Security Risk Analysis
A Security Risk Analysis is an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic patient health information (ePHI). The HIPAA Security Rule requires all covered entities to conduct a Security Risk Analysis and states the Risk Analysis should be an ongoing process. Once you have completed the Risk Analysis, you must take any additional “reasonable and appropriate” steps to reduce identified risks to reasonable and appropriate levels. (45 CFR 164.308(a)(1)(ii)).

HIPAA Security Rule

The HIPAA Security Rule establishes national standards to protect individuals’ health information that is created, received, used, or maintained in electronic form by a covered entity (also known as ePHI). The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.
The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164.

Contact the Kentucky REC today for more information on how we can help with your security risk analysis.

Covered Entity

A covered entity is one of the following:

A Health Care ProviderA Health PlanA Health Care Clearinghouse
This includes providers such as:

  • Doctors
  • Clinics
  • Psychologists
  • Dentists
  • Chiropractors
  • Nursing Homes
  • Pharmacies
...but only if they transmit any information in an electronic form in connection with a transaction for which HHS has adopted a standard.
This includes:

  • Health insurance companies
  • HMOs
  • Company health plans
  • Government programs that pay for health care, such as Medicare, Medicaid, and the military and veterans’ health care programs

This includes entities that process nonstandard health information they receive from another entity into a standard (i.e., standard electronic format or data content), or vice versa.

Covered Entity Guidance Tool

Protecting patients’ ePHI is as important as protecting their paper PHI. An SRA helps to identify vulnerabilities and threats surrounding your EHR and other IT systems containing and transmitting ePHI. Once identified, you will need to mitigate the vulnerabilities to reasonable level.

Please note all providers who are covered entities under HIPAA are required to perform a Security Risk Analysis.

Use the following tool to help determine if you are a Covered Entity

Why Do I Need a Security Risk Analysis (SRA)?

The Administrative Safeguards provisions in the HIPAA Security Rule require covered entities to perform risk analysis as part of their security management processes. Specifically, the Security Rule states that covered entities are required to:

“Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity or business associate.” §164.308(a)(1)(ii)(A):

• A risk analysis process includes, but is not limited to, the following activities:

• Evaluate the likelihood and impact of potential risks to e-PHI

• Implement appropriate security measures to address the risks identified in the risk analysis

• Document the chosen security measures and, where required, the rationale for adopting those measures

• Maintain continuous, reasonable, and appropriate security protections

Risk analysis should be an ongoing process, in which a covered entity regularly reviews its records to track access to e-PHI and detect security incidents, periodically evaluates the effectiveness of security measures put in place, and regularly reevaluates potential risks to e-PHI.

Summary of the HIPAA Security Rule
Quality Payment Programs/MIPS Guidance


Kentucky REC Annual Conference Oct 26: Quality Presentation

Hybrid Event with Special Guest Speakers - In Person and Virtual Oct. 26 2023, Lexington Kentucky, Harper HallKentucky REC Quality Team Speakers: Jessica Elliott & Vance Drakeford Balancing Cost & Quality: Strategies for Providing Safe and Efficient Care...

Register Today! Oct 26 – Kentucky REC Annual Conference

Lexington, Kentucky – Join Us in Person or Online During our day together we’ll discuss quality initiatives, HIPAA, Social Drivers of Health, and more to ensure that clinicians, hospital and ambulatory administrators, and clinic staff are well prepared for the...