How To Secure PHI Data Covered by HIPAA with Identity Governance Without Vendor Lock-In

PHI data security requires top-down planning and execution to ensure there are no gaps that may put your business in breach of data protection regulations. You must protect personal health information in live systems, data storage, email, archives, and backups from cybersecurity threats, and be able to prove the measures taken to do this with hard evidence during audits.

This guide explains what you can do to further secure PHI data and help prevent HIPAA violations as part of your broader identity governance and management for sensitive healthcare data.

What is PHI data security?

PHI (Protected Health Information) is a subset of PII (Personally Identifiable Information) that must be protected to remain HIPAA compliant. Failure to comply can lead to serious legal repercussions for your business – and if a breach occurs, this can lead to further legal ramifications as well as serious reputational damage, in addition to the harm caused to those you handle sensitive health data for.

The information in this guide will help you enact the following best practices for PHI data security and assist you with HIPAA compliance:

Full compliance cannot be achieved by reading a single online guide. HIPAA may not be the only privacy framework that affects you – you must refer directly to the different legislations that cover your organization and anyone you store personal data about, and seek legal and technical assistance to ensure that your implementation and ongoing data protection measures reach your compliance requirements.

What you need to secure personal data for HIPAA compliance

The technical measures required to secure PHI will be unique to your business and depend on what systems you use and where the data is processed and stored. At a minimum, you’ll need:

• Current PHI data mapped alongside all relevant systems, workflows, custodians, and retention policies
• Defined user roles for clinical/day-to-day and administrative functions, including emergency access policies
• Access to your identity provider (for example, Microsoft Entra ID) user and group management, as well as tools that integrate with it for access control
• Centralized logging for authentication, authorization, and administrative actions

What’s the best way to prevent a HIPAA violation without vendor lock-in?

Choosing HIPAA-compliant tools to build on is also crucial – for example, NinjaOne provides a trust page for its integrated suite of IT management tools, which details how compliance with data privacy laws like HIPAA, CCPA, GDPR, SOC, and others is achieved.

However, many organizations will be wary of vendor lock-in when selecting the HIPAA-compliant tools that they will rely on. Make sure that your tools allow for data mobility with import and export functions, and can integrate with the other tools using extensible APIs.

Map PHI and tag systems for governance

Understand the data you are tasked to protect by mapping it: what it is, who it is about, where it is stored, and how it is used should all be inventoried.

Then, categorize and tag systems and user groups that handle PHI so that policies and data protection measures can be targeted, and full coverage can be reached. Documentation is vital for this, and all policies and measures, as well as the custodian of each system or data store, should be recorded as evidence of compliance and to assign responsibility.

Define least-privilege user roles

How PHI is used will define the user roles that can access different subsets of it, and either read or write data. Translate these roles into groups in your authentication platform, with each being assigned the minimum necessary permissions to access or update data while being able to perform their intended function. This also applies to service accounts.

Regularly review these roles and check for overlap and flag conflicts or potentially lax restrictions.

Automate joiner-mover-leaver and enforce time-bound access

Automate the provisioning of new users to ensure they are consistently configured. Do the same for departmental transfers and deprovisioning to ensure users are not left with trailing permissions that were not properly cleaned up. For highly sensitive operations (for example, database maintenance that requires access to all records), assign just-in-time access with a limited time window to prevent broad access from being constantly available, reducing an attacker’s ability to use a compromised account or session to access data.

If emergency access is anticipated, create highly-privileged ‘break-glass’ accounts with once-off credentials. Monitor these accounts carefully with alerts configured if they are used, log and review all actions, and rotate passwords after the required emergency task is complete.

Protect email, cloud resources/SaaS, archives, and backups that contain PHI

Enforce encryption on all client devices that handle PHI, as well as in file storage and the cloud. Ensure that any SaaS providers you use are HIPAA-compliant and take the appropriate measures to protect the patient data you entrust to them. Maintaining a SaaS inventory can assist with this.

Archives and backups must also be protected. SaaS services should be backed up securely – HIPAA has data retention and backup requirements that must be met, including email and data in SaaS platforms like Google Workspace or Microsoft 365.

Require MFA and session controls on systems that can access PHI

User accounts on all systems or services that can access PHI should be protected with multifactor authentication (MFA), and additional session controls like time limits (for example, preventing users from logging in out-of-hours).

Conditional access, if supported, can automatically trigger additional authentication and verification measures for suspicious logins. Federated authentication, where all of your user accounts and groups are managed through a service like Microsoft Entra ID, centralizes this and provides built-in security against account takeover attempts like password spraying or session hijacking.

Run periodic access reviews and check exceptions

Any administrative actions regarding PHI, or who has access to it, should be logged. Data or system owners should schedule the review of the elements they oversee, and remove exceptions that are no longer needed, as well as stale permissions and user accounts. All management and compliance actions should be documented alongside any exceptions that remain active.

Produce audit-ready HIPAA evidence and continue to improve

Periodically collect all documentation and logs relating to compliance and create an evidence packet for ready auditing. Include things like role definitions, changes, certifications, exceptions, and administrative logs. Summarizing these packets for internal reviews provides an opportunity to demonstrate your competence to stakeholders and to refine your PHI data security measures, including tightening role definitions and permissions, removing exceptions, and ensuring that all relevant activity is logged.

NinjaOne unifies IT administration, management, support, and governance, helping you stay compliant

Maintaining PHI data security and continually upholding HIPAA compliance, as well as compliance with other privacy laws, is critical for the protection of your healthcare customers and the continuity of your business. Implementing the required cybersecurity and governance measures for personal health information and collecting evidence to prove them ensures seamless operations and oversight for IT teams.

NinjaOne provides a unified remote monitoring and management (RMM), mobile device management (MDM), endpoint protection, automation, documentation, and remote assistance platform that is HIPAA-compliant. You can base your IT operations on a secure foundation and implement your own technical and operational measures on top of this, rather than trying to patch holes in a disjointed IT toolchain from multiple vendors.

Using NinjaOne, you can schedule jobs to update role-based access, automatically expire time-based exceptions, compile data for review and certification, and export evidence containing decisions, exceptions, and log excerpts ready for auditing. Endpoint policies and automation can enforce encryption and secure configurations on devices that deal with PHI, extending into the cloud for SaaS backup and log collection.