Managed HIPAA Security Program
Overview
The Managed HIPAA Security Program provides ongoing cybersecurity and HIPAA Security Rule support for healthcare organizations that need continuous guidance, risk management, and compliance oversight. The program is designed to supplement existing IT providers while helping organizations maintain compliance, reduce risk, and improve their overall security posture.
The service combines periodic reviews, compliance management, security advisory services, and risk monitoring into a predictable monthly engagement.
Program Objectives
The Managed HIPAA Security Program helps organizations:
- Maintain HIPAA Security Rule compliance
- Reduce the likelihood of data breaches and ransomware incidents
- Demonstrate due diligence during audits and investigations
- Identify and address emerging security risks
- Maintain current security documentation
- Provide leadership with visibility into cybersecurity risks
- Establish a repeatable security governance process
Scope of Services
1. Annual ePHI Risk Assessment
Conduct a comprehensive annual assessment of risks to electronic Protected Health Information (ePHI).
Activities include:
- Review of administrative safeguards
- Review of technical safeguards
- Review of physical safeguards
- Risk identification and analysis
- Likelihood and impact scoring
- Risk register development
- Executive summary report
- Remediation roadmap
Deliverables:
- Annual Risk Assessment Report
- Risk Register
- Executive Summary
- Remediation Plan
2. Quarterly Security Reviews
Conduct quarterly reviews to evaluate security posture and compliance progress.
Activities include:
- Review remediation status
- Review security incidents
- Review major technology changes
- Review vendor additions or changes
- Review workforce changes
- Update risk register as necessary
Deliverables:
- Quarterly Security Review Report
- Updated Risk Register
3. HIPAA Security Rule Compliance Monitoring
Provide ongoing oversight of Security Rule requirements.
Activities include:
- Policy review schedule management
- Documentation review
- Compliance gap identification
- Security control validation
- Safeguard maturity tracking
Deliverables:
- Compliance Status Dashboard
- Gap Tracking Report
4. Security Policy Management
Review and maintain required security documentation.
Typical policies include:
- Information Security Policy
- Access Control Policy
- Password Policy
- Incident Response Policy
- Workforce Security Policy
- Business Associate Management Policy
- Data Retention Policy
- Mobile Device Policy
Deliverables:
- Policy Library
- Annual Policy Review Documentation
5. Business Associate Oversight
Assist with vendor and Business Associate management.
Activities include:
- Vendor inventory review
- Business Associate Agreement tracking
- Security questionnaire review
- Vendor risk discussions
Deliverables:
- Business Associate Inventory
- Vendor Risk Register
6. Security Awareness Program
Provide workforce security awareness support.
Activities include:
- Annual HIPAA Security training
- Security awareness materials
- Phishing awareness guidance
- Incident reporting education
Deliverables:
- Training Records
- Security Awareness Materials
7. Incident Response Advisory
Provide guidance during security incidents.
Activities include:
- Initial incident consultation
- Breach assessment support
- Documentation guidance
- Coordination recommendations
Deliverables:
- Incident Documentation Templates
- Advisory Support During Events
Note: Digital forensics, legal services, breach notification services, and incident recovery are outside the scope of this engagement.
8. Virtual Security Officer (vISO) Services
Provide access to an experienced security advisor.
Activities include:
- Monthly leadership meetings
- Security strategy guidance
- Compliance consultation
- Security roadmap planning
- Budget planning recommendations
Deliverables:
- Monthly Executive Security Report
- Security Roadmap
Customer Responsibilities
Customer will:
- Designate a primary point of contact
- Provide access to requested documentation
- Maintain an IT support provider or internal IT function
- Implement approved remediation activities
- Notify SBY-TECH of significant environmental changes
Out of Scope
The following services are not included:
- Managed IT services
- Security Operations Center (SOC)
- Endpoint monitoring
- Vulnerability scanning
- Penetration testing
- Digital forensics
- Legal or regulatory representation
- Cyber insurance claim support
- System administration activities
- Technical remediation implementation
These services may be provided under separate agreements.
Service Cadence
| Activity |
Frequency |
| ePHI Risk Assessment |
Annually |
| Security Review Meetings |
Quarterly |
| Executive Meetings |
Monthly |
| Policy Reviews |
Annually |
| Security Training |
Annually |
| Risk Register Updates |
Quarterly |
| Compliance Reporting |
Quarterly |
Program Deliverables
At the end of each year, the customer will maintain:
- Current ePHI Risk Assessment
- Updated Risk Register
- Security Improvement Roadmap
- Policy Library
- Business Associate Inventory
- Security Training Records
- Quarterly Compliance Reports
- Executive Security Dashboard
These artifacts collectively support HIPAA Security Rule compliance efforts while providing management with ongoing visibility into organizational security risks.
