Healthcare facilities in the United States should be aware of changes surrounding HIPAA compliance policies in 2025. These changes include updates such as protections against cyber threats and stricter penalties for non-compliant facilities.
While it may sound intimidating, as long as your facility stays up-to-date on important HIPAA modifications in 2025, you can ensure a smooth transition into the new regulations.
Let’s first dive into the basics of HIPAA, then explore the changes this new year will bring.
So, what does HIPAA stand for?
HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, a federal law establishing national standards for safeguarding health information. Think of HIPAA as a value system that healthcare organizations and their staff members need to abide by in order to protect sensitive information that circulates through the network—both tangibly and virtually.
HIPAA compliance: How does it affect healthcare facilities?
The Health Insurance Portability and Accountability Act is a guide for healthcare providers, insurance companies, and other institutions on safeguarding patients' personal information.
HIPAA compliance has a direct effect on healthcare facilities since it requires stringent safeguards to maintain the safety of patient information. These strict guidelines apply to both electronic and physical documents. Staff must be trained on privacy policy precautions that ensure patient data is stored securely.
HIPAA compliance essentially protects patient information (sensitive data) and promotes accountability throughout organizations.
What is required under HIPAA?
Covered entities under HIPAA are required to safeguard patients’ protected health information (PHI). When implemented and followed correctly, HIPAA keeps the following medical records from being disclosed without consent:
- A patient’s medical records, including mental and physical records
- Nursing documents that include a patient’s address, phone number, social security number, birth date, and e-mail address
- A description of a patient’s healthcare insurance coverage
- A history of a patient’s healthcare insurance payments
- A patient’s imaging reports and labs
- A patient’s hospital admissions and discharge
- Records of prescriptions
In a nutshell, facilities are required under HIPAA to protect a patient’s medical history. This includes securely maintaining information regarding a patient’s past, present, or future physical or mental health afflictions. A document that can individually identify a person and their private health information should be treated as sensitive data and handled with care.
What is the HIPAA Privacy Rule?
HIPAA regulations are enforced through the HIPAA Privacy Rule. The Privacy Rule addresses the disclosure and use of protected health information by “covered entities.”
Who are covered entities?
There is often confusion about what types of entities this rule covers. Covered entities are persons or organizations that transmit health information electronically or physically as part of their healthcare execution.
Typically, covered entities include the following:
- Healthcare providers
- Health insurance companies
- Healthcare clearing houses (and business partners or associates)
As a patient, the Privacy Rule gives you the right to access your medical records upon request. Covered entities are required to provide records within a specific timeframe and may be fined if they do not meet the established time.
According to the U.S. Department of Health and Human Services, the Privacy Rule allows entities to access protected information without the written authorization of an individual for the following purposes or situations:
- To the individual
- Treatment, payment, and healthcare operations
- Uses and disclosures with opportunity to agree or object
- Incidental use and disclosure
- Public interest and benefit activities
- Limited data set for research, public health, or healthcare operations
In a nutshell, the goal of the Privacy Rule is not only to protect sensitive personal information but also to facilitate the flow of health information, allowing for more streamlined processes and overall higher-quality services.
What is the HIPAA Facility Access Control Policy?
The Facility Access Control Policy under HIPAA consists of guidelines that healthcare facilities and other entities must put in place to ensure physical security in areas where sensitive patient information is stored. This policy also applies to wherever patient information is processed or transmitted. This policy is part of the HIPAA Security Rule, which we will get to next.
In a nutshell, the Facility Access Control Policy under HIPAA was designed to prevent access to unauthorized physical information of sensitive patient medical records. By adhering to this policy, healthcare organizations can stay compliant with HIPAA regulations.
What is the HIPAA Security Rule?
The Security Rule is an overarching rule of the Facility Access Control Policy and addresses specific cases of personal health information that is processed, stored, or transmitted electronically. It outlines the handling of electronic patient healthcare information (ePHI) that covered entities and their associates must comply with. Aspects such as encryption, audit logging, and access controls, like passwords and two-way authentications, are key components of the Security Rule.
In a nutshell, the HIPAA Security Rule was developed to ensure certain protocols are followed to avoid security and data breaches of electronic personal health information.
What is considered a HIPAA violation?
According to the HIPAA Journal, the most common HIPAA violation is “Snooping on Healthcare Records.” In other words, making an unauthorized inquiry about a family member, friend, neighbor, coworker, or celebrity is considered the number one cause of a HIPAA violation.
What are the most common HIPAA violations?
Commonly recurring violations are the following:
- Failing to carry out an organization-wide risk analysis
- Failure to appropriately manage security risks
- Denying patient access to their health records
- Exceeding the timeframe for providing access (which reduced from 30 to 15 days in 2020)
- Insufficient ePHI Access Management and Access Control
- Failure to activate encryption or an equivalent measure to safeguard ePHI on portable devices
- Going beyond the 60-day deadline for issuing a notification on breaches
- Carelessly discussing patient information
In a nutshell, common HIPAA violations may result when someone or an entity gains access to protected health information without authorization. One of the top HIPAA violations is accessing a patient’s record without an accepted motive. Other common HIPAA violations in 2025 are taking too long to give patients access to their records or denying them access altogether. Security breaches and insufficient management of ePHI are additional concerns that could lead to HIPAA violations for facilities.
What HIPAA changes should facilities be aware of this year?
2025 will bring forth several changes to HIPAA policies. Most of them are related to increased security—especially related to electronic documents. Below are three HIPAA changes facilities should be aware of in the course of this year:
1. Enhanced cybersecurity measures
2025 is introducing changes regarding cybersecurity measures. This may include the requirement for entities that handle ePHIs to implement a technology that illustrates the inventory and movement of electronic documents through the system. Moreover, at least every 12 months, a review of the movement of these documents will be required.
2. More compliance audits
HIPAA Security Rule audits regarding compliance will be more frequent. Like cyber security audits, proposed 2025 changes will make it obligatory for HIPAA-covered entities to perform and report an internal HIPAA Security Rule audit every 12 months at least.
3. Technical safeguards for mobile devices
In 2025, more technical safeguards will be applied to keep information that is shared on mobile devices safe. Certain precautions such as encrypting all electronic PHIs when at “rest” and in transit will aim to keep protected patient information safe. Multifactor authentication, network segmentation, and anti-malware software will play a role in addressing security vulnerabilities in mobile devices.
In a nutshell, the biggest change in 2025 will be centered around keeping electronic patient information safe. With the explosion of online technology, it’s more important than ever for facilities to ensure that patient data is not at risk for cyber threats. Other changes for 2025 include tracking how information is spread online and requiring that a facility conduct audits more frequently.
What do these new changes mean for nursing documentation?
Nurses are the backbone of the healthcare system. This role comes with a lot of responsibility. One major responsibility is keeping patient information safe.
Nursing documentation may include health history, lab results, and a diagnosis. A patient assessment form will likely indicate their name along with email addresses and telephone numbers. Therefore, this documentation must remain private.
Nurses should exercise caution when sharing individual health identifiers that are considered private data. Some ways to do this are to secure all mobile devices, change passwords regularly, learn about appropriate disposal of PHI documentation, and report all inappropriate disclosures promptly.
Is a HIPAA violation considered medical malpractice?
Medical malpractice is a result of a negligent act that causes harm or injury to a patient. Although HIPAA violations may indirectly cause harm to a patient, they are not typically considered medical malpractice.
The importance of staying informed about HIPAA
In extreme cases, HIPAA violations can result in civil penalties or even criminal action. Failure to comply with HIPAA rules can lead to fines that may range from $141 to $2,134,831 per violation.
Some HIPAA violations are intentional, but this is rare. Most HIPAA violations are unintentional and result from being ill-informed about HIPAA rules and regulations.
A healthcare facility must stay informed about HIPAA to prevent the accidental spread of protected patient information. One of the best ways to do this is to make sure your staff is trained on HIPAA policies and fully understand where, when, and how it would be permissible to share patient information.
Interested in more resources for healthcare facilities? Explore more articles or learn about using Nursa to fill urgent contingent staffing needs.
Sources:
- The HIPAA Journal: The 10 Most Common HIPAA Violations You Should Avoid
- The HIPAA Journal: What are the Penalties for HIPAA Violations?
- The HIPAA Guide: New HIPAA Regulations 2024-2025
- Hyperproof: What to Know About the Proposed New HIPAA Rules
- U.S Department of Health and Human Services: Summary of the HIPAA Privacy Rule
.png)
.png)
