All Posts Tagged: hippa

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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small hipaa violations

Small HIPAA Violations Can Cause BIG Problems

The large data breaches that compromise the protected health information (PHI) of thousands of people are the ones that receive all the attention, but the smaller violations of the Health Insurance Portability and Accountability Act (HIPAA) can be just as harmful, if not more so, to those involved. Healthcare leaders too often devote most of their attention to the large breaches and not enough to the more common, smaller violations, experts say.

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hospitals hit with ransomware

2 More Hospitals Hit With Ransomware

Hospitals and healthcare providers are increasingly falling victim to crypto-ransomware attacks. While attacks over the past few months have not been highly targeted thus far, they have caused a great deal of disruption. And disruptions at hospitals can have a much more dire impact than at most other organizations vulnerable to malware-based extortion.

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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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secure texting in healthcare

Before Tackling Secure Texting in Healthcare, Change Culture

While data breaches in the retail and government sectors grabbed the lion’s share of headlines last year, hospitals and healthcare systems remain a favorite target of cyberattacks. The reason is simple: the combination of vast amounts of personally identifiable information, along with electronic health records.

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