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Healthcare and hospitals

DPDP for the Chief risk officer in Healthcare

Patient-data risk now sits next to clinical and financial risk.

Open this seat in the interactive tool

What is different here

Ransomware stops care, wrong sends hurt patients, and insurer and TPA flows create vendor risk.

The first four things to sort out

  1. Add DPDP duties to the risk register.
  2. Track downtime risk for the HIS.
  3. Track TPA and lab vendor risk.
  4. Report quarterly with incidents.

A worked example: DPDP enters the hospital risk register

  1. Step 1Each duty becomes a risk line with an owner.
  2. Step 2Accreditation and security controls are linked.
  3. Step 3Downtime and vendor risks are rated.
  4. QuarterlyThe register goes to management with evidence.

Evidence kept: Register; Evidence.

One register, one set of evidence.

What others in the sector usually do. Risk teams track wrong-send incidents as a key indicator.

Where it usually goes wrong, by organisation type

Organisation typeHotspots
Multi-specialty hospital chainShared logins on ward computers; Reports forwarded on messaging apps; VIP or staff records viewed out of curiosity
Standalone hospital or nursing homePaper case sheets at nursing stations; Vendor remote access to the hospital software; Records room with no access log
Diagnostic labs and imagingReport links sent to the wrong number; Franchisees keeping patient lists; PCPNDT records and images
Health-tech and telemedicineAnalytics and ad SDKs in health apps; Chat transcripts kept with no period; Sharing user data with partner pharmacies for offers
Pharmacy chain and e-pharmacyPrescription images in the app and with stores; Refill reminders used for marketing; Delivery partners with addresses and order details

9 guides for the Chief risk officer, in full

Can we share patient records with insurers and TPAs?

Short answer: Yes for the patient's claim; only what it needs

Yes, for a claim the patient has asked for, because that is part of the purpose. Share only what the claim needs, through the TPA portal or a secure channel, and keep a record of what was sent. Sharing for anything else, such as an insurer's own marketing, needs consent.

From your seat: Chief risk officer. TPA flows are a vendor risk line.
What the law says

Section 7(a) covers the claim purpose; Section 8(1) and 8(5) apply to how data is sent. Section 7 · Section 8(5) · Rule 6 · Sections 11–14 · Rule 14

Steps
  1. Use TPA portals, not email.
  2. Send only claim documents.
  3. Log what was sent, to whom, when.
  4. Answer patient questions about sharing.
  5. Check TPA agreements.
Evidence to keep
  • Sharing log
  • TPA agreement
Common mistakes
  • Full case files by email
  • No record of what was sent
  • Insurer representatives reading records on wards
Related questions

Imaging machines and lab analysers hold patient data. What do we do?

Short answer: Separate network, controlled vendor access, wipe before disposal

Imaging and lab devices store names, ages and results, often on old operating systems. Put them on a separate network, control vendor remote access, change default passwords, and wipe disks before a device is returned or scrapped.

What the law says

Rule 6 safeguards apply to devices that store personal data. Section 8(5) · Rule 6 · Section 8(7) · Rule 8

Steps
  1. List devices that store patient data.
  2. Segment them.
  3. Control vendor remote access.
  4. Change default passwords.
  5. Wipe before disposal.
Evidence to keep
  • Device list
  • Network diagram
  • Wipe certificates
Common mistakes
  • Devices on the general network
  • Vendor modems always on
  • Disks leaving with old machines
Related questions

How do we put DPDP into the risk register?

Short answer: One line per duty, with owner and evidence

Turn each duty into a risk line with an owner, a control, evidence and a review date. Map controls you already run for your regulator, auditors or certifications, so the same evidence serves several purposes. Track vendor risk separately.

From your seat: Chief risk officer. Split DPDP into separate duties. One line called 'DPDP compliance' hides where the risk actually is.
In Healthcare

Add downtime and wrong-send lines.

What the law says

The Act sets duties in Sections 5 to 12. A risk register shows management where each duty stands. Section 8(1)–(2) · Section 8(5) · Rule 6 · Section 8(6) · Rule 7 · Section 10 · Rule 13

Steps
  1. List the duties that apply to you.
  2. For each, write the risk in plain words, the control and the owner.
  3. Link existing controls and audits as evidence.
  4. Rate likelihood and impact in your usual way.
  5. Review every quarter with management.
Evidence to keep
  • Risk register extract
  • Linked evidence
  • Quarterly review minutes
Common mistakes
  • One line saying 'DPDP compliance'
  • No owners
  • Evidence that is only a policy document
Related questions

Something has gone wrong. What happens in the first 72 hours?

Short answer: Six hours for CERT-In; without delay for people and the Board; 72 hours for the detailed report

Contain it, then tell people. A reportable cyber incident goes to CERT-In within six hours of being noticed. Under DPDP, each affected person and the Data Protection Board must be told without delay, and the Board needs a detailed report within 72 hours. Sector regulators may have their own clock too.

From your seat: Chief risk officer. Map every reporting clock that applies to you on one page: CERT-In, your regulator and the Data Protection Board.
In Healthcare

A ransomware attack on the HIS needs a CERT-In report in six hours and the DPDP messages.

What the law says

Section 8(6) and Rule 7 set the DPDP steps. The CERT-In Directions of 28 April 2022 set the six-hour report. A breach includes accidental disclosure and loss of access, not only hacking. Section 8(6) · Rule 7 · Section 8(5) · Rule 6

Steps
  1. Name one incident lead and a back-up, with phone numbers that work at night.
  2. Write the first-hour steps: isolate, preserve logs, tell the DPO and the incident lead.
  3. Keep ready-made drafts for CERT-In, the regulator, the Board and affected people.
  4. Decide in advance who signs off each message.
  5. Rehearse once a year with the people who would actually be called.
Evidence to keep
  • Incident plan with clocks
  • Rehearsal record
  • Incident log with times of each step
Common mistakes
  • Waiting to finish the investigation before telling anyone
  • Treating a wrong email or a lost laptop as 'not a breach'
  • Only IT knowing the plan
Related questions

What must a vendor contract say about personal data?

Short answer: Yes, every vendor that touches personal data

You stay responsible for what your vendors do with personal data. The contract should say what data they get, for what purpose, the security they must keep, how fast they must tell you about an incident, that sub-contractors need your approval, and how data is returned or deleted at the end.

From your seat: Chief risk officer. Vendor risk is usually the largest single item. Track the top vendors as separate risk lines.
In Healthcare

Labs, teleradiology, HIS vendors, TPAs and ambulance services.

What the law says

Section 8(1) keeps responsibility with you. Section 8(2) allows a processor only under a valid contract. Rule 6 asks for security terms in that contract. Section 8(1)–(2) · Section 8(5) · Rule 6 · Section 8(6) · Rule 7 · Section 8(7) · Rule 8

Steps
  1. List vendors who receive or can see personal data.
  2. Rank them by how much and how sensitive.
  3. Add a data-protection schedule to each contract, starting with the top ten.
  4. Ask for evidence: certificates, test results, deletion confirmations.
  5. Review the top vendors every year.
Evidence to keep
  • Vendor register
  • Signed data-protection schedules
  • Annual review notes
Common mistakes
  • Relying on the vendor's standard terms
  • No incident-notice time
  • No exit and deletion clause
Related questions

Could we be a Significant Data Fiduciary?

Short answer: Only by notification; none notified yet

Only the government can notify an organisation or a class of organisations as a Significant Data Fiduciary, based on the volume and sensitivity of data and the risk to people or the State. None had been notified when this page was last reviewed. Large holders of sensitive data should plan as if it could happen.

From your seat: Chief risk officer. Keep notification as a scenario in the register, with a trigger and an owner.
In Healthcare

Large hospital chains and health platforms hold sensitive data at scale; plan as a possible candidate.

What the law says

Section 10 and Rule 13 set the extra duties: a DPO in India, an independent data auditor, a yearly Data Protection Impact Assessment and audit, and checks on algorithms. Rule 13(4) allows the government to restrict some data from leaving India. Section 10 · Rule 13 · Section 16 · Rule 15

Steps
  1. Estimate how many people's data you hold and how sensitive it is.
  2. Note any public or security role your data plays.
  3. If you are a likely candidate, run a trial impact assessment this year.
  4. Identify an auditor you could appoint.
  5. Watch MeitY notifications.
Evidence to keep
  • Volume and sensitivity note
  • Trial impact assessment
  • Board note
Common mistakes
  • Assuming 'not notified' means 'never'
  • Waiting for notification to start
  • Thinking only tech companies will be notified
Related questions

Can personal data be stored or accessed outside India?

Short answer: Yes, unless a sector rule says otherwise

Under DPDP, yes, unless the government restricts a country, and none had been restricted when this page was last reviewed. A sector rule can be stricter, for example RBI's rule that payment system data must be stored only in India. Remote support access from abroad also counts as data going outside India.

From your seat: Chief risk officer. Record every system or support team outside India, and check each against sector localisation rules.
In Healthcare

Teleradiology and some software vendors use teams abroad; this is a transfer.

What the law says

Section 16 allows transfers unless restricted, and keeps stricter sector laws in force. Rule 15 adds conditions on making data available to foreign states. Section 16 · Rule 15 · Section 8(1)–(2)

Steps
  1. List where each system is hosted and where support teams log in from.
  2. Check sector rules for localisation.
  3. Put location and access terms in cloud and vendor contracts.
  4. Keep the list current; new SaaS tools change it quietly.
  5. Tell people in your notice if data goes abroad.
Evidence to keep
  • Hosting and access-location list
  • Contract clauses
  • Sector rule check
Common mistakes
  • Forgetting email, CRM and helpdesk SaaS
  • Ignoring overseas support logins
  • Assuming 'Indian vendor' means 'data in India'
Related questions

Does ISO 27001 or NIST CSF cover our DPDP duties?

Short answer: They cover security, not the whole Act

They help a great deal with the security part. ISO/IEC 27001 and NIST CSF 2.0 are good evidence of reasonable security safeguards. They do not cover notice, consent, rights, complaints or children's data. ISO/IEC 27701 adds privacy controls, but no certificate replaces the Act.

From your seat: Chief risk officer. Use existing certifications as evidence, but record the DPDP duties they do not cover as their own risk lines.
In Healthcare

NABH information management standards and ISO 27001 support Rule 6.

What the law says

Section 8(5) and Rule 6 ask for reasonable security safeguards. A recognised standard is strong evidence of that duty, and only of that duty. Section 8(5) · Rule 6

Steps
  1. Map your current controls to Rule 6.
  2. Add the DPDP-only items: notice, consent, rights, complaints, children, retention.
  3. Use the same evidence for audits and for DPDP.
  4. Include privacy in the scope of your next internal audit.
  5. Consider ISO/IEC 27701 if clients ask for it.
Evidence to keep
  • Control map
  • Audit reports
  • Gap list for DPDP-only items
Common mistakes
  • Treating a certificate as DPDP compliance
  • Scope that leaves out the systems with the most personal data
  • No owner for the non-security duties
Related questions

How much effort and time will it take to be ready by 13 May 2027?

Short answer: Six to nine months of steady work for most

For most organisations it is a programme of six to nine months, not a single project. The heavy parts are the data inventory, vendor contracts, access control and the request process. Notices, the contact person and training are lighter. Starting now leaves time to fix what you find.

From your seat: Chief risk officer. Track the programme against dated milestones and report slippage early.
In Healthcare

Access control and vendor contracts take the longest.

What the law says

Most duties under the DPDP Rules start on 13 May 2027. Section 8(5) · Rule 6 · Section 8(1)–(2) · Sections 11–14 · Rule 14

Steps
  1. Month 1: name the owner, set a budget line, start the inventory.
  2. Months 2 to 3: notices, consent records, contact person, request register.
  3. Months 3 to 6: vendor contracts, access control, logs, retention schedule.
  4. Months 6 to 8: breach rehearsal, training, internal review.
  5. Month 9: management review with evidence.
Evidence to keep
  • Programme plan with owners
  • Monthly status with evidence
  • Management minutes
Common mistakes
  • Leaving it to the last quarter
  • Buying a tool before knowing the gaps
  • Status colours with no evidence behind them
Related questions

Practical examples

Notice wording, request log, retention schedule, vendor clause and breach notice for healthcare and hospitals.

The sections you will use most

Other rules that sit alongside DPDP

RuleWhat it saysWhat it means alongside DPDPSource
Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002Regulation 1.3.1: keep indoor patients' medical records for 3 years from the start of treatment. Regulation 1.3.2: issue records to patients, authorised attendants or legal authorities within 72 hours of a request. Regulation 2.2: keep patient confidences.Set retention at or above these minimums. Use the 72-hour record copy rule as the base for patient access requests.Code of Medical Ethics, 2002
Telemedicine Practice Guidelines, 2020 (Appendix 5 to the 2002 Regulations)Consent is implied when the patient starts a teleconsultation and must be explicit when a health worker or caregiver starts it. The doctor records consent and keeps logs, records and prescriptions as for in-person care.Telemedicine apps must add DPDP notices and protect chat, video and prescription data.MoHFW
Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994Records of tests and procedures, including Form F, must be preserved for 2 years, or until a legal proceeding ends.These records cannot be erased early on request; protect them carefully.Tamil Nadu health department FAQ
Medical Termination of Pregnancy Regulations, 2003The admission register is a secret document, kept by the head of the hospital, not open to inspection except under law, and kept for five years.MTP records need the tightest access in the hospital.MTP Regulations
Mental Healthcare Act, 2017Section 23: right to confidentiality. Section 24: no photos or information to media without consent. Section 25: right to access basic medical records.Psychiatry and counselling records need separate access and a careful request process.NHSRC copy of the Act
HIV and AIDS (Prevention and Control) Act, 2017HIV status may be disclosed only with informed consent, except in narrow cases. Establishments keeping HIV-related records must adopt data protection measures.Restrict HIV results and counselling notes to the treating team.Act
New Drugs and Clinical Trials Rules, 2019Informed consent of trial participants; ethics committees keep records for five years after the trial ends (Rule 13).Trial data needs both informed consent and DPDP safeguards.NDCT Rules
Drugs Rules: Schedule H1 registerPharmacies record prescriber's name and address, patient's name, drug and quantity, kept for three years.Keep the register for three years, then dispose of it.NHSRC
ABDM Health Data Management PolicyFor entities in the Ayushman Bharat Digital Mission, health records are shared through a consent manager, with consent artefacts for each request.If you are ABDM-linked, the ABDM consent flow and your DPDP notices must agree.ABDM / NHA
Clinical Establishments Act, 2010 and Rules, 2012 (states that adopted it)Registered establishments maintain medical records, and electronic records as the government specifies.Check whether your state follows this Act or its own nursing home law.MoHFW
IRDAI health insurance master circular, 2024Insurers decide cashless requests within one hour and final discharge within three hours.Fast TPA sharing is needed, but only the records the claim needs, through secure channels.IRDAI
CERT-In Directions, 2022Report specified cyber incidents within six hours; keep ICT logs 180 days in India.A ransomware attack needs a CERT-In report and the DPDP messages.CERT-In
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