CEHRS Study Guide: High-Yield Topics on HIPAA Compliance and Data Security in the Digital Healthcare Era

HIPAA compliance is more than a legal requirement for healthcare practices—it’s the backbone of trust in the digital age. For CEHRS candidates, the high-yield themes aren’t just definitions. They’re workflows, decisions, and risks you will face inside an EHR every day. This guide focuses on the core HIPAA rules and practical data security skills you must master, with examples and exam-friendly takeaways.

What CEHRS Candidates Must Know About HIPAA

HIPAA sets national standards for protecting health information. You’ll see it in three main rules:

• Privacy Rule: Who can use or disclose protected health information (PHI), and when.
• Security Rule: How to protect electronic PHI (ePHI) with administrative, physical, and technical safeguards.
• Breach Notification Rule: What to do if PHI is compromised.

PHI is any information that can identify a patient and relates to health, care, or payment. It includes names, dates, MRNs, phone numbers, device IDs, full-face photos, and more. If it can point back to a person, treat it as PHI.

Covered entities (providers, plans, clearinghouses) and their business associates (vendors handling PHI, like cloud EHRs or billing companies) must protect PHI. Vendors need a Business Associate Agreement (BAA) spelling out safeguards, breach reporting, and responsibilities. Cloud services are business associates if they store or process PHI—encryption does not remove that obligation.

Minimum necessary means share the least PHI needed to do the job. Why it matters: the more data you expose, the bigger the risk. Exceptions: disclosures for treatment, disclosures to the patient, uses with authorization, and disclosures required by law.

Patient rights drive many workflows: access to records, request for amendments, restrictions, confidential communications, and an accounting of disclosures. These rights tie directly to common CEHRS tasks (releasing records, logging disclosures, processing corrections).

Privacy Rule: Workflows You Will See

Right of access. Patients have the right to get their records within 30 days (one 30-day extension with written reason). Fees must be reasonable and cost-based (copying labor, supplies, postage). No retrieval fees. Why this is tested: delays and overcharging are common violations.

Authorization vs. consent. Routine treatment, payment, and operations (TPO) don’t need patient authorization. Marketing usually does. Research generally needs authorization or an IRB waiver. Keep this clean in your mind: if it’s not TPO or required by law, you likely need written authorization.

Verification. Before releasing PHI, verify identity. Two identifiers (e.g., name + DOB) are a simple, effective practice. Why: most breaches start with misdirected disclosures—wrong patient, wrong fax, wrong portal account.

Minimum necessary in action. When a payer asks for documentation, send only what supports the claim. When a scheduler checks benefits, they don’t need lab notes. The narrower the access, the safer the organization.

Amendments (corrections). Patients can request corrections. You must respond within 60 days (one 30-day extension allowed). You can deny if the record is accurate and complete, but you must explain why and let the patient add a statement of disagreement. Why: accuracy and transparency reduce legal exposure and improve care.

Accounting of disclosures. Patients can request an accounting of certain disclosures (not for TPO), covering up to 6 years. Maintain clear logs of public health reports, law enforcement disclosures, and disclosures required by law.

Sensitive data. 42 CFR Part 2 applies stricter rules to substance use disorder treatment records; many states add extra protections for mental health, HIV, minors, and reproductive health. Rule of thumb: if state law is more protective than HIPAA, the stricter standard applies.

Security Rule: Safeguards That Actually Work

HIPAA Security Rule is risk-based. It doesn’t demand specific tools; it expects effective controls. You must perform a risk analysis, then implement safeguards that address those risks.

• Administrative safeguards: risk analysis, risk management, policies, training, sanctions, and contingency planning (backup, disaster recovery, emergency operations). Why: most breaches stem from weak processes, not fancy hackers.
• Physical safeguards: facility access controls, secure workstations, and device/media controls (disposal, reuse, tracking). Why: a lost unencrypted laptop is still a breach.
• Technical safeguards: unique user IDs, role-based access, automatic logoff, audit logs, integrity controls, and transmission security. Encryption is “addressable,” but in practice, you need it—at rest and in transit—to meaningfully reduce risk.

Contingency plan essentials. Keep tested backups, document recovery steps, and know which systems are critical. Why: if ransomware hits, the only quick path to continuity is tested, offline or immutable backups.

Documentation. Keep HIPAA policies, risk analyses, BAAs, and training records for 6 years. If it isn’t documented, it didn’t happen.

Breach Notification: What to Do When Things Go Wrong

A breach is an impermissible use or disclosure that compromises PHI. If ePHI is encrypted and the key is safe, there may be no breach. If ransomware encrypts ePHI, OCR presumes it’s a breach unless you show a low probability of compromise.

Perform a four-factor risk assessment to determine if notification is required:

• Type and volume of PHI involved (identifiers, clinical details).
• Who received it (trusted entity vs unknown person).
• Whether the PHI was actually viewed or acquired.
• How the risk was mitigated (retrieval, exact match verification, destruction).

Timelines. Notify affected individuals without unreasonable delay and no later than 60 days from discovery. If 500+ residents in a state are affected, notify the media and HHS promptly. Fewer than 500: report to HHS within 60 days after year-end. Why this matters: timing and documentation drive OCR penalties.

Immediate steps: contain (disable accounts, isolate systems), preserve logs, document decisions, start the risk assessment, and engage privacy/security leads and legal counsel as needed.

High-Yield Numbers and Definitions to Memorize

• Right of access: 30 days (one 30-day extension, written reason).
• Accounting of disclosures: 6-year lookback; respond within 60 days.
• HIPAA documentation retention: 6 years.
• Breach notification: notify individuals within 60 days of discovery.
• Media notice: required if 500+ residents of one state/jurisdiction affected.
• Minimum necessary does not apply to: treatment, disclosures to the patient, uses/disclosures with authorization, and those required by law.
• De-identification (safe harbor): remove 18 identifiers, including names, smaller-than-state geography, all elements of dates (except year), phone, email, MRN, full-face photos, device IDs, IP addresses, and more; ages 90+ are grouped as 90+.
• Limited Data Set: dates and some geography allowed; requires a Data Use Agreement.

Data Security in Modern EHRs: What Works

• Least privilege and role-based access. Give staff only the access they need. Why: it limits the blast radius of mistakes or insider threats.
• Strong authentication. Use multi-factor authentication (MFA) for EHRs, portals, email, and VPNs. Passwords alone are routinely phished.
• Automatic logoff and session timeouts. Prevents screen-peeking risks at nursing stations and shared rooms.
• Audit logs and alerts. Log access, printing, exports, and unusual patterns (after-hours lookups, VIP snooping). Why: you can’t investigate what you didn’t log.
• Email and messaging. Encrypt PHI in transit. Use secure messaging apps with BAAs. If a patient requests unencrypted email, warn them of risks and document their preference.
• Telehealth. Use HIPAA-compliant platforms with BAAs. Verify the patient, confirm a private setting, and avoid recording unless policy allows.
• Mobile devices. Enforce MDM: screen lock, encryption, remote wipe, no local downloads of PHI. BYOD needs explicit policy and user enrollment.
• Cloud security. Cloud providers operate under a shared responsibility model. You still manage access, MFA, audit, and data classification. Always have a signed BAA.
• APIs and apps. Modern EHRs use FHIR APIs and OAuth2. Approve apps, limit data scopes, and review app permissions. Why: third-party apps can siphon more data than intended.
• Patch and vulnerability management. Apply updates promptly. Most exploits hit known, unpatched flaws.

Ransomware, Phishing, and Insider Threats

Phishing remains the top entry point. Continuous training, realistic simulations, and clear reporting channels reduce clicks. Why: people, not tools, stop phish early.

Ransomware defense basics:

• 3-2-1 backups (three copies, two media, one offline/immutable); test recovery regularly.
• Network segmentation to limit spread.
• MFA on remote access; disable unused services.
• Endpoint protection with behavior-based detection.

Insider threats. Most are accidental—wrong attachment, wrong fax number. Use confirmation practices (read-back phone numbers, secure fax cover sheets, pre-programmed numbers) and reinforce “stop and verify” culture.

Data Lifecycle, Retention, and Disposal

PHI risk exists from creation to destruction. Manage each stage intentionally.

• Retention. Follow clinical, regulatory, payer, and state retention rules. Keep HIPAA documentation at least 6 years; medical record retention varies by state and specialty.
• Backups and archives. Encrypt, test, and limit access. Label archives clearly so they aren’t accidentally restored to open file shares.
• Data minimization. Collect only what you need. Less data means less to secure and disclose.
• De-identification. Use safe harbor or expert determination when sharing data for analytics. Remember re-identification risk increases with rare conditions and small populations.
• Disposal. Follow defensible methods (e.g., media shredding, secure wipe per established standards). Document chain of custody and certificates of destruction. Why: discarded devices cause preventable breaches.

Practical Scenarios and Best Answers

• Spouse calls for results. Check if the patient has authorized disclosure or if the patient is present to agree. Otherwise, do not disclose. Why: relationship does not equal permission.
• Misdirected fax. Notify privacy officer, request destruction from recipient, document, and assess breach risk. Confirm and correct the number in your system.
• “Break-the-glass” in EHR. Use only for emergencies. System should log reason. Regular audits deter curiosity snooping.
• Patient wants unencrypted email. Inform risks, obtain documented preference, then send. Use minimum necessary and double-check the address.
• Chart correction request. Route to provider, respond within timeline, and if denied, add patient’s statement of disagreement.
• Law enforcement request. Require proper legal process (subpoena, court order) unless an emergency exception applies. Verify authority and scope before disclosing.
• Public health reporting. Allowed and often required by law (e.g., infectious diseases). Disclose only what the law requires.
• Teen seeking confidential care. Follow state minor consent laws; stricter state rules override HIPAA’s default. Segment sensitive notes if your EHR supports it.
• Vendor needs database access. Confirm BAA, limit to minimum necessary, enable time-bound access, and monitor logs. Remove access when the task ends.

Faxing, Printing, and the “Analog” Edge Cases

• Faxing. Confirm number with a callback or a directory, use a cover sheet, and pre-program frequently used numbers. Why: misdials are a top cause of small breaches.
• Printing. Use secure print release where possible. Collect pages immediately; avoid leaving PHI on printers or desks.
• Photography and screenshots. Prohibit personal devices for PHI. If imaging is clinical, use approved devices that upload directly into the EHR.

E-Prescribing and Controlled Substances

• E-prescribing. Ensure encrypted transmission and correct patient matching. Wrong patient/wrong pharmacy errors are common and dangerous.
• Electronic prescribing of controlled substances (EPCS). Requires multi-factor authentication and identity proofing. Audit logs must capture prescribing events.

Study Tactics for CEHRS Success

• Memorize the timelines (30 days access, 60 days breach notice, 6-year retention) and the minimum necessary exceptions.
• Drill the 18 HIPAA identifiers and the limited data set rules.
• Map the three Security Rule safeguard categories to real controls you’ve seen in an EHR environment.
• Practice scenario questions (spouse calls, law enforcement request, patient amendment) and write the exact steps you’d take.
• Create a one-page checklist: verification steps, ROI requirements, breach decision tree, and escalation contacts.

Quick Self-Check Quiz

• Q: Does minimum necessary apply to disclosures for treatment? A: No. Treatment is exempt.
• Q: Deadline to provide patient access to records? A: 30 days (one 30-day extension with written reason).
• Q: Is ransomware always a breach? A: It’s presumed a breach unless a documented risk assessment shows low probability of compromise.
• Q: What’s required for a Limited Data Set? A: A Data Use Agreement; direct identifiers removed.
• Q: How long must HIPAA policies be retained? A: 6 years from creation or last effective date.
• Q: Patient wants records via standard email. Allowed? A: Yes, after you warn them of risks and document their preference.

Bottom Line for CEHRS Candidates

HIPAA compliance is about predictable, defensible workflows. Verify identity. Apply minimum necessary. Log and audit. Encrypt in transit and at rest. Train people to pause and double-check. When in doubt, escalate early to your privacy or security lead. These practices protect patients, keep your organization out of trouble, and will carry you through the CEHRS exam and real-world work.

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com