All Posts Tagged: hippaa

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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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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interoperability hurdles restrain acos

Interoperability Hurdles Restrain ACOs

For accountable care organizations, a lack of interoperability between their health information technology systems and those of providers outside their ACO is the No. 1 challenge they face, cited by 79% of respondents to a survey of 68 ACOs by group purchaser and performance-improvement company Premier and health IT collaborative eHealth Initiative.

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certified hipaa compliance

Quovant Certified HIPAA Compliance

Legal spend and matter management solutions provide focus on developing technology and delivering services to corporate legal departments, claims and risk departments in the US and Europe. Having a solution that is HIPAA Compliant is key to these departments. 

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montana va privacy violations

Missing Box of Records Among Montana VA Privacy Violations

FORT HARRISON – A recent report shows a pattern of patient privacy violations at the Veterans Affairs medical system. And the VA Montana at Fort Harrison has not been immune — with dozens of violations since 2011, including the apparent disappearance of a box containing the records of 171 patients.

Online news organization ProPublica obtained the data from the U.S. Department of Veterans Affairs and the U.S. Department of Health and Human Services Office of Civil Rights, which track violations of the the nation’s main privacy law — the Health Insurance Portability and Accountability Act, or HIPAA.

The report shows 59 HIPAA violations in Montana reported in 2011 or thereafter — 44 of them involving VA Montana (including two violations at the VA’s Denver office that involved Montana patients).

Nearly all of the HIPAA violations involved mistakenly sending information, bills or lab results to the wrong veteran.

But one violation stands out: Back in 2010, the VA in Sheridan, Wyoming sent a box with the records of 171 veterans to the wrong location — a VA warehouse at Fort Harrison, where a VA worker signed for it, according to a letter uncovered by ProPublica.

“Following receipt at the VA’s warehouse, the box was lost and never found,” the regional director of the USHHS Office of Civil Rights recounted in a letter to the VA in November 2011. The letter says it’s possible warehouse personnel forwarded the papers to the correct recipient, the Network Authorization Office. But the NAO was unable to confirm it ever got them. The VA revised its mail procedures as a result of the breach, the letter says, and instituted a new software system to the allow the NAO access to scanned records to perform its audits.

In another case, an unauthorized VA staffer found a patient’s cell phone number in medical records. In all cases, the VA provided credit monitoring services for those affected.

In an email a VA Montana spokesman noted that the most common violation — information mailed to the wrong veteran — occurred in just 18 of the more than 500,000 mailing VA Montana sent in Fiscal Year 2015. “Despite the incredibly low incidence of missed mailings, VA Montana has worked diligently to reduce them entirely by implementing strict staff procedures that emphasize quality and accountability,” the spokesman, Mike Garcia, wrote.

The VA requires annual privacy and information security training for all its employees and contractors, he said, and they are required to report all violations. In addition to the 44 violations connected to the VA, the ProPublica data shows 15 violations at health care providers and others in Montana.

Available details on most of those violations are sparse, but the incidents include the 2014 hack of data at the Montana Department of Public Health and Human Services, in which hundreds of thousands of pieces of sensitive information may have been vulnerable.

Original Content by KBZK

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