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How to Protect PHI?

  • 30 Jan 2024
  • 3 min read

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Protected Health Information (PHI) is at the core of healthcare operations, containing sensitive patient data that must be safeguarded from unauthorized access and breaches. As healthcare providers and organizations increasingly rely on electronic systems, the need to protect PHI becomes even more critical. In this comprehensive guide, we will delve into the best practices for securing PHI against public viewing, overheard conversations, and electronic threats. Additionally, we will explore the importance of conducting a PHI breach risk assessment to identify vulnerabilities and stay compliant with the HIPAA Breach Notification Rule.

What is Protected Health Information (PHI)?

Protected Health Information (PHI) refers to individually identifiable health information transmitted, maintained, or stored by covered entities and their business associates. This includes any information related to a patient's past, present, or future physical or mental health, healthcare treatment, and payment for healthcare services. PHI can exist in various forms, such as electronic, paper, or verbal records.

Why Providers Must Protect PHI?

The protection of PHI is paramount for several reasons:

  • Privacy and Confidentiality:

    Patients have a right to expect that their healthcare information will remain private and confidential.

  • Compliance with HIPAA:

    The Health Insurance Portability and Accountability Act (HIPAA) mandates covered entities to safeguard PHI to ensure patient privacy and data security.

  • Avoiding Breaches and Penalties:

    PHI breaches can lead to significant financial penalties, damage to reputation, and loss of patient trust.

  • Train Employees:

    Comprehensive training on HIPAA rules and security protocols is essential for all employees, including healthcare providers, administrative staff, and support personnel. Training should cover the importance of patient privacy, how to handle PHI securely, and the consequences of PHI breaches. Regular refresher courses and updates on evolving security threats should be conducted to keep employees informed and vigilant.

  • Implement Access Controls:

    Limiting access to PHI to authorized personnel helps prevent unauthorized viewing or use of sensitive information. Healthcare organizations should implement strong authentication measures such as unique usernames and strong passwords. Multi-factor authentication adds an extra layer of security, reducing the risk of unauthorized access.

  • Manage Third-party Vendors:

    Healthcare providers often work with third-party vendors, such as IT service providers or billing companies, who may handle PHI. It is essential to ensure that these vendors comply with HIPAA regulations and maintain the same level of security as required by the covered entity. Executing Business Associate Agreements (BAAs) is a critical step in establishing responsibilities and expectations regarding PHI protection.

  • Backup Your Data:

    Regularly backing up electronic PHI is crucial to safeguard against data loss due to system failures, natural disasters, or cyber-attacks. Data should be stored securely, either on-premises or in encrypted cloud storage, to ensure its availability and integrity when needed.

  • Protect Printed Records:

    Physical safeguards must be implemented to protect printed records containing PHI. Secure storage areas, such as locked cabinets or restricted access rooms, help prevent unauthorized individuals from accessing sensitive information. Employees should be trained to handle printed records with care, ensuring they are not left unattended in public areas.

  • Protect Verbal PHI:

    Sensitive conversations involving PHI should take place in private areas to prevent unintentional disclosure. Employees must be mindful of their surroundings and avoid discussing PHI in public spaces, where conversations could be overheard by unauthorized individuals.

  • Secure Mobile Devices:

    With the increasing use of mobile devices in healthcare, securing these devices is crucial. Mobile devices containing PHI should be encrypted to protect data in case of loss or theft. Remote wiping capabilities can be enabled to erase data from lost or stolen devices to prevent unauthorized access.

  • Update Software and Firmware:

    Regularly updating software and firmware is vital to patch known security vulnerabilities and protect against cyber threats. Implementing a robust patch management system ensures that all devices and systems within the organization are up-to-date and secure.

  • Encrypt PHI:

    Encryption is a critical security measure for protecting electronic PHI. By converting data into an unreadable format, encryption ensures that even if unauthorized access occurs, the information remains unusable. Encryption should be applied to data both at rest (stored) and in transit (during transmission).

  • Conduct Risk Assessments:

    Regular risk assessments help identify potential vulnerabilities in the organization's security measures. By evaluating and addressing these risks, healthcare providers can implement targeted security improvements to protect PHI effectively.

Greater Visibility is Crucial for Securing PHI:

To enhance the security of PHI, healthcare organizations should invest in solutions that provide greater visibility into their systems. Real-time monitoring and analytics enable prompt detection and response to potential threats, reducing the time it takes to identify and mitigate security incidents. Advanced security technologies, such as intrusion detection systems, data loss prevention tools, and behavior analytics, can provide invaluable insights to safeguard PHI proactively.

PHI Breach Reporting:

Know Your Responsibility Under the HIPAA Breach Notification Rule: In the event of a PHI breach, covered entities must comply with the HIPAA Breach Notification Rule. If the breach affects 500 or more individuals, the entity must report the incident to the HHS, affected individuals, and the media without unreasonable delay. Smaller breaches can be aggregated and reported annually to the HHS. Timely and accurate breach reporting is critical to minimize the impact of unauthorized access to PHI and comply with legal obligations.

PHI vs. ePHI:

While PHI encompasses all forms of individually identifiable health information, ePHI specifically refers to electronically stored and transmitted PHI.


Protecting PHI is a fundamental responsibility for healthcare providers and organizations. By adhering to best practices, conducting regular risk assessments, and ensuring greater visibility into security measures, healthcare professionals can safeguard sensitive patient information effectively. Understanding the HIPAA Breach Notification Rule and promptly reporting breaches are essential steps to maintain compliance and protect patient privacy. By adopting robust security solutions, healthcare providers can create a safe environment for PHI and instill patient trust in the healthcare system.


Frequently Asked Questions

What are best practices for protecting PHI against public viewing?

To protect PHI from public viewing, ensure physical documents are stored in secure areas, restrict access to authorized personnel only, use unique identifiers instead of patient names during verbal communications, and implement strong security measures, such as data encryption and access controls, for electronic PHI.

What are best practices for preventing conversations about PHI from being overheard?

To prevent conversations about PHI from being overheard, avoid discussing sensitive information in public areas, use private meeting rooms for sensitive discussions, and educate employees about the importance of maintaining patient privacy during verbal communications.

What are best practices for the storage and disposal of documents that contain PHI?

For the storage and disposal of documents containing PHI, use secure storage locations, such as locked cabinets, to prevent unauthorized access, and establish secure procedures for document disposal, such as shredding or incineration.

What are best practices for safeguarding computer workstations and databases that contain PHI?

To safeguard computer workstations and databases containing PHI, implement strong access controls, enforce password policies, regularly update software and firmware, use encryption for data at rest and in transit, and monitor for unauthorized access or suspicious activities.

What are best practices for faxing PHI?

When faxing PHI, ensure the recipient's fax number is correct and verified, use a cover sheet with a confidentiality notice, double-check the recipient's identity, and follow up to confirm the successful receipt of the faxed information. Consider using secure faxing services for added protection.