| Risk assessment |
§164.308(a)(1)(ii)(A)Accurate and thorough risk analysis |
CC3.2Identifies and analyzes risk to objectives |
12.3.1Targeted risk analysis per requirement |
Secure Score and Workspace security health as the recurring baseline |
| Multi-factor authentication |
§164.312(d)Person or entity authentication |
CC6.1Logical access security measures |
8.4.2MFA for all access into the CDE |
Conditional Access with FIDO2 passkeys / 2-Step Verification with security keys |
| Least privilege |
§164.308(a)(4)Information access management |
CC6.3Access added, modified and removed |
7.2.2Access by job function and least privilege |
Privileged Identity Management, just-in-time roles / delegated admin roles |
| Encryption in transit |
§164.312(e)(1)Transmission security |
CC6.7Transmission and movement of information |
4.2.1Strong cryptography over open networks |
Exchange Online TLS connectors / Gmail TLS compliance rules |
| Audit logging |
§164.312(b)Audit controls over ePHI systems |
CC7.2Monitoring for anomalies |
10.2.1Audit logs for all system components |
Purview Audit with extended retention / admin audit exported to BigQuery |
| Data loss prevention |
§164.312(c)(1)Integrity of ePHI |
CC6.7Restricts movement of information |
3.5.1PAN rendered unreadable wherever stored |
Purview DLP on PHI and PAN classifiers / Drive and Gmail DLP rules |
| Incident response |
§164.308(a)(6)Security incident procedures |
CC7.4Responds to identified security incidents |
12.10.1Incident response plan, tested annually |
Defender XDR incidents / Alert Center rules routed to an on-call owner |
| Third-party risk |
§164.308(b)(1)Business associate contracts |
CC9.2Assesses and manages vendor risk |
12.8.2Written agreements with service providers |
Enterprise app consent governance / API access control with an app allowlist |
| Backup and recovery |
§164.308(a)(7)(ii)(A)Data backup plan |
A1.2Recovery infrastructure, only if Availability is in scope |
—Not directly required by v4.0 |
Retention policies and litigation hold / Google Vault retention rules |
| Security awareness |
§164.308(a)(5)Training and periodic reminders |
CC1.4Competence of personnel |
12.6.3Training at hire and annually |
Attack simulation training / phishing reporting wired into the Alert Center |