol security with TLS 1.3 for all web-based communications
- Monitoring and protection against man-in-the-middle attacks
Malware Protection
Our multi-layered defense against malware includes:
- Enterprise-grade antivirus and anti-malware solutions
- Real-time monitoring and threat detection
- Automated patch management for all systems and applications
- Regular vulnerability scanning and penetration testing
Physical Safeguards
Physical safeguards are essential components of our HIPAA compliance program. These measures protect our physical facilities and the systems within them from unauthorized access, tampering, theft, or natural disasters.
Facility Security
Our facilities are protected through:
- 24/7 monitoring with security personnel and surveillance systems
- Multi-factor electronic access controls to restricted areas
- Visitor management systems with escort requirements
- Physical barriers preventing unauthorized entry
Data Center Security
Our data centers feature:
- Tier III or higher certified data centers with redundant systems
- Biometric access controls and mantrap entry points
- Environmental controls monitoring temperature, humidity, and power
- Fire detection and suppression systems designed for data centers
Workstation Security
Our workstation security measures include:
- Physical positioning of workstations to prevent unauthorized viewing
- Automatic screen locking after periods of inactivity
- Clear desk policy for all employees
- Secure disposal of physical media and documents
Mobile Device Management
We protect mobile devices through:
- Enforced device encryption and strong authentication
- Remote wiping capabilities for lost or stolen devices
- Containerization of business applications and data
- Restrictions on installation of unauthorized applications
Administrative Safeguards
Administrative safeguards form the foundation of our HIPAA compliance program. These policies, procedures, and organizational actions ensure that our workforce properly manages and protects PHI.
Policies & Procedures
Our comprehensive documentation includes:
- Detailed privacy and security policies aligned with HIPAA requirements
- Standardized procedures for handling PHI in all situations
- Regular policy reviews and updates to address regulatory changes
- Sanctions policy for workforce members who violate policies
Security Officer
Our designated Security Officer is responsible for:
- Overseeing implementation of security policies and procedures
- Ensuring compliance with the HIPAA Security Rule
- Managing security incident response
- Conducting regular security evaluations
Risk Management
Our risk management program includes:
- Annual comprehensive risk assessments
- Continuous risk monitoring throughout the year
- Formal risk mitigation planning and tracking
- Regular testing of security controls and remediation of findings
Workforce Training
Our security awareness program includes:
- Mandatory HIPAA training for all new employees
- Annual refresher training for the entire workforce
- Role-specific security training for technical staff
- Regular security awareness communications and phishing simulations
Workforce Clearance
Our workforce management includes:
- Background checks for all employees prior to hire
- Confidentiality agreements signed by all workforce members
- Formal termination procedures including access revocation
- Regular access reviews to ensure appropriate permissions
Incident Response
Our incident response program includes:
- Documented incident response plan with clear roles and responsibilities
- Regular testing through tabletop exercises and simulations
- Forensic capabilities to investigate security incidents
- Post-incident analysis to identify opportunities for improvement
Business Associate Agreement
As a Business Associate to covered entities under HIPAA, Astute Medic enters into Business Associate Agreements (BAAs) that clearly define our responsibilities for safeguarding PHI.
Our BAA Includes:
- Permitted and required uses and disclosures of PHI
- Provisions prohibiting the use or disclosure of PHI beyond what is permitted by the contract or required by law
- Requirements to implement appropriate safeguards to protect PHI
- Reporting obligations for security incidents and breaches
- Terms for the return or destruction of PHI upon contract termination
- Provisions requiring subcontractors to comply with the same restrictions and conditions
We understand that a robust BAA is critical for establishing clear expectations and responsibilities between Astute Medic and our clients. Our standard BAA template has been reviewed by healthcare compliance attorneys to ensure it meets all statutory and regulatory requirements.
For clients who require the use of their own BAA template, our compliance team works collaboratively to review and negotiate terms that satisfy both parties' requirements while maintaining compliance with HIPAA regulations.
Breach Notification
Astute Medic has established a comprehensive breach notification process that complies with the HIPAA Breach Notification Rule. In the unlikely event of a breach of unsecured PHI, we are prepared to respond promptly and effectively.
Our Breach Notification Process:
Discovery & Investigation
Upon discovery of a potential breach, our incident response team conducts a thorough investigation to determine whether a breach has occurred and the extent of any compromised PHI.
Risk Assessment
We perform the required risk assessment to determine if the incident constitutes a reportable breach under HIPAA, evaluating factors such as the nature of the PHI involved and the likelihood of misuse.
Client Notification
We notify affected clients (covered entities) without unreasonable delay and no later than 60 days after discovery, providing all information required for the covered entity to fulfill their notification obligations.
Mitigation
We take immediate steps to mitigate any potential harm resulting from the breach, including securing systems, patching vulnerabilities, and recovering compromised data when possible.
Documentation
We maintain detailed documentation of each breach investigation, risk assessment, notification, and mitigation efforts in accordance with HIPAA requirements.
Breach Prevention is Our Priority
While we maintain a robust breach notification process, our primary focus is on preventing breaches from occurring. Our multi-layered security approach, regular assessments, and employee training are designed to protect PHI and minimize the risk of unauthorized access or disclosure.
Compliance Documentation
Astute Medic maintains comprehensive documentation of our HIPAA compliance program. This documentation serves as evidence of our commitment to safeguarding PHI and demonstrates our compliance to both clients and regulators.
Available Documentation
The following documentation is available to clients under NDA:
- HIPAA Risk Assessment Reports
- Security Policies and Procedures
- Penetration Testing Results
- Compliance Certification Reports
- Employee Training Records
- Audit Reports
Client Support
We support our clients' compliance efforts by providing:
- Documentation for client audits
- Assistance with risk assessments
- Security questionnaire responses
- Compliance artifacts for regulatory inquiries
- Regular compliance updates
- Access to our compliance team
Certifications & Assessments
Astute Medic undergoes regular independent assessments and maintains industry certifications to validate our security and compliance programs. These third-party validations provide our clients with additional assurance of our commitment to protecting their data.
HITRUST CSF Certified
Our systems have achieved HITRUST CSF certification, demonstrating compliance with one of the most comprehensive security frameworks in healthcare.
SOC 2 Type II
Annual SOC 2 Type II audits verify our controls related to security, availability, processing integrity, confidentiality, and privacy.
ISO 27001
We maintain ISO 27001 certification for our information security management system, demonstrating our adherence to international standards.
Industry Recognized
HIPAA Compliance FAQ
Yes, Astute Medic is fully HIPAA compliant. We have implemented comprehensive technical, physical, and administrative safeguards to protect PHI in accordance with HIPAA regulations. Our compliance program is regularly assessed through internal audits and third-party evaluations, and we maintain certifications such as HITRUST CSF, SOC 2 Type II, and ISO 27001 to validate our security practices.
Yes, Astute Medic is prepared to sign Business Associate Agreements (BAAs) with covered entities. We offer a standard BAA template that has been reviewed by healthcare compliance attorneys, but we are also willing to review and sign client-provided BAAs subject to legal review. Please contact our compliance team to initiate the BAA process.
Astute Medic protects PHI through multiple layers of security controls:
- End-to-end encryption for data in transit using TLS 1.3
- AES-256 encryption for all data at rest
- Role-based access controls limiting access to only authorized personnel
- Multi-factor authentication for system access
- Comprehensive audit logging and monitoring
- Regular security assessments and penetration testing
- Employee security awareness training
- Secure data centers with physical security controls
Astute Medic conducts comprehensive security risk assessments annually, with more targeted assessments performed throughout the year. These include:
- Annual HIPAA Security Risk Assessment
- Quarterly vulnerability scanning of all systems
- Semi-annual penetration testing by independent security firms
- Continuous security monitoring and threat detection
- Ad-hoc assessments following significant system changes
In the event of a breach involving PHI, Astute Medic follows a structured response process:
- Immediate containment of the breach and mitigation of any ongoing risk
- Thorough investigation to understand the scope and impact
- Notification to affected clients without unreasonable delay and within 60 days
- Providing detailed information to help clients fulfill their notification obligations
- Implementing corrective actions to prevent similar incidents
- Documenting all aspects of the breach and response activities
Our breach notification procedures comply with all HIPAA requirements and are outlined in our BAAs.
Astute Medic provides comprehensive HIPAA training for all employees:
- All new employees receive HIPAA training during onboarding
- Annual refresher training is required for all staff members
- Role-specific training for employees who handle PHI directly
- Additional security awareness training throughout the year
- Training on incident reporting and breach notification procedures
- Training effectiveness is assessed through knowledge checks and simulations
Contact Our Compliance Team
If you have any questions about our HIPAA compliance program or would like to request additional information, please don't hesitate to contact our dedicated compliance team.
Get in Touch
Request Documents
To request any of the following documents, please contact our compliance team:
- HIPAA Compliance Documentation
- Business Associate Agreement Template
- Security Whitepapers
- Certifications and Attestations