Who Should Be the HIPAA Compliance Officer at a Startup?

The person does not necessarily need to be a full-time compliance professional. HHS gives a practical example: the privacy official at a small physician practice may be its office manager, who also handles other duties, while a large health plan may employ someone full-time. A small telehealth company can therefore consider people already on its team, provided the designated officials have enough authority, knowledge, and time to fulfill their responsibilities.

For most early telehealth startups, the most practical choice is the person who already manages vendors, staff access, and support workflows, usually the operations lead, as privacy official, with a technical lead or outside specialist covering the security role. The founder can fill the role while the team is very small, and the sections below show when each option works.

The Founder or CEO

The founder often understands how the entire company operates. They negotiate vendor agreements, approve budgets, oversee hiring, and decide on technology and patient acquisition.

For an early-stage business, that broad view can help connect privacy requirements to everyday operations.

• Works when: The organization is small, the founder already reviews vendor contracts, and there are relatively few employees, systems, and clinical workflows to oversee. Direct responsibility can make it easier to approve security investments and resolve compliance issues without waiting for another executive.
• Watch for: Founders also face pressure to launch products, acquire customers, and expand revenue. Those priorities can compete with the less visible work of updating policies, delivering employee training, investigating complaints, and reviewing how patient information moves between systems.

A founder may understand the business strategy without understanding every privacy or security requirement. Technical knowledge, regulatory interpretation, and incident response may still require specialized support.

Independence is also a practical question. When the same person approves aggressive marketing plans and evaluates their privacy implications, the company needs a process to recognize and escalate concerns rather than letting commercial urgency override them.

The founder can be a reasonable candidate, but the role should involve documented responsibilities and recurring work, not merely a name listed in a policy.

The Medical Director

The medical director may have the clearest understanding of how patient information moves through clinical care.

They know which records clinicians need, how treatment decisions are documented, where prescription information goes, and what happens when patients request access to their information.

That knowledge can be valuable when a telehealth organization is designing privacy policies around real clinical workflows.

• Works when: Most protected health information moves through clinical systems, and the medical director has meaningful operational authority. Their experience can help ensure that access policies and patient-record procedures reflect how care is actually delivered.
• Watch for: Clinical time is limited, particularly when the medical director is also seeing patients or supervising other professionals. Administrative tasks such as workforce training, vendor reviews, documentation, and complaints can become difficult to maintain alongside clinical responsibilities.

The organizational structure matters as well.

A branded telehealth business may work with an affiliated medical group rather than employing all clinicians directly. In that situation, the brand and medical group may have different legal responsibilities, and the founder should not assume that appointing the medical director satisfies every relevant entity's designation requirements.

That distinction also affects which officials each company must name. HHS lists Security Rule compliance among the requirements business associates must meet, so a brand that operates as a business associate still needs a security official. The Privacy Rule's administrative requirements for covered entities include designating a privacy official, which usually falls to the medical group when it is the covered entity. However, a business associate agreement can still assign brand-related privacy duties.

The parties should determine which organization is subject to which HIPAA obligations, with qualified legal guidance when necessary.

A medical director can provide valuable oversight even when someone else handles day-to-day privacy administration. The key question is whether the person in the role can implement and maintain the required policies.

The Operations Lead

For many small telehealth companies, an operations leader is a practical choice because much of the compliance work already falls within their responsibilities.

Operations teams commonly manage software subscriptions, employee onboarding, customer support procedures, access permissions, and communication with outside vendors.

Those responsibilities give an operations lead direct visibility into the systems and processes where privacy problems can develop.

• Works when: One person already manages vendors, employee access, and patient support workflows. The compliance role can build on existing operational processes, making it easier to maintain a current vendor inventory, coordinate training, and follow up when a security or privacy issue is reported.
• Watch for: Operational experience does not automatically provide the technical expertise needed for Security Rule responsibilities. Risk analysis, system configuration, cybersecurity controls, and security testing may require help from IT professionals or qualified external specialists.

The distinction between privacy administration and technical security oversight becomes important here.

An operations lead may be well positioned to track complaints and workforce training but needs support when evaluating encryption, access controls, system vulnerabilities, or security reports.

For example, reviewing SOC 2 documentation can support vendor due diligence, but interpreting a report and understanding its relevance to the company's risks requires appropriate knowledge.

The organization should establish a clear relationship between the person responsible for privacy and those implementing technical safeguards.

An operations leader does not have to perform every technical task personally. They do need an effective process to identify issues, assign work, and confirm that important actions are completed.

An Outside Consultant

A startup may not have anyone internally with substantial HIPAA experience.

Outside consultants can provide useful expertise when the company needs to establish policies, conduct a security risk analysis, evaluate existing processes, or prepare employees for their responsibilities.

This can be particularly helpful during launch, when a small team is setting up clinical and administrative operations at the same time.

• Works when: The company needs specialized guidance for work its employees have not previously performed. A consultant can translate regulatory requirements into practical procedures, review existing safeguards, or identify gaps internal teams have overlooked.
• Watch for: Hiring a consultant does not eliminate the organization's need to designate the right officials and remain responsible for its decisions. A consulting engagement can produce policies and recommendations, but someone within the operating structure still needs to ensure they are implemented and followed.

For example, a consultant might identify a weakness in employee access controls. The company must still decide who will fix it, approve the needed resources, and verify the issue is addressed.

The relationship should clearly identify deliverables, ongoing support expectations, and how employees will report privacy or security concerns after the initial engagement ends.

External expertise can strengthen a startup's compliance program, but a static policy document cannot replace active oversight of the systems and people handling patient information.

What a HIPAA Compliance Officer Owns

The role becomes easier to assign when the company separates its privacy responsibilities from its information security responsibilities.

According to HHS's Summary of the HIPAA Privacy Rule, covered entities must designate a privacy official to develop and implement their privacy policies and procedures.

The Privacy Rule also requires a designated contact person or office for complaints and information about privacy practices.

Privacy Responsibilities

The privacy official's work should connect written policies to the organization's actual activities.

Core responsibilities include coordinating:

• Written privacy policies and procedures governing protected health information
• Appropriate workforce training on privacy requirements
• Procedures for receiving and addressing privacy complaints
• Appropriate sanctions for workforce members who violate privacy policies
• Mitigation of harmful effects from improper uses or disclosures, where practicable
• Reasonable administrative, technical, and physical safeguards against improper use or disclosure of PHI
• Required documentation and retention of relevant records
• Procedures protecting individuals against retaliation for exercising their rights, and against being asked to waive those rights as a condition of treatment or coverage

HIPAA requires specified privacy documentation to be retained for six years after the later of its creation or last effective date. That is a documentation requirement, not a universal six-year retention period for every medical record.

An effective privacy official also needs visibility into what employees actually do. Policies covering patient communications should reflect the tools and channels staff use every day, including HIPAA-compliant email, patient portals, and support systems.

Security Responsibilities

The HIPAA Security Rule separately requires designation of a security official responsible for developing and implementing the Security Rule's policies and procedures.

Security responsibilities include coordinating an accurate and thorough assessment of risks to electronic protected health information, managing identified risks, and overseeing relevant safeguards.

The work also includes workforce security training, procedures for identifying and responding to security incidents, periodic evaluations, and reviews to ensure technical and organizational safeguards remain appropriate.

The organization's risk analysis should change when new technology, vendors, or operations introduce meaningful new risks.

Vendor Oversight and Daily Operations

Designated officials need a usable inventory of external services involved in handling protected information.

This includes clinical platforms, billing tools, messaging systems, any CRM that stores patient data, and other services that handle PHI on the organization's behalf. The inventory should identify what information each vendor handles, the relevant contractual arrangements, and who is responsible for reviewing its security and privacy practices.

The goal is to assign responsibility for actual work. Someone should know who reviews new vendors, approves employee access, handles complaints, coordinates incidents, and confirms that required documentation is maintained.

When Part-Time Stops Working

HIPAA does not prescribe one staffing level for every healthcare organization. HHS describes the Security Rule as scalable, with safeguards influenced by an organization's size, complexity, capabilities, and risks.

A part-time compliance assignment can therefore work for a small operation, provided the work is completed effectively. As the business grows, however, the amount and complexity of oversight can change.

Training becomes difficult to maintain. New employees join more often, existing workers change responsibilities, and the person responsible for compliance struggles to keep training and policy acknowledgments up to date. When training depends on finding spare time between unrelated duties, gaps can become harder to notice.

Vendor reviews fall behind. New software, messaging services, or outside partners begin handling patient information faster than anyone can evaluate their role and safeguards. The organization may need more dedicated capacity to maintain a reliable inventory and review process.

Complaints and incidents demand regular attention. A growing volume of patient privacy complaints, access questions, or security incidents creates work that cannot always be handled between other priorities. Investigations, documentation, mitigation, and follow-up require clear ownership and sufficient time.

The business expands into new states or service lines. Additional clinical partners, new treatment programs, different patient populations, and more complicated workflows can change the organization's privacy and security risk profile. The designated officials need enough capacity to evaluate those changes before the operational environment moves beyond their oversight.

Proposed Security Rule changes add recurring work. HHS's proposed Security Rule update would require, among other things, a written risk analysis, a technology asset inventory and network map updated at least once every 12 months, and a compliance audit at least once every 12 months. Business associates would also have to verify to their covered entities, at least once a year, that required technical safeguards are in place. The rule has not been finalized, and the federal regulatory agenda now lists July 2027 as the target date. Still, each task needs an owner and a schedule, which is harder to guarantee when compliance takes up only a small part of someone's week.

FAQs

What Is the Difference Between a Privacy Officer and a Security Officer?

The Privacy Rule requires a privacy official responsible for developing and implementing privacy policies and procedures. The Security Rule separately requires a security official responsible for its required security policies and procedures.

Privacy responsibilities focus on the appropriate use and disclosure of protected health information and patients' privacy rights. Security responsibilities focus on protecting electronic protected health information through administrative, physical, and technical safeguards.

Can One Person Be the Privacy Official and the Security Official?

Yes. The Privacy Rule and the Security Rule each require a designated official, but neither requires two different people. A small telehealth company can assign both roles to one person, provided that person can get technical help with risk analysis and security controls.

Does a HIPAA Compliance Officer Need a Certification?

The HHS Privacy Rule and Security Rule summaries require the designation of responsible officials but do not specify a professional certification for those positions.

Instead, the organization should evaluate whether its designated officials have the knowledge, authority, resources, and support needed to perform their required responsibilities.

Can the Office Manager Be the Privacy Officer?

Yes. HHS explicitly identifies the office manager at a small physician practice as an example of someone who may serve as the privacy official while also performing unrelated administrative duties.

The arrangement should still give the individual sufficient time and authority to develop, implement, and maintain the organization's applicable privacy policies and procedures.

References

1. U.S. Department of Health and Human Services. (n.d.). Summary of the HIPAA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
2. U.S. Department of Health and Human Services. (n.d.). Summary of the HIPAA Security Rule. https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html
3. U.S. Department of Health and Human Services. (n.d.). Standards for privacy of individually identifiable health information. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/standards-privacy-individually-identifiable-health-information/index.html