How to Know If Your IT Is Really HIPAA Compliant: 6 Signs You’re at Risk
You can’t “wing it” with HIPAA compliance. Regulators, cyber insurers, and business partners all expect proof that your healthcare IT systems meet the HIPAA Security Rule not just verbal assurances or scattered tools.
This guide walks you through 6 key checkpoints to help you quickly determine whether your current IT setup is fully compliant or quietly exposing you to risk.
If you missed our deep dive on why HIPAA compliance is non-negotiable, read that first here. Then come back and use this checklist to assess your posture. You can also learn more about the HIPAA Security Rule on HHS.gov
1. You Haven’t Done a Documented Risk Assessment in the Last 12 Months
HIPAA requires a formal, documented Security Risk Analysis that identifies threats to electronic Protected Health Information (ePHI) and outlines mitigation steps.
If your last risk assessment is older than a year or never documented at all you’re already out of compliance.
2. You Can’t Prove That PHI Is Encrypted at Rest and in Transit
HIPAA doesn’t mandate encryption but if you don’t encrypt ePHI, you must prove why and what alternative safeguards are in place. That’s rarely a winnable argument in 2025.
Encryption is now the expected baseline for any healthcare system, device, or backup storing PHI.
3. You Don’t Have Audit Logs or Don’t Review Them
Who accessed what PHI, and when? If you can’t answer that or produce logs OCR may treat it as noncompliance.
Audit logging is required for access control, breach detection, and forensic investigation. It’s not optional.
4. You Don’t Have a Written, Tested Incident Response Plan
HIPAA requires more than reacting when something goes wrong. You need a documented and tested plan that outlines what your organization will do when a breach is suspected or confirmed.
A tabletop exercise with your IT team isn’t a luxury it’s a compliance requirement.
5. You Haven’t Signed BAAs with All IT and Cloud Vendors
Any vendor that handles, stores, or transmits PHI on your behalf must sign a Business Associate Agreement (BAA). That includes MSPs, MSSPs, cloud storage, EHR providers, and email systems.
If your vendors don’t have BAAs on file, your organization, not theirs, is on the hook.
Keywords: HIPAA BAA, healthcare IT vendor compliance
6. You Have the Tools, But Not the Documentation
Having MFA, antivirus, or backups in place is great. But compliance is about being able to show how they’re configured, what policies govern them, and when they were last tested.
HIPAA requires evidence, not effort.
Don’t Assume Compliance. Confirm It.
Healthcare leaders are often surprised to learn that their IT environment isn’t fully HIPAA compliant not because of bad technology, but because of missing documentation, planning, and process.
At Total Technology Resources, we help healthcare organizations bridge the gap between “secure enough” and provably compliant with support, structure, and simplicity.
Want to validate your compliance before an audit does?
Request a Cyber Security Risk Assessment and see where you stand. No jargon, no pressure.