Quick Answer: A MIPS security risk analysis (SRA) is a required measure under the Promoting Interoperability (PI) category of the Merit-based Incentive Payment System. It’s ONE measure within PI—not all of MIPS—but failing to complete it results in a zero PI score and potential Medicare payment reductions of up to 9%. The SRA must follow HIPAA Security Rule standards and document your practice’s risk assessment process.

MIPS Security Risk Analysis: Complete Guide for Providers

If you’re a provider or practice manager managing Medicare billing, you’ve heard of MIPS and the Security Risk Analysis requirement. The compliance language is dense, and the consequences feel abstract—until you realize that failing one measure can cost your practice 9% of Medicare reimbursement. That’s not theoretical; that’s real revenue loss.

The confusion starts here: MIPS is complex, with four different scoring categories. Many providers mistakenly believe that completing a security risk analysis satisfies MIPS entirely. It doesn’t. The SRA is ONE measure within ONE category (Promoting Interoperability), and while it’s critical, it’s only part of the picture. But here’s the truth that keeps compliance leaders up at night: failing the SRA = zero points in PI = automatic Medicare payment reduction. That’s why understanding exactly what the SRA is, what CMS requires, and how to complete it correctly matters for your bottom line.

This guide clarifies where the SRA fits in MIPS, what CMS auditors actually look for, the 2026 requirement updates, and the step-by-step process to complete a defensible SRA. Medcurity helps practices meet MIPS SRA requirements with guided risk assessments and compliance documentation that stands up to CMS audit.

Understanding MIPS and Where SRA Fits

MIPS—the Merit-based Incentive Payment System—is Medicare’s quality and value measurement program for clinicians and practices. It was created under MACRA (the Medicare Access and CHIP Reauthorization Act) in 2015 and affects clinicians with $937,500+ in Medicare billing or 200+ Medicare patients annually.

Here’s what many providers miss: MIPS isn’t one metric. It’s four metrics, weighted differently, and you must succeed in all of them to avoid payment adjustments. Failing in one category costs you points and money. Failing the SRA specifically means zero points in an entire category.

The MIPS score is calculated across four categories:

MIPS Category Weight SRA Role
Quality 30% No direct role; separate clinical measures
Cost 30% No direct role; calculated by CMS
Promoting Interoperability (PI) 25% SRA is ONE required measure within PI
Improvement Activities (IA) 15% No direct role; separate improvement initiatives

This is critical: The Promoting Interoperability category is worth 25% of your total MIPS score. Within PI, the security risk analysis is one of several required measures (others include e-prescribing, health information exchange, and healthcare system interoperability). The SRA doesn’t carry the entire 25% weight—but failing it means you get zero points in the entire PI category. That zero in PI immediately reduces your total MIPS score by up to 25 percentage points, which translates to a potential Medicare payment adjustment of up to 9%.

Let’s put that in dollars. For a small practice with $2 million in annual Medicare revenue, a 9% adjustment equals $180,000. For a larger practice with $5 million, it’s $450,000. That’s not a compliance nice-to-have; it’s a financial emergency.

The SRA requirement under MIPS comes from the Promoting Interoperability definition: clinicians must document that they’ve conducted a security risk analysis aligned with HIPAA Security Rule standards. CMS uses “security risk analysis” and “SRA” interchangeably with what healthcare calls a “risk assessment” or “formal risk evaluation.”

What Counts as a Valid SRA for MIPS

Not every document called an “SRA” meets CMS MIPS requirements. This is where many practices fail audit. CMS is specific about what constitutes a valid security risk analysis:

It must follow HIPAA Security Rule standards. Your SRA cannot be a simple checklist or a self-assessment questionnaire. It must be a formal, documented risk assessment that follows HIPAA Security Rule Section 164.308(a)(1)(ii)(A), which requires you to identify ePHI, evaluate risks and vulnerabilities to that ePHI, and document the results. CMS auditors compare your SRA against the HIPAA Security Rule framework.

It must document your current security posture. The SRA must identify all systems and processes that create, receive, maintain, or transmit electronic protected health information (ePHI). For most practices, this includes the EHR, billing system, patient portal, email systems, mobile devices, and cloud storage. Your SRA must describe how each system handles ePHI and what security controls currently exist (or don’t exist).

It must identify vulnerabilities and threats. A valid SRA doesn’t just list what you have; it evaluates what could go wrong. It identifies vulnerabilities (gaps in security controls, outdated software, lack of encryption, weak passwords) and threats (unauthorized access, malware, natural disasters, insider threats). The analysis must be specific to your practice, not generic.

It must quantify risk. Vulnerabilities + threats = risk. A valid SRA evaluates the likelihood and impact of each identified vulnerability. Which vulnerabilities pose the highest risk to your practice? What could a breach cost in liability, notification expenses, and regulatory fines? The SRA must rank risks and explain your reasoning.

It must include a remediation roadmap. The SRA doesn’t just identify problems; it charts solutions. For each identified vulnerability, the SRA must recommend controls (encryption, MFA, access restrictions, software patches, training) and a timeline for implementation. CMS wants to see that you know what’s wrong and have a plan to fix it.

It must be documented and signed. CMS requires the SRA to be a formal written document, typically signed by a practice leader (provider, compliance officer, IT director) or an external qualified assessor. The document must be dated and retained for audit. A verbal assessment or informal notes don’t count.

It cannot be a simple checklist or questionnaire. Many EHR vendors and compliance companies provide “security assessment” checklists with questions like “Do you use passwords?” or “Is your EHR encrypted?” Checking boxes doesn’t satisfy HIPAA or CMS. These checklists are a starting point, but a valid SRA requires depth: documentation of your specific systems, specific vulnerabilities, specific risks, and specific remediation steps.

Red flag: If your SRA is fewer than 10-15 pages of substantive analysis (not counting appendices), it’s probably too shallow for CMS. A valid SRA for even a small practice typically runs 20-40 pages, depending on complexity.

2026 SRA Requirement Updates

The SRA requirement is evolving. CMS and HHS have announced changes effective in 2026 that will reshape how practices approach security risk analysis:

Risk management attestation becomes mandatory. Starting in 2026, the Promoting Interoperability measure requires not just that you conduct an SRA, but that you attest to CMS that you’ve completed it and documented a risk management plan. The attestation is part of your annual MIPS submission. This means your SRA must be finalized, documented, and available for review before you submit your MIPS data—no late completions.

SAFER Guides alignment. CMS has endorsed the HHS SAFER (Security Awareness and Security Fundamentals Engagement and Resources) Guides as the framework for conducting security risk assessments. The updated MIPS guidance (2026 onward) references SAFER Guides explicitly. This means your SRA should follow SAFER Guides methodology: identifying ePHI, mapping information flows, evaluating existing security controls, and documenting risk mitigation steps. If you’ve been using a proprietary or generic SRA template, you may need to update it to align with SAFER.

HIPAA Security Rule 2024/2026 updates context. The final HIPAA Security Rule amendments (published in May 2024, effective compliance in 2026) shift several controls from “addressable” to “required”—meaning they’re no longer optional. Key changes: encryption for ePHI in transit and at rest is now mandatory (not addressable), multi-factor authentication for remote access is mandatory, and vulnerability scanning is mandatory. Your 2026 SRA must reflect these updated requirements. If your 2024 SRA documented that encryption was “not applicable to your practice,” your 2026 SRA must explain how you’ll implement mandatory encryption by the 2026 deadline.

Third-party vendor assessment becomes more detailed. CMS has tightened requirements around Business Associate management. Your 2026 SRA must document that you’ve assessed vendor risk, confirmed that vendors have appropriate security controls, and have signed Business Associate Agreements (BAAs) that require HIPAA compliance. Many practices have sloppy vendor documentation; 2026 SRA audits will flag this.

Mobile device management and remote work. The rise of remote work and mobile device usage means your SRA must address how clinicians securely access ePHI from home, on mobile phones, and on personal devices. If your 2024 SRA didn’t thoroughly address mobile device security or remote access, your 2026 update must.

For practices that completed an SRA in 2023 or 2024, this doesn’t mean you start over—but you do need to review your existing SRA against 2026 requirements and document any gaps or changes in your 2026 update.

Step-by-Step SRA Completion Process

A complete SRA follows a structured methodology. Here are the four phases and approximately 12 core steps:

Phase 1: Preparation and Scope Definition (Weeks 1-2)

Step 1: Identify and document all ePHI locations. Map every system, database, file storage location, and paper storage area where patient data exists. This includes the EHR, practice management system, billing software, patient portal, email, mobile devices, cloud storage, USB drives, external hard drives, and paper charts. For each location, document the type of data (demographics, diagnoses, lab results, etc.), the number of patients, and the access restrictions that should exist.

Step 2: Identify information flows and access points. Document how ePHI moves through your practice. A patient calls to schedule an appointment (ePHI enters your system). The scheduler accesses the EHR and books the visit. The EHR is accessed by physicians, nurses, billing staff, and vendors. Data flows from the EHR to the billing system, to insurance companies, to the patient portal, to email, and to cloud backup. For each flow, identify who has access, how the data is transmitted (encrypted? unencrypted?), and what could go wrong.

Step 3: Assemble the SRA team and define roles. SRA development requires input from clinical staff, IT, billing, front office, and leadership. Define who leads the SRA (often compliance officer or IT director), who gathers information from each department, and who approves the final document. Set a timeline: a thorough SRA typically takes 4-8 weeks of part-time work, or 1-2 weeks of full-time focused effort.

Phase 2: Assessment and Documentation (Weeks 3-6)

Step 4: Document current security controls. For each ePHI location and information flow, document what security measures currently exist. Does your EHR have access controls by user role? Is data encrypted in transit (HTTPS)? Is data encrypted at rest? Who can access the backup server? Is there audit logging? Are devices password-protected? Are remote access tools (VPN, RDP) used, and do they require MFA? Document what’s in place—and what’s missing.

Step 5: Identify vulnerabilities and threats. Vulnerabilities are gaps in security controls. Threats are potential bad actors or events that could exploit those gaps. For example: vulnerability—your EHR doesn’t require complex passwords. Threat—a disgruntled employee could guess a colleague’s password. Vulnerability—backup files aren’t encrypted. Threat—a backup tape could be stolen from off-site storage. Vulnerability—vendors have access to production EHR data but don’t have data security agreements. Threat—a vendor could be hacked, exposing your data. Document 20-50+ vulnerabilities specific to your practice and the threats that could exploit them.

Step 6: Evaluate risk likelihood and impact. For each vulnerability-threat pair, assess the likelihood (low, medium, high) and the business impact if a breach occurred. Which vulnerabilities are most likely to be exploited? Which would cause the most damage if exploited? Create a risk matrix (likelihood vs. impact) and rank vulnerabilities by overall risk. Focus your remediation roadmap on high-risk items.

Step 7: Conduct staff interviews and input gathering. Talk to physicians, clinical staff, billing staff, and IT about how they use ePHI, what security challenges they face, and what controls they believe are in place. Staff interviews often reveal undocumented vulnerabilities (unauthorized access, shared passwords, lack of training, confusion about access restrictions). Document what you learn, even if it’s uncomfortable.

Phase 3: Gap Analysis and Remediation Planning (Weeks 7-8)

Step 8: Compare current state against HIPAA Security Rule and SAFER Guides. The HIPAA Security Rule requires 18 administrative safeguards, 12 technical safeguards, and 3 physical safeguards (36 controls total across addressable and required). For each control, assess whether you’ve implemented it. Where are the gaps? Are encryption, MFA, access controls, audit logging, and workforce training in place? Use the HIPAA Security Rule checklist or SAFER Guides to structure this assessment.

Step 9: Develop remediation recommendations and timeline. For each identified vulnerability and control gap, recommend a specific remediation: “Implement MFA for all remote EHR access by Q3 2026,” or “Encrypt all backup files within 60 days,” or “Establish vendor risk assessment process and update all Business Associate Agreements within 90 days.” Include estimated cost and resource requirements. Prioritize high-risk items and quick wins (items you can address in 30-90 days).

Phase 4: Documentation and Approval (Week 9)

Step 10: Write the formal SRA report. Compile your findings into a professional, dated document. Structure: executive summary, methodology, current-state assessment (systems, data flows, existing controls), identified vulnerabilities and threats, risk analysis (likelihood, impact, overall risk ranking), remediation roadmap (recommendations, timelines, cost), and appendices (HIPAA Security Rule checklist, detailed control inventory, staff interview summary). The report should be 25-40 pages for a typical practice.

Step 11: Review and approve the SRA. Have the document reviewed by your compliance officer, IT leadership, and practice leadership. Get formal approval and signature from the practice owner or designated leadership representative. This signals that leadership has reviewed the SRA and committed to the remediation roadmap. Date the document.

Step 12: Implement remediation and conduct annual updates. Don’t let your SRA sit on a shelf. Use it as a working document. Track remediation progress monthly. When you implement a control (encryption, MFA, new access restriction), document it and update the SRA. Conduct an annual SRA update (reviewing what’s changed, what’s been remediated, what new vulnerabilities have emerged). By the time CMS audits, you should have documented evidence that you’ve made progress on your remediation roadmap.

Total effort: 4-8 weeks part-time, or 1-2 weeks full-time for a small to mid-size practice. Practices with complex IT infrastructure or significant vulnerabilities may take longer.

Common SRA Audit Failures and How to Avoid Them

CMS auditors have reviewed thousands of SRAs from MIPS-obligated providers. Here are the most common failures they find—and how to avoid them:

Failure #1: The SRA is too generic or templated. Auditors immediately spot SRAs that are clearly copy-paste templates with no practice-specific details. A generic SRA talks about “EHR systems” and “network security” in abstract terms. A valid SRA identifies YOUR specific EHR (Epic, Cerner, eClinicalWorks), YOUR specific network architecture, YOUR specific vulnerabilities. If your SRA could apply to any practice in America, it won’t pass audit. To avoid: customize every section with your practice’s actual systems, configurations, staffing, and vulnerabilities.

Failure #2: The SRA lacks depth on specific vulnerabilities. Auditors expect to see detailed vulnerability documentation—not a checklist. Instead of “EHR access controls need improvement,” auditors want: “Eight staff members (50% of total) have EHR access to all patient records regardless of job function. Clinicians can access records outside their patients, which violates role-based access control requirements. Audit logs are not enabled for EHR access.” Depth matters. To avoid: interview staff, review logs and configurations, and document specific, measurable findings.

Failure #3: The remediation roadmap is vague or missing. Some SRAs identify vulnerabilities but don’t propose concrete fixes or timelines. Auditors want to see: vulnerability identified, recommended control, specific implementation steps, responsible party, timeline, and estimated cost. “We will improve security” isn’t a remediation plan. “We will implement MFA for remote EHR access using [specific vendor], configure it by [date], and train all remote users by [date]” is. To avoid: for each vulnerability, spell out exactly what you’ll do, who will do it, when, and what it costs.

Failure #4: The SRA doesn’t align with HIPAA Security Rule. Auditors compare your SRA against HIPAA requirements. If your SRA doesn’t reference HIPAA or address all 36 HIPAA safeguards (administrative, technical, physical), it looks incomplete. To avoid: use HIPAA Security Rule Section 164.308, 164.309, and 164.310 as your framework. Address each requirement explicitly in your SRA. Include a HIPAA Security Rule checklist as an appendix.

Failure #5: No evidence of implementation or progress. An SRA is dated, let’s say January 2024. An auditor reviews it in March 2025 and asks: what’s been done since? If you can’t point to implemented controls, staff training, vendor agreements updated, or vulnerabilities remediated, auditors conclude the SRA was a compliance checkbox, not a management tool. To avoid: maintain a remediation tracking spreadsheet. Document evidence of implementation (meeting notes, configuration screenshots, training records). Update your SRA annually with progress.

Failure #6: Missing third-party and vendor risk assessment. Many practices conduct an SRA of their own systems but don’t assess vendor risk. If you use a cloud EHR, billing vendor, patient portal, or email system, those vendors handle ePHI. Your SRA must document that you’ve assessed vendor security (requested security assessments, reviewed penetration test results, confirmed encryption, verified Business Associate Agreements). To avoid: for each third-party vendor, document what data they access, whether a BAA is in place, and what security controls they claim to have. Include vendor risk as a section of your SRA.

Failure #7: Inadequate documentation of the SRA process. Auditors may ask: who conducted the SRA? What methodology did you follow? What information did you gather? If you can’t explain the process, auditors may suspect the SRA was outsourced and never reviewed by leadership. To avoid: document the SRA process (who participated, when meetings were held, what questions were asked). Have leadership review and formally approve the final SRA. Keep meeting notes and interview summaries as evidence.

Failure #8: SRA doesn’t address mobile device or remote access security. With telehealth and remote work, mobile device and remote access security are critical. Many older SRAs (2020-2022) didn’t adequately address these. Updated SRAs must describe how clinicians access ePHI remotely, what encryption and MFA is required, and what vulnerabilities exist. To avoid: explicitly address mobile devices, remote access tools (VPN), and home network security in your SRA.

The pattern: CMS auditors want to see evidence that you’ve thoughtfully assessed your security posture, identified real vulnerabilities, and committed to remediation. A superficial or generic SRA signals you’re checking a compliance box, not managing risk. A thorough, detailed, practice-specific SRA signals that you take security seriously.

Ensure Your SRA Passes CMS Audit

A thorough security risk analysis is your foundation for MIPS compliance and Pi scoring. Medcurity’s guided SRA methodology and expert advisors help practices document vulnerabilities, prioritize remediation, and create audit-ready SRA documentation that stands up to CMS review.

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How Technology Streamlines MIPS SRA Compliance

Conducting and maintaining a comprehensive SRA is complex and resource-intensive, especially for practices with limited IT staff or compliance expertise. This is where technology and guided platforms can accelerate the process and ensure quality:

Guided SRA frameworks. Platforms like Medcurity provide step-by-step SRA templates aligned with HIPAA Security Rule and SAFER Guides methodology. Instead of starting from scratch, you work through a structured framework: system inventory, control assessment, vulnerability documentation, and remediation planning. This reduces the time and expertise required and ensures consistency.

Risk assessment questionnaires and data gathering tools. Automated questionnaires directed to IT staff, clinicians, and billing staff accelerate information gathering. Instead of scheduling interviews and manually compiling feedback, a platform sends targeted questionnaires, collects responses, and consolidates findings. This is faster and more comprehensive than manual interviews.

HIPAA Security Rule mapping and gap analysis. Compliance platforms automatically map your assessed controls against HIPAA requirements and highlight gaps. You answer: “Do you have access controls by user role?” and the platform references HIPAA Security Rule 164.312(a)(2)(i) and explains what the requirement means and how it applies to your practice. This ensures your SRA is legally defensible.

Remediation roadmap generation. Based on identified vulnerabilities and risks, platforms can suggest remediation recommendations and timelines. You customize these recommendations for your practice and assign ownership. Over time, you track completion, and the platform updates remediation status.

Ongoing monitoring and annual updates. Instead of conducting a new SRA every 2-3 years (which leaves you exposed to new vulnerabilities), platforms enable continuous assessment. You update your SRA quarterly or annually as your environment changes. When CMS audits, you have current, evidence-backed documentation.

Professional guidance and expert review. Medcurity provides more than software—it includes access to compliance advisors who review your SRA for completeness, accuracy, and audit-readiness. Advisors help interpret HIPAA requirements, recommend controls, and advise on implementation priorities. This expert layer is critical: many practices find that having an external compliance professional review their SRA catches gaps they would have missed.

Medcurity’s MIPS SRA platform advantage. Medcurity has helped 1,000+ healthcare organizations since 2018 conduct SRAs and achieve MIPS compliance. The platform includes HIPAA Security Rule mapping, SAFER Guides alignment, CMS audit preparation, and access to dedicated compliance advisors. Practices start at $499/year and can conduct, document, and maintain their SRA without hiring additional compliance staff.

The financial math is straightforward: the cost of conducting a thorough SRA ($5,000-$15,000 if outsourced, or $3,000-$8,000 if using a guided platform) is dramatically cheaper than the cost of failing MIPS PI ($180,000+ in Medicare payment reductions for a small practice). Moreover, an updated SRA helps you prevent breaches, which cost far more than compliance.

Key Takeaways: What Providers Must Remember About MIPS SRA

Before you move forward, cement these core points:

SRA is ONE measure within PI, not all of MIPS. Providers often misunderstand this. The SRA is a specific requirement within the Promoting Interoperability category, which is worth 25% of your MIPS score. Succeeding in SRA doesn’t mean you’ve solved MIPS. You still need to address Quality (30%), Cost (30%), and Improvement Activities (15%). But failing the SRA means zero PI points, which tanks your overall score and costs you up to 9% in Medicare reductions.

A valid SRA is not a checklist. CMS requires a formal, documented risk assessment that identifies your systems, existing controls, vulnerabilities, threats, and remediation roadmap. It must be practice-specific, aligned with HIPAA Security Rule, and signed by leadership. A simple yes/no questionnaire doesn’t count.

2026 brings tighter requirements and new expectations. Risk management attestation, SAFER Guides alignment, updated HIPAA requirements, and tighter vendor assessment standards are coming. If your last SRA was 2023 or earlier, you need an update before 2026.

CMS auditors are experienced and thorough. Don’t assume a generic or shallow SRA will pass audit. Auditors expect to see depth, practice-specific detail, and evidence of remediation. If they spot a templated or incomplete SRA, they’ll flag it and ask for corrective action.

An SRA is a living document, not a checkbox. The most defensible SRAs are updated annually, tied to an active remediation program, and reviewed by leadership. Use your SRA to manage risk, not just to satisfy compliance. This shifts it from a burden to a business tool.

Frequently Asked Questions About MIPS SRA

Q: Can our EHR vendor’s security assessment satisfy the MIPS SRA requirement?
A: Partially, but likely not fully. Many EHR vendors provide security assessment checklists or self-assessments. These are a starting point, but they typically address only the EHR itself, not your entire environment (other systems, mobile devices, vendor risk, physical security, staff access). A valid MIPS SRA must document your practice’s complete security posture, not just one system. You can incorporate the EHR vendor’s assessment into your broader SRA, but it’s not a substitute.

Q: How often do we need to update our SRA?
A: HIPAA requires an annual assessment; CMS MIPS guidance recommends annual SRA updates. However, if your environment is relatively stable and you’ve implemented most recommended controls, you could conduct a formal update every 18-24 months with quarterly or semi-annual reviews to catch new vulnerabilities. The more critical practice: if you’ve implemented major changes (new EHR, new cloud vendor, new access controls), update your SRA to reflect the new environment. Don’t let your SRA become obsolete.

Q: What if we can’t afford to remediate all identified vulnerabilities immediately?
A: That’s expected and understood by CMS. Remediation takes time and money. What auditors want to see is a prioritized roadmap with timelines and responsible parties. Address high-risk vulnerabilities first (those with high likelihood and high impact). Quick wins (encryption, access control updates, training) should be tackled in the near term (30-90 days). Longer-term remediation (system upgrades, vendor changes) can span 6-12 months. Document your priorities and progress. An audit roadmap with incremental progress is far better than a complete remediation plan with no execution.

Q: Can we use an external consultant to conduct our SRA?
A: Absolutely. Many practices engage healthcare IT consultants or compliance firms to conduct or guide their SRA. This is entirely valid, as long as the final SRA is thorough, practice-specific, and approved by your leadership. Be cautious of consultants who offer templated or quick SRAs (if an SRA takes them 2-3 days to complete, it’s probably too shallow). Expect a thorough SRA to take 4-8 weeks of work. Also, be sure your consultant uses a HIPAA Security Rule framework (not just a generic IT security checklist). Medcurity’s MIPS and SRA guide can help you evaluate what a thorough SRA should include.

Q: If we fail the SRA in Year 1 but complete it in Year 2, will we have penalties in Year 1?
A: Yes. MIPS scoring is annual. If you don’t submit evidence of an SRA in your 2026 MIPS data submission (typically due March 31, 2027), you receive zero PI points for 2026. The 2026 penalty applies to 2027 and 2028 Medicare payments. You cannot retroactively fix a 2026 failure. This is why completing and documenting your SRA before the annual MIPS submission deadline is critical. For 2026, your SRA must be completed by early 2027, in time to include it in your MIPS submission.

Q: What’s the difference between a HIPAA risk analysis and a MIPS SRA?
A: They’re essentially the same thing. HIPAA requires covered entities to conduct a documented risk assessment of their ePHI (Security Rule 164.308(a)(1)(ii)(A)). MIPS requires clinicians to have conducted a security risk analysis aligned with HIPAA Security Rule. The terminology differs slightly (“risk analysis” vs. “SRA”), but the substance is identical: a formal, documented assessment of your security posture, vulnerabilities, and remediation plan. If you have a HIPAA-compliant risk assessment, it satisfies MIPS SRA requirements.

Q: Does our SRA need to address cloud-based systems and vendors?
A: Yes, absolutely. If you use cloud-based EHR, billing systems, patient portals, email, or backup storage, your SRA must address these. For each cloud vendor, document: what data they access (patient demographics? clinical notes? payment info?), what encryption they provide, what security controls they claim, and what Business Associate Agreement terms protect you. Cloud vendors are a common vulnerability because practices often assume “cloud means secure” and don’t assess vendor risk. This is a high-audit-failure area. Include vendor risk assessment in your SRA.

Next Steps: Building Your MIPS SRA

If your practice hasn’t completed a formal security risk analysis, or if your last SRA is more than a year old, now is the time to act. The 2026 requirement changes are coming, and MIPS audits are becoming more frequent and rigorous.

Start by understanding your current state: Do you have a documented SRA? Is it HIPAA Security Rule-aligned? Is it practice-specific or templated? When was it last updated? Based on these questions, you’ll know whether you need a new SRA, an update to an existing one, or expert review of what you have.

Medcurity’s SRA platform and advisors can guide you through each step, ensuring your SRA is thorough, audit-ready, and reflects your actual security posture. For practices managing MIPS compliance alongside HIPAA requirements, Medcurity’s small practice solutions provide a streamlined path to both.

Your MIPS SRA isn’t a burden if you approach it strategically: it’s your roadmap to better security, reduced breach risk, and MIPS compliance. Done right, it protects your patients, your revenue, and your reputation.

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