The Health Insurance Portability and Accountability Act (HIPAA) was enacted to protect the confidentiality, integrity, and availability of protected health information (PHI). However, small practices continue to struggle to comply with the regulation. As the article published by JD Supra, Compliance With HIPAA—Help For Small And Mid-Sized Providers, notes, “Smaller Providers continue to struggle with HIPAA compliance. While large providers typically have a dedicated compliance staff, smaller providers often lack such resources and must rely on employees who wear multiple hats, including those unrelated to HIPAA and compliance.”
This reality is emphasized in the study Implementing a Standardized HIPAA Program in Private Practice, which examines how resource constraints in private practices translate into non-compliance. The article stresses that the issue lies not with a lack of awareness of HIPAA obligations, but rather the absence of a structured, repeatable compliance framework that small practices can realistically maintain over time. Without such a framework, HIPAA compliance efforts often become informal, undocumented, and dependent on individual staff members rather than institutional processes.
The article stresses that HIPAA regulations are applied uniformly across the healthcare sector, but the capacity to implement them is not. Private practices are held to the same standards as large hospital systems, yet they often operate without compliance departments, cybersecurity teams, or legal counsel dedicated to privacy and security oversight.
As noted in the study Implementing a Standardized HIPAA Program in Private Practice, HIPAA responsibilities in small practices are frequently assigned to staff members who already manage billing, scheduling, clinical coordination, or office administration. This “multiple hats” approach increases the risk that HIPAA compliance becomes secondary to day-to-day operational demands, leading to overlooked safeguards, outdated policies, and inconsistent training.
This misalignment between regulatory expectations and operational capacity is particularly evident in areas such as:
Each of these areas is required under the HIPAA Privacy and Security Rules, yet the article demonstrates how private practices often struggle to implement them in a consistent and sustainable way.
The study argues that standardization closes the compliance gap. Rather than treating HIPAA as isolated tasks, the study proposes a standardized programmatic approach that integrates HIPAA compliance into routine practice operations.
Standardization offers several key advantages for private practices:
Additionally, the article notes that standardization means developing clear, repeatable processes that align with HIPAA requirements and can be maintained by small teams.
The study identifies administrative safeguards as the most critical and most commonly neglected component of HIPAA compliance in private practice. Administrative safeguards include policies, procedures, training, and governance structures that guide how PHI is handled.
According to the study, many private practices lack:
The absence of formal administrative safeguards creates a compliance risk. HHS guidance reinforces that administrative safeguards are not optional and comprise “over half of the HIPAA Security requirements.” Without them, technical and physical safeguards cannot function effectively.
A major finding discussed in the article is the misunderstanding of HIPAA risk analysis requirements among small practices. Many providers assume that using an electronic health record system or outsourcing IT functions satisfies their Security Rule obligations. However, the study clarifies that risk analysis must be practice-specific, documented, and ongoing. A standardized HIPAA program incorporates risk analysis as a continuous process, rather than a one-time compliance exercise.
This aligns with the HHS Office for Civil Rights enforcement rule, which has repeatedly identified failure to conduct an adequate risk analysis as a leading cause of HIPAA violations. This includes instances where small and mid-sized providers faced enforcement actions. The article reinforces that standardization helps ensure risk analysis is performed consistently and updated as systems, workflows, or vendors change.
In private practices, where staff frequently perform multiple functions, the risk of inadvertent PHI disclosure is high. Examples include misdirected emails, improper verbal disclosures, or unauthorized access to patient records. However, the study advocates for structured, role-based HIPAA training as a core component of standardization. Rather than generic or infrequent training, a standardized program ensures that:
Read also: HIPAA training courses and programs
Another area where the article indicates the value of standardization is business associate management. Private practices increasingly rely on third parties for billing, IT support, cloud storage, telehealth platforms, and email services. Each of these relationships introduces HIPAA risk.
The study notes that a standardized HIPAA program formalizes vendor oversight by:
HHS has made it clear that covered entities remain responsible for protecting PHI, even when it is handled by third parties. The standardized approach outlined in the study helps private practices meet this obligation without relying on assumptions or informal assurances.
What makes the study Implementing a Standardized HIPAA Program in Private Practice particularly valuable is that its findings align with real-world HIPAA enforcement. “According to an OCR representative, of the 166 covered entities selected for a desk audit in Phase 2 of the audit program, 90% were health care providers, and while some hospitals and nursing homes were included in the audit pool, most of the providers were Smaller Providers,” notes the JD Supra article. “A recent report concluded that 69% of Smaller Providers participating in the HITRUST CyberAid Program experienced intrusion attempts and 65% detected malicious URL and command-and-control events,” the article added.
These findings reinforce the study’s central argument that smaller practices are both highly targeted and heavily scrutinized, yet often lack the structured compliance frameworks needed to respond effectively. The standardized HIPAA program outlined in the study offers a practical solution by translating regulatory requirements into repeatable operational processes.
By formalizing administrative safeguards, conducting routine risk analyses, and implementing structured workforce training, smaller providers can move from reactive to proactive approach to compliance. This approach reduces security and regulatory risk and improves audit readiness by ensuring documentation and safeguards are consistently maintained.
See also: HIPAA Compliant Email: The Definitive Guide (2025 Update)
Yes. HIPAA regulations apply uniformly across all healthcare providers, regardless of size. However, smaller practices commonly lack resources, like compliance departments or cybersecurity teams that larger organizations have.
Administrative safeguards are the policies, procedures, and actions that healthcare organizations use to manage how protected health information (PHI) is handled. They include training staff on HIPAA rules, assigning privacy and security roles, developing clear procedures for handling data and breaches, and regularly reviewing compliance efforts. These safeguards help ensure that all other protections, like technical and physical security measures, work effectively to keep patient information safe.
Everyone in a healthcare practice shares responsibility for HIPAA compliance. However, the practice must designate specific individuals or teams to oversee and manage HIPAA policies, training, risk assessments, and incident responses. In large organizations, this might be a dedicated compliance officer or department, while in small practices, staff members often handle HIPAA duties alongside other roles. Clear assignment of responsibility helps ensure compliance is consistent and effective.