All Posts Tagged: hiipa

false sense of security

Does HIPAA Compliance Give A False Sense of Security?

The fact that HIPAA compliance isn’t bulletproof – that cyber security frameworks around health information require a new level of vigilance – is now axiomatic.Perhaps owing to whatever legislative sausage-making gave birth to HIPAA, to protect the privacy and security of protected health information, the law offers no guidance on how to follow it.

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doctor's mobile devices

1 in 5 Doctor’s Mobile Devices May Be At High Risk

As important a role as mobile plays in healthcare, it may also pose an equally serious threat, according to a report by Skycure, a mobile threat defense company based in Palo Alto, Calif. In fact, the report found that the doctors who use mobile devices—approximately 80% of doctors use mobile devices and 28% store patient data on their mobile device, according to the report– in their day-to-day practice are exposed to network threats that increase over time.

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ransomware hackers steal hospital

Ransomware Hackers Steal A Hospital. Again.

A month after a hospital in Hollywood was shut down by a ransomware infection that encrypted all the files on its computers and computer-controlled instruments and systems, another hospital, this one in Kentucky, has suffered a similar fate.

The hacker who stole Hollywood Presbyterian asked for $3.6 million, but settled for a piddling $17,000 (40 bitcoin), presumably after they realized that their random infectious agent had kidnapped a giant, high-profile institution that would be able to motivate serious law-enforcement investigations that would move ever-closer to their true identity the longer the ransom negotiations continued.

Ransomware Hackers Steal Hospital Information, Again

Henderson, Kentucky’s Methodist Hospital has declared an “Internal State of Emergency,” having been shut down by a piece of ransomware called “Locky.” The hospital’s spokeslawyer, David Park, said that they’re addressing the ransomware attack using plans designed to help the hospital weather a tornado or other natural disaster.

The attackers are only asking for $1,600 (4 bitcoin) to unlock the hospital’s files.

Brian Krebs speculates that the attackers didn’t set out to hold a hospital to ransom, and have no real appreciation of how much they could be asking for (though the Kentucky hospital seems to have been less compromised than the one in Hollywood). He warns that in future, ransomware creeps will start targeting their attacks, aiming for victims who have more to lose, and more to spend, when their data is taken from them.

“We haven’t yet made decision on that, we’re working through the process,” with the FBI, he said. “I think it’s our position that we’re not going to pay it unless we absolutely have to.”

The attackers are demanding a mere four bitcoins in exchange for a key to unlock the encrypted files; that’s a little more than USD $1,600 at today’s exchange rate.

Park said the administration hasn’t ruled out paying the ransom.

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hipaa audits underway

HIPAA Audits Underway! OCR’s Phase 2 Has Begun

On Monday, the HHS Office for Civil Rights (OCR) announced it has rolled out Phase 2 of its HIPAA audits, and entities have already begun receiving initial emails from OCR seeking audit contact information. The Phase 2 Audit Program is aimed at reviewing the policies and procedures of selected covered entities and their business associates to evaluate compliance with the HIPAA Privacy, Security and Breach Notification Rules. OCR’s announcement comes after data breaches in the health care industry compromised over 112 million records in 2015, according to OCR.

Phase 1 Audits

The HITECH Act required OCR to conduct periodic audits of covered entities and their business associates. Beginning in late 2011, OCR implemented a pilot audit program to assess the privacy and security controls and processes implemented by 115 covered entities across the country. Auditors then made site visits to each covered entity to evaluate compliance efforts. Following the site visits, auditors drafted a report describing how the audit was conducted, the compliance findings, and what actions the covered entity had taken in response to those findings. The covered entity then had an opportunity to develop corrective actions to address any identified concerns. The final report submitted to OCR incorporated the steps the covered entity took to resolve any compliance issues.

OCR reviewed the final reports to better understand compliance efforts with respect to the HIPAA Privacy, Security and Breach Notification Rules. In particular, OCR studied the final reports to ascertain what types of technical assistance should be developed and what forms of corrective action are the most effective. In reviewing the final reports, OCR determined several common shortcomings among covered entities, including inadequate risk analysis, outdated policies and procedures, and non-existent contingency plans.

OCR then announced its intentions to initiate a permanent audit program that was originally slated to begin in 2014. However, due to a lack of funding, OCR delayed the program. In May 2015, OCR began sending pre-audit screening surveys to covered entities classified as potential candidates for a Phase 2 Audit Program. In late 2015, OCR confirmed Phase 2 audits would begin in early 2016.

Phase 2 Audits

In the Phase 2 Audit Program, there will be a few significant changes from Phase 1 audits. First, business associates will be included in this round of audits. Additionally, most of the audits will be desk audits while only a few may ultimately result in more extensive on-site audits.

Phase 2 has already begun, with OCR sending out emails to covered entities to verify contact information. Every covered entity and business associate is eligible for an audit. Once OCR confirms an entity’s contact information, it will transmit a pre-audit questionnaire to gather data that will be used to create potential audit subject pools. OCR will then identify pools of covered entities and business associates who represent a wide range of organizations subject to the HIPAA Rules.

The Phase 2 Audit Program will be a three step audit process. The first set of audits will be desk audits of covered entities followed by a second round of desk audits of business associates. The desk audits will examine specific compliance requirements of the Privacy, Security and Breach Notification Rules. According to OCR, all desk audits will be completed by the end of December 2016. Finally, while OCR states there will be fewer in-person audits than in the Phase 1 Audit Program, a third set of audits may be conducted onsite, which will be more comprehensive than desk audits and cover a broader range of HIPAA requirements.

In an effort to promote transparency, OCR will post audit protocols on its website closer to the 2016 audits. OCR has also announced the procedures used and results found in the Phase 2 audits will be evaluated so as to develop a permanent HIPAA audit program.

Implications for Health Care Entities

The launch of the Phase 2 Audit Program confirms OCR’s commitment to the evaluation of compliance with and enforcement of the HIPAA Privacy, Security and Breach Notification Rules.

If you are an entity subject to the HIPAA Rules, be on the lookout for emails from OCR and review your HIPAA policies and procedures, risk analysis, and other compliance documents.

OCR’s announcement regarding the launch of Phase 2 of the HIPAA Audit Program can be found here.

If you need Risk Assessments, Managed Services, or just IT Support, give us a call at (818) 356-7188.

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northwell health hipaa settlement

Northwell Health HIPAA Settlement-Agrees To Pay $3.9M

The Feinstein Institute for Medical Research has agreed to settle potential HIPAA violations with a $3.9 million payment and a substantial corrective action plan.

Feinstein is a biomedical research institute based in Manhasset, N.Y., that falls under the Great Neck, N.Y.-based Northwell Health enterprise. In 2012, Feinstein reported a data breach after a computer containing the electronic protected health information of nearly 13,000 patients and research participants was stolen from an employee’s car. Information stored on the laptop included names, birth dates, addresses, Social Security numbers, diagnoses, laboratory results, medications and other medical information.

Northwell Health HIPAA Settlement

HHS’ Office of Civil Rights launched an investigation into the breach and determined Feinstein’s security management processes to be incomplete and insufficient to address potential risks and vulnerabilities of electronic PHI, including failure to restrict access to unauthorized users and a lack of policies and procedures to govern the removal of laptops out of its facilities.

“Research institutions subject to HIPAA must be held to the same compliance standards as all other HIPAA-covered entities,” said OCR Director Jocelyn Samuels. “For individuals to trust in the research process and for patients to trust in those institutions, they must have some assurance that their information is kept private and secure.”

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okay to share hipaa

When It’s Okay To Share – HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that sets rules about who can look at and receive an individual’s health information. “Covered entities” that must follow the HIPAA regulations include health plans, most healthcare providers, and healthcare clearinghouses. Business associates of covered entities also must follow parts of the HIPAA regulations.

“Business associates” are generally contractors, subcontractors, and other outside persons and companies that need to be able to access individual health records held by a covered entity to provide a service. Examples of business associates include:

  • Billing companies
  • Companies that help administer health plans
  • Lawyers, accountants, and IT specialists
  • Data management companies

These covered entities and business associates must follow HIPAA regulations or face heavy fines and other penalties. Generally, a covered entity cannot use or share an individual’s health information without written permission, unless the law allows for it.

Examples of when it;s okay to share HIPAA info/patient information without written consent include:

  • When the information is necessary to provide treatment.
  • When not disclosing it would interfere with a disaster relief organization’s ability to respond to an emergency.
  • As necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.
  • To relay information about a patient’s location in the facility and general condition.

Providers also may share patient information to the extent necessary to seek payment for services rendered.

Original Content by H.H.S.

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