A Guide to HIPAA-Compliant Workstation Use Policies for Your Staff (45 CFR § 164.310(b))

Executive Summary

For small medical practices, computers and workstations are a daily necessity, but they also present a major risk under HIPAA if used improperly. Section § 164.310(b) of the HIPAA Security Rule mandates that covered entities implement policies and procedures that govern the proper use of workstations to prevent unauthorized access to electronic protected health information (ePHI). This guide breaks down how to create effective, enforceable workstation use policies that protect patient data and ensure compliance without disrupting your daily operations.

Introduction

A workstation is more than a desktop computer, it can be a laptop, tablet, or any device used to access patient records or health systems. Because these devices can be easily exposed to unauthorized access, HIPAA requires covered entities to implement safeguards that control their use.

Under § 164.310(b), small practices must develop formal “workstation use policies” that specify how and when workstations can be used, by whom, and under what physical and operational conditions.

Failing to develop or enforce such policies leaves patient information vulnerable and exposes your practice to penalties in the event of a data breach or audit.

What does § 164.310(b) Require?

The workstation use standard is one of the Physical Safeguards within the HIPAA Security Rule. It requires covered entities and business associates to:

“Implement policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access electronic protected health information.”

In practical terms, this means your practice must decide and document:

• What your staff can do on workstations (e.g., no personal browsing, no removable media)
• When workstations may be used (e.g., during clinic hours, by scheduled staff)
• Where workstations are located (e.g., not in public or patient-facing areas)
• Who may access them (e.g., credentialed staff only, using unique logins)

Why Workstation Use Policies Matter

• Minimizes insider threats: Many data breaches stem from careless employee behavior, not hackers.
• Controls physical access: Ensures workstations are positioned and secured to prevent “shoulder surfing” or unauthorized use.
• Supports audit readiness: A documented policy helps demonstrate HIPAA compliance during an investigation.
• Protects from fines: Enforcement actions often cite poor workstation security as a failure of the Security Rule.

A Case Study: Improper Workstation Use Triggers OCR Settlement

In 2022, a dermatology clinic located in the Northeastern United States agreed to pay a $25,000 civil monetary penalty following a HIPAA audit that uncovered serious security violations related to workstation use. The issue came to light after a patient submitted a complaint stating they had seen another patient’s private health information displayed on a computer screen while passing through a hallway.

An investigation by the Office for Civil Rights (OCR) revealed that the clinic had placed an active workstation in a semi-public corridor. The terminal remained logged in under a shared staff account throughout the day and was routinely used to access sensitive information such as patient records, prescriptions, and insurance details. Multiple staff members used the workstation without any controls over who accessed it or what was viewed.

OCR determined that the clinic had failed to implement basic safeguards, including a workstation use policy, access restrictions, and physical security measures to protect electronic protected health information (ePHI). These deficiencies violated the HIPAA Security Rule’s requirements for access control and workstation security.

In addition to the financial penalty, the clinic was placed under a two-year corrective action plan (CAP). The CAP required comprehensive staff retraining, the development and enforcement of written workstation use procedures, and regular reporting to OCR. This case highlights the importance of securing all points of access to patient data, even within your own facility.

Key Elements of a HIPAA-Compliant Workstation Use Policy

1. Define What Constitutes a Workstation

Start by identifying all devices in your practice that fall under the workstation definition:

• Desktop computers
• Laptops
• Tablets used for documentation or patient intake
• Any internet-connected terminal accessing ePHI

Be clear in your policy that these devices must follow the same security standards, regardless of whether they are fixed or mobile.

2. Specify Permitted Functions

Your policy should state what activities are allowed on workstations used to access ePHI:

• Accessing and updating EHR
• Sending secure messages
• Billing and insurance verification
• Scheduling and patient communication via approved channels

You should also prohibit:

• Personal internet use
• Downloading unauthorized apps
• Connecting external storage devices (USBs)
• Accessing social media platforms unless medically relevant

3. Control Physical Placement and Access

• Positioning screens away from public view
• Using privacy filters for terminals in patient-accessible areas
• Requiring badge access or locked rooms for certain terminals
• Automatically logging off workstations after inactivity

4. Assign Individual Accountability

• Unique login credentials for each user
• Time-limited sessions with auto-logout
• Logging out when stepping away from the device
• Prohibiting the sharing of usernames or passwords

5. Set Time and Usage Limits

• Authorized hours (e.g., business hours or authorized after-hours access)
• Authorized personnel only (e.g., no family or non-medical staff use)
• Specific network connections (e.g., disallow public Wi-Fi access)

6. Clarify Remote Use Rules

• Secure VPN connections
• Approved devices only
• No use of shared home computers
• Screen-locking and timeout settings

Common Pitfalls in Workstation Security

• Using shared logins or generic usernames (e.g., "frontdesk1")
• Allowing terminals in patient-accessible areas without physical safeguards
• Failing to log off devices during breaks or between users
• Not updating policies as devices or workflows change
• Assuming vendors or IT staff manage all risks without internal oversight

Expert Tips for Small Practice Implementation

• Conduct a walkthrough audit to assess workstation locations and visibility
• Use simple checklists to verify each terminal’s compliance
• Include workstation use policies in employee onboarding and annual training
• Use technical controls like screen savers, inactivity timeouts, and access logs
• Document all corrective actions taken in response to violations or complaints

Workstation Use Compliance Checklist (§ 164.310(b))

Regulatory References and Official Guidance

• 45 CFR § 164.310(b) – Workstation Use policy requirement
• HHS Security Rule Guidance Material
• NIST SP 800-66 Rev. 1 – HIPAA Security Rule Implementation Guide
• OCR Case Examples and Resolution Agreements

Concluding Recommendations and Next Steps

A strong, practical workstation use policy is more than a regulatory checkbox, it’s a frontline defense against data breaches, insider threats, and patient complaints. Small practices often overlook this requirement, assuming basic password protection is enough.

• Identify all workstations accessing ePHI
• Define clear usage rules and technical safeguards
• Train staff regularly on secure workstation behavior
• Monitor for compliance and correct violations quickly

When your entire team understands and follows appropriate workstation protocols, your patient data and your practice’s HIPAA standing are significantly more secure.