HIPAA Compliance for Recovery Coach

This skill helps you maintain HIPAA compliance when developing features that handle Protected Health Information (PHI).

DECISION POINTS

PHI Classification Decision Tree

Is this user data?
├─ NO → No HIPAA requirements, proceed normally
└─ YES → Is it health-related or personally identifiable?
   ├─ NO (aggregated analytics, page views) → No audit logging needed
   └─ YES → PHI detected, proceed to access type:
      ├─ READ access → Use logPHIAccess() + authentication check
      ├─ WRITE/UPDATE → Use logPHIModification() + change tracking
      ├─ DELETE → Use logPHIModification() + soft delete preferred
      └─ EXPORT → Use logAdminAction() + encryption required

Ambiguous Data Classification

Data Type	PHI Status	Decision Rule
Check-in mood/cravings	PHI	Always audit - health condition
Journal entries	PHI	Always audit - personal health notes
Chat messages	PHI	Always audit - health discussions
User profile (name/email)	PHI	Audit modifications only
Sobriety date	PHI	Always audit - health milestone
Usage patterns (timing)	Depends	If linkable to individual → PHI
Error logs with userIds	PHI	If contains health context → PHI

Logging Performance Decision Tree

Is this a high-frequency operation (>100/min)?
├─ NO → Use synchronous audit logging
└─ YES → Performance consideration needed:
   ├─ Critical PHI access → Async logging with failure retry
   ├─ Bulk operations → Batch logging every 100 records
   └─ Analytics tracking → Sample logging (1 in 10)

FAILURE MODES

Anti-Pattern: Audit Log Gaps

Symptoms: Missing entries in audit trail, incomplete access records Detection: if (auditLog.count < actualOperations.count) Fix: Add try-catch around all PHI operations, implement audit middleware

Anti-Pattern: PHI Content Leakage

Symptoms: Actual health data appears in logs or error messages Detection: if (logEntry.includes(personalHealthInfo)) Fix: Use sanitization middleware, audit log reviews, content redaction

Anti-Pattern: Session Hijacking Vulnerability

Symptoms: Users accessing data without recent authentication Detection: if (timeSinceLastAuth > 15_MINUTES && accessingPHI) Fix: Force re-authentication for PHI access, implement session timeouts

Anti-Pattern: Break Glass Abuse

Symptoms: Emergency access used for non-emergencies Detection: if (breakGlassUsage.frequency > normalPatterns) Fix: Require written justification, automated compliance officer alerts

Anti-Pattern: Encryption At Rest Failures

Symptoms: PHI stored in plaintext, backup files unencrypted Detection: if (database.encryption === false && containsPHI) Fix: Enable database encryption, encrypt export files, audit storage

WORKED EXAMPLES

Scenario: Building Chat History Viewer with Performance Trade-offs

Context: User wants to view 6 months of chat history (1000+ messages).

Step 1 - PHI Classification:

// Decision: Chat messages contain health discussions → PHI
const messageType = 'chat';
const isPHI = true; // Health-related conversations

Step 2 - Performance vs Compliance Trade-off:

// OPTION A: Real-time logging (high latency)
messages.forEach(async (msg) => {
  await logPHIAccess(userId, 'chat', msg.id, AuditAction.PHI_VIEW);
});

// OPTION B: Batch logging (chosen solution)
const batchSize = 100;
const messageChunks = chunk(messages, batchSize);

for (const chunk of messageChunks) {
  await logBatchPHIAccess(
    userId, 
    'chat_bulk', 
    chunk.map(m => m.id),
    AuditAction.PHI_VIEW,
    { messageCount: chunk.length }
  );
}

Expert vs Novice:

• Novice miss: Would log each message individually, causing 5+ second load times
• Expert catch: Batch logging maintains compliance while preserving UX, includes metadata count for audit completeness

Step 3 - Implementation:

export async function getChatHistory(userId: string) {
  const session = await requireAuth();
  
  // Performance: Paginated fetch
  const messages = await db.messages.findMany({
    where: { userId },
    orderBy: { createdAt: 'desc' },
    take: 100 // First page only
  });
  
  // Compliance: Batch audit log
  await logBatchPHIAccess(
    session.userId,
    'chat_history',
    messages.map(m => m.id),
    AuditAction.PHI_VIEW,
    { 
      pageSize: messages.length,
      totalRequested: '6_months',
      loadTime: performance.now()
    }
  );
  
  return messages;
}

QUALITY GATES

Before deploying any PHI-related feature:

• All PHI read operations have corresponding audit log entries
• All PHI write operations include change metadata (never actual content)
• Authentication check exists before any PHI access
• Session timeout enforcement is active (15 min for PHI routes)
• Error handling never exposes PHI in error messages
• Database queries use parameterized statements (SQL injection prevention)
• PHI export features create audit trail entries
• Failed access attempts trigger security event logs
• Break glass access requires written justification
• All audit logs exclude actual PHI content (IDs and metadata only)

NOT-FOR BOUNDARIES

Do NOT use this skill for:

• Non-health applications → For general privacy compliance, use [gdpr-compliance] skill instead
• Financial data protection → For PCI DSS compliance, use [financial-security] skill instead
• Internal analytics → For usage tracking without PHI, use [analytics-privacy] skill instead
• API rate limiting → For general security, use [api-security] skill instead
• Database design → For schema design, use [data-modeling] skill instead

When to delegate:

• If handling payment data: Use [pci-compliance] skill
• If building authentication: Use [auth-security] skill
• If designing data retention: Use [data-lifecycle] skill
• If incident response needed: Use [security-incident] skill