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January 26, 2026
Complex HIPAA compliance questions answered clearly for small healthcare practices in Illinois and Indiana.
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Here’s what most compliance guides won’t tell you: you don’t necessarily need to hire a dedicated compliance officer. The confusion comes from how HIPAA actually structures these requirements.
HIPAA requires you to designate both a Privacy Officer and a Security Officer. But here’s the key—in smaller organizations, the same person can wear both hats. You can assign these roles to an existing employee, like your practice manager or administrator, rather than creating an entirely new position.
The real question isn’t whether you need someone in this role—you absolutely do. The question is how to make it work with your current team and budget.
Your practice manager can absolutely serve as your HIPAA compliance officer, and this arrangement works well for most small practices. The role requires someone with organizational authority who can implement policies, conduct training, and handle patient complaints about privacy issues.
What matters most is that this person has the time and authority to actually fulfill the responsibilities. They need to stay current on HIPAA updates, coordinate risk assessments, and ensure your team follows established procedures. If your practice manager is already stretched thin, you might need to redistribute some of their other duties or consider outsourcing compliance support.
The compliance officer role isn’t about having a specific degree or certification—it’s about having someone who can manage the ongoing requirements systematically. Your practice manager likely already handles similar organizational responsibilities, making them a natural fit for overseeing compliance activities.
Many successful small practices operate this way. The key is providing adequate training and support so your designated officer feels confident handling compliance questions and situations as they arise. You might also want to establish a relationship with a compliance consultant for complex situations or annual reviews.
Outsourcing your compliance officer duties can make sense, especially during the initial setup phase or if your internal team lacks the bandwidth to handle ongoing requirements. Many small practices start with outsourced support to get their compliance program established, then transition to internal management once everything is running smoothly.
The decision often comes down to cost and complexity. If you’re a solo practice or small clinic with straightforward operations, an internal appointment usually works fine once you have proper training and systems in place. Larger practices or those with complex workflows might benefit from ongoing external expertise.
Consider outsourcing if you’re facing an immediate compliance deadline, dealing with a potential violation, or implementing major system changes. External experts can accelerate your timeline and help avoid costly mistakes during critical periods.
However, don’t assume outsourcing means you can completely hands-off compliance management. You still need internal coordination and someone who understands your daily operations well enough to implement policies effectively. The best approach often combines external expertise for complex issues with internal management for day-to-day compliance activities.
Think of it this way: you can outsource the expertise, but you can’t outsource the responsibility. Someone in your organization needs to own the relationship with external consultants and ensure recommendations actually get implemented in your workflow.
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The “at least annually” guidance you see everywhere is just the starting point. Your actual risk assessment schedule depends on what’s happening in your practice and how your technology environment changes throughout the year.
Yes, you need a comprehensive annual assessment. But you also need to conduct targeted assessments whenever you make significant changes—new software, different workflows, staff changes, or after any security incident. These aren’t necessarily full-scale reviews, but they should address how changes affect your overall risk profile.
Certain changes in your practice environment automatically trigger the need for updated risk assessments. Installing a new electronic health records system is an obvious example, but smaller changes can also create new vulnerabilities that need evaluation.
Staff changes, especially in roles that handle patient information, should prompt a review of access controls and training needs. Moving to a new location, adding telehealth services, or changing business associate relationships all introduce new risk factors that your annual assessment might not have anticipated.
Security incidents—even minor ones that don’t rise to the level of reportable breaches—provide valuable opportunities to reassess your safeguards. If an employee accidentally emails patient information to the wrong recipient, that incident should trigger a review of your email policies and training procedures.
The goal isn’t to conduct a full-scale assessment every time something changes. Instead, you’re evaluating whether the change introduces new risks that require additional safeguards or policy updates. Document these evaluations as part of your ongoing compliance efforts.
Technology changes deserve special attention because they often affect multiple aspects of your security posture simultaneously. Cloud migrations, software updates, or new device deployments can all create unexpected vulnerabilities if not properly evaluated beforehand.
Documentation doesn’t have to be overwhelming if you approach it systematically. The key is creating templates and processes that make ongoing assessments manageable rather than dreading them as major undertakings.
Start with a simple risk register that tracks identified vulnerabilities, assigned risk levels, and remediation plans. Update this document throughout the year rather than starting from scratch each time. When you conduct your annual comprehensive review, you’re updating and expanding existing documentation rather than creating entirely new materials.
Use your practice management software or a simple spreadsheet to track assessment activities. Include dates, scope, findings, and follow-up actions. This ongoing record demonstrates your commitment to regular evaluation and provides valuable context for future assessments.
Many small practices benefit from quarterly “mini-assessments” that focus on specific areas—physical security one quarter, technical safeguards the next. This approach spreads the workload throughout the year and ensures nothing gets overlooked during your annual comprehensive review.
Remember that your risk assessment documentation serves multiple purposes. It helps you identify and address vulnerabilities, demonstrates compliance efforts to auditors, and provides a roadmap for continuous improvement. Keep it practical and actionable rather than trying to create perfect documentation that no one actually uses.
Consider using the free HHS Security Risk Assessment tool as your starting framework. It provides structure and guidance while allowing you to customize the approach for your specific practice needs.
HIPAA compliance doesn’t have to feel like an impossible puzzle when you focus on the fundamentals that actually matter for your practice size and complexity. You now understand that compliance officer roles can be handled by existing staff, risk assessments need regular attention beyond annual requirements, and the minimum necessary rule requires thoughtful implementation rather than guesswork.
The key is building systems that work with your current operations rather than against them. Start with proper documentation, establish clear procedures, and ensure your team understands their responsibilities. Most importantly, don’t let perfect become the enemy of good—consistent, documented efforts toward compliance serve you far better than paralysis over complex requirements.
If you’re ready to implement a compliance program that actually fits your practice, we can help you navigate these requirements with practical, cost-effective solutions designed specifically for small healthcare practices in Illinois and Indiana.
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