Our HIPAA compliance news section keeps you up to date with HIPAA breaches, OCR updates and HITECH and GDPR compliance issues. Make sure you remain up to date with the latest HIPAA compliance news by subscribing to our newsletter or follow us on Twitter @HIPAAJournal.

OCR Issues Request for Information on Potential Updates to HIPAA Rules to Improve Data Sharing
Dec13

OCR Issues Request for Information on Potential Updates to HIPAA Rules to Improve Data Sharing

The Department of Health and Human Services’ Office for Civil Rights (OCR) has issued a request for information (RFI) seeking comments from the public on potential modifications to Health Insurance Portability and Accountability Act (HIPAA) Rules to promote coordinated, value-based healthcare. OCR is seeking suggestions about changes to aspects of the HIPAA Privacy and Security Rules that are impeding the transformation to value-based healthcare and provisions of HIPAA Rules that are discouraging coordinated care between individuals and their healthcare providers. HIPAA was first enacted 22 years ago at a time when few healthcare providers were using digital health records. While there have been updates to HIPAA over the years, many industry stakeholders believe further updates are necessary now that the majority of healthcare organizations have transitioned to digital health records. Recently, the American Medical Informatics Association (AMIA) and American Health Information Management Association (AHIMA) explained to Congress that changes to HIPAA are required to improve...

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Failure to Terminate Former Employee’s PHI Access Costs Colorado Hospital $111,400
Dec12

Failure to Terminate Former Employee’s PHI Access Costs Colorado Hospital $111,400

OCR has fined a Colorado hospital $111,400 for the failure to terminate a former employee’s access to a web-based scheduling calendar, which resulted in an impermissible disclosure of 557 patients’ ePHI. Pagosa Springs Medical Center (PSMC) is a critical access hospital, part of the Upper San Juan Health Service District, which provides more than 17,000 hospital and clinic visits a year. As a HIPAA-covered entity, PSMC is required to comply with the HIPAA Privacy, Security, and Breach Notification Rules. One of the provisions of the HIPAA Privacy Rule is to limit access to protected health information to authorized individuals. When an employee is terminated, leaves the organization, or changes job role and is no longer required to have access to PHI, access rights must be terminated. The failure to terminate remote access is a violation of HIPAA Rules and could potentially result in an impermissible disclosure of ePHI. On June 7, 2013, OCR received a complaint about a former employee of PSMC who continued to have remote access to a web-based scheduling calendar after leaving PSMC....

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EmblemHealth Pays $100,000 HIPAA Violation Penalty to New Jersey for 2016 Data Breach
Dec11

EmblemHealth Pays $100,000 HIPAA Violation Penalty to New Jersey for 2016 Data Breach

The health insurance provider EmblemHealth has been fined $100,000 by New Jersey for a 2016 data breach that exposed the protected health information (PHI) of more than 6,000 New Jersey plan members. On October 3, 2016, EmblemHealth sent Medicare Part D Prescription Drug Plan Evidence of Coverage documents to its members. The mailing labels included beneficiary identification codes and Medicare Health Insurance Claim Numbers (HCIN), which mirror Social Security numbers. The documents were sent to more than 81,000 policy members, 6,443 of whom were New Jersey residents. The New Jersey Division of Consumer Affairs investigated the breach and identified policy, procedural, and training failures. Previous mailings of Evidence of Coverage documents were handled by a trained employee, but when that individual left EmblemHealth, mailing duties were handed to a team manager who had only been given minimal task-specific training and worked unsupervised. That individual sent a data file to EmblemHealth’s mailing vendor without first removing HCINs, which resulted in the HCINs being printed...

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12 State Attorneys General File HIPAA Breach Lawsuit Against Medical Informatics Engineering
Dec05

12 State Attorneys General File HIPAA Breach Lawsuit Against Medical Informatics Engineering

A multi-state federal lawsuit has been filed against Medical Informatics Engineering and NoMoreClipboard over the 2015 data breach that exposed the data of 3.9 million individuals. Indiana Attorney General Curtis Hill is leading the lawsuit and 11 other states are participating – Arizona, Arkansas, Florida, Iowa, Kansas, Kentucky, Louisiana, Minnesota, Nebraska, North Carolina and Wisconsin. This is the first time that state attorneys general have joined forces in a federal lawsuit over a data breach caused by violations of the Health Insurance Portability and Accountability Act. The lawsuit seeks a financial judgement, civil penalties, and the adoption of a corrective action plan to address all compliance failures. A Failure to Implement Adequate Security Controls The lawsuit alleges Medical Informatics Engineering failed to implement appropriate security to protect its computer systems and sensitive patient data and, as a result of those failures, a preventable data breach occurred. According to the lawsuit, “Defendants failed to implement basic industry-accepted data...

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OCR Fines Florida Contractor Physicians’ Group $500,000 for Multiple HIPAA Compliance Failures
Dec04

OCR Fines Florida Contractor Physicians’ Group $500,000 for Multiple HIPAA Compliance Failures

An HHS’ Office for Civil Rights (OCR) investigation into an impermissible disclosure of PHI by a business associate of a HIPAA-covered entity revealed serious HIPAA compliance failures. Advanced Care Hospitalists (ACH) is a Lakeland, FL-based contractor physicians’ group that provides internal medicine physicians to nursing homes and hospitals in West Florida. ACH falls under the definition of a HIPAA-covered entity and is required to comply with the HIPAA Privacy, Security, and Breach Notification Rules. ACH serves approximately 20,000 patients a year and employed between 39 and 46 staff members per year during the time frame under investigation. Between November 2011 and June 2012, ACH engaged the services of an individual who claimed to be a representative of Doctor’s First Choice billings Inc., a Florida-based provider of medical billing services. That individual used First Choice’s company name and website, but according to the owner of First Choice, those services were provided without the knowledge or permission of First Choice. A local hospital notified ACH on February 11,...

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OCR Fines Allergy Practice $125,000 for Impermissible PHI Disclosure
Nov26

OCR Fines Allergy Practice $125,000 for Impermissible PHI Disclosure

The Department of Health and Human Services’ Office for Civil Rights (OCR) has fined a Hartford allergy practice $125,000 over alleged violations of the HIPAA Privacy Rule. On October 6, 2015, OCR received a copy of a civil rights complaint that had been filed with the Department of Justice (DOJ). The complainant alleged Allergy Associates of Hartford – A Connecticut healthcare provider that specializes in treating patients with allergies – had impermissibly disclosed her protected health information to a TV reporter. The complainant had previously contacted a local TV station after she had been turned away from the allergy practice because of her service animal. The TV reporter subsequently contacted the practice seeking comment. A physician at the practice spoke to the reporter and impermissibly disclosed some of the patient’s protected health information. OCR’s investigation confirmed there had been an impermissible disclosure of PHI, in violation of the HIPAA Privacy Rule – 45 C.F.R. § 164.502(a). The physician in question had already been advised by the practice’s...

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October 2018 Healthcare Data Breach Report
Nov21

October 2018 Healthcare Data Breach Report

Our October 2018 healthcare data breach report shows there has been a month-over-month increase in healthcare data breaches with October seeing more than one healthcare data breach reported per day. 31 healthcare data breaches were reported by HIPAA-covered entities and their business associates in October – 6 incidents more than the previous month. It should be noted that one breach at a business associate was reported to OCR as three separate breaches. The number of breached records in September (134,006) was the lowest total for 6 months, but the downward trend did not continue in October. There was a massive increase in exposed protected health information (PHI) in October. 2,109,730 records were exposed, stolen or impermissibly disclosed – 1,474% more than the previous month. In October, the average breach size was 68,055 records and the median was 4,058 records. Largest Healthcare Data Breaches in October 2018 There were 11 healthcare data breaches of more than 10,000 records reported in October – A 120% increases from the five 10,000+ record breaches in September. The...

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AMIA Calls for Greater Alignment of Federal Data Privacy Rules
Nov20

AMIA Calls for Greater Alignment of Federal Data Privacy Rules

The American Medical Informatics Association (AMIA) is calling for the Trump Administration to tighten data privacy rules through greater alignment of HIPAA and the Common Rule and recommends adoption of a more integrated approach to privacy that includes both the healthcare and consumer sectors. The call follows a request for comment by the NTIA to initiate a conversation about consumer privacy. In a letter to the National Telecommunications and Information Administration (NTIA), a division of the Department of Commerce, AMIA explained that its comments are informed by extensive experience of dealing with both the Health Insurance Portability and Accountability Act and the Federal Protections for Human Subjects Research (Common Rule). Currently, there is a patchwork of federal and state regulations that complicates compliance and creates information sharing challenges which results in ‘perverse outcomes’ due to different interpretations of existing privacy policies. AMIA illustrated the problem of the current patchwork of privacy policies using Pennsylvania and New Jersey as an...

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Do HIPAA Rules Create Barriers That Prevent Information Sharing?
Nov19

Do HIPAA Rules Create Barriers That Prevent Information Sharing?

The HHS has drafted a Request for Information (RFI) to discover how HIPAA Rules are hampering patient information sharing and are making it difficult for healthcare providers to coordinate patient care. HHS wants comments from the public and healthcare industry stakeholders on any provisions of HIPAA Rules which are discouraging or limiting coordinated care and case management among hospitals, physicians, patients, and payors. The RFI is part of a new initiative, named Regulatory Sprint to Coordinated Care, the aim of which is to remove barriers that are preventing healthcare organizations from sharing patient information while retaining protections to ensure patient and data privacy are protected. The comments received through the RFI will guide the HHS on how HIPAA can be improved, and which policies should be pursued in rulemaking to help the healthcare industry transition to coordinated, value-based health care. The RFI was passed to the Office of Management and Budget for review on November 13, 2018. It is currently unclear when the RFI will be issued. Certain provisions of...

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$200,000 Settlement Agreed with Business Associate Behind Virtua Medical Data Breach
Nov05

$200,000 Settlement Agreed with Business Associate Behind Virtua Medical Data Breach

New Jersey Attorney General Gurbir S. Grewal has announced a $200,000 settlement has been agreed with Best Medical Transcription to resolve violations of the Health Insurance Portability and Accountability Act that were discovered during an investigation of a 2016 breach of 1,650 individuals’ protected health information. Protected Health Information of 1,654 Patients Was Accessible Through Search Engines Best Medical Transcription was a business associate of Virtua Medical Group, a network of medical and surgical practices in southern New Jersey. Best Medical Transcription was provided with dictated medical notes, letters, and reports which were transcribed for Virtua Medical Group physicians. In January 2016, it was discovered that transcribed documents had been uploaded to File Transfer Protocol (FTP) website that was accessible over the Internet without the need for any authentication. The files had been indexed by Google and could be found using search terms including information contained in the files. Password-protection had been removed when software on the website was...

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Cybersecurity Best Practices for Healthcare Organizations
Nov01

Cybersecurity Best Practices for Healthcare Organizations

The Department of Health and Human Services’ Office for Civil Rights has drawn attention to basic cybersecurity safeguards that can be adopted by healthcare organizations to improve cyber resilience and reduce the impact of attempted cyberattacks. The advice comes at the end of cybersecurity awareness month – a four-week coordinated effort between government and industry organizations to raise awareness of the importance of cybersecurity. While all organizations need to implement policies, procedures, and technical solutions to make it harder for hackers to gain access to their systems and data, this is especially important in the healthcare industry. Hackers are actively targeting healthcare organizations as they store large quantities of highly sensitive and valuable data. Healthcare organization need to ensure that their systems are well protected against cyberattacks, which means investing in technologies to secure the network perimeter, detect intrusions, and block malware and phishing threats. Large healthcare organizations have the resources to invest heavily in...

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OCR Launches Campaign to Raise Awareness of Civil Rights Protections for Patients Being Treated for Opioid Use Disorder
Oct29

OCR Launches Campaign to Raise Awareness of Civil Rights Protections for Patients Being Treated for Opioid Use Disorder

On October 26, 2017, President Donald Trump declared the opioid crisis a national public health emergency. The one-year anniversary of that declaration has seen a new opioid bill signed into law. On October 24, 2018, President Donald Trump added his signature to the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act – or “SUPPORT for Patients and Communities Act” for short. The Act will help strengthen the government’s response to the opioid crisis, improve access to addiction treatment services, and expand data sharing in cases of opioid abuse. There have been calls for changes to be made to 42 CFR Part 2 to align the legislation with the HIPAA Privacy Rule and allow the sharing of information about a patient’s substance abuse treatment, without consent, for the purposes of treatment, payment or healthcare operations. The SUPPORT for Patients and Communities Act does go that far, although the new law does allow information relating to opioid use disorder and treatment – and details of treatment for abuse of other...

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The HIPAA Risk Analysis: Guidance and Tools for HIPAA Covered Entities and Business Associates
Oct17

The HIPAA Risk Analysis: Guidance and Tools for HIPAA Covered Entities and Business Associates

The HIPAA Risk analysis is a foundational element of HIPAA compliance, yet it is something that many healthcare organizations and business associates get wrong. That places them at risk of experiencing a costly data breach and a receiving a substantial financial penalty for noncompliance. The HIPAA Risk Analysis The administrative safeguards of the HIPAA Security Rule require all HIPAA-covered entities to “conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information.” See 45 C.F.R. § 164.308(u)(1)(ii)(A). The risk analysis is a foundational element of HIPAA compliance and is the first step that must be taken when implementing safeguards that comply with and meet the standards and implementation specifications of the HIPAA Security Rule. If a risk analysis is not conducted or is only partially completed, risks are likely to remain and will therefore not be addresses through an organization’s risk management process – See § 164.308(u)(1)(ii)(B) – and will not be...

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$16 Million Anthem HIPAA Breach Settlement Takes OCR HIPAA Penalties Past $100 Million Mark
Oct16

$16 Million Anthem HIPAA Breach Settlement Takes OCR HIPAA Penalties Past $100 Million Mark

OCR has announced that an Anthem HIPAA breach settlement has been reached to resolve potential HIPAA violations discovered during the investigation of its colossal 2015 data breach that saw the records of 78.8 million of its members stolen by cybercriminals. Anthem has agreed to pay OCR $16 million and will undertake a robust corrective action plan to address the compliance issues discovered by OCR during the investigation. The previous largest ever HIPAA breach settlement was $5.55 million, which was agreed with Advocate Health Care in 2016. “The largest health data breach in U.S. history fully merits the largest HIPAA settlement in history,” said OCR Director Roger Severino. Anthem Inc., an independent licensee of the Blue Cross and Blue Shield Association, is America’s second largest health insurer. In January 2015, Anthem discovered cybercriminals had breached its defenses and had gained access to its systems and members’ sensitive data. With assistance from cybersecurity firm Mandiant, Anthem determined this was an advanced persistent threat attack – a continuous and targeted...

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Aetna Settles HIPAA Violation Case with State AGs
Oct15

Aetna Settles HIPAA Violation Case with State AGs

In 2017, errors occurred with two Aetna mailings that resulted in the impermissible disclosure of the protected health information of plan members, including HIV statuses and AFib diagnoses. A class action lawsuit was filed on behalf of the victims of the HIV status breach which was settled for $17 million in January. Now Aetna has reached settlements with the attorneys general for New Jersey, Connecticut, and the District of Columbia to resolve the alleged HIPAA violations discovered during an investigation into the privacy breaches. The first mailing was sent on July 28, 2017 by an Aetna business associate. Over-sized windowed envelopes were used for the mailing, through which it was possible to see the names and addresses of plan members along with the words “HIV Medications.” Approximately 12,000 individuals received the mailing. In September, a second mailing was sent on behalf of Aetna to 1,600 individuals. This similarly resulted in an impermissible disclosure of PHI. In addition to names and addresses, the logo of an IMPACT AFib study was visible, which suggested the...

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HSS Secretary Issues Limited Waiver of HIPAA Penalties Following Declaration of Public Health Emergency in Florida and Georgia
Oct12

HSS Secretary Issues Limited Waiver of HIPAA Penalties Following Declaration of Public Health Emergency in Florida and Georgia

Following the presidential declaration of public health emergencies in the states of Florida and Georgia in the wake of hurricane Michael, secretary of the Department of Health and Human Services (HHS) Alex Azar has followed suit in both states and has exercised his authority to waive HIPAA sanctions and penalties for certain provisions of the HIPAA Privacy Rule in the disaster areas. The HHS announced the public health emergency in Florida on October 9, and Georgia on October 11. The HIPAA Privacy Rule does permit healthcare providers to share protected health information during disasters to assist patients and ensure they receive the care they need, including sharing information with friends, family members and other individuals directly involved in a patient’s care. The HIPAA Privacy Rule allows the sharing of PHI for public health activities and to prevent or reduce a serious and imminent threat to health or safety. HIPAA-covered entities are also permitted to share information with disaster relief organizations that have been authorized by law to assist with disaster relief...

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Hospitals Failing to Fully Comply with HIPAA Requirement for Providing Patients with Copies of Medical Records
Oct10

Hospitals Failing to Fully Comply with HIPAA Requirement for Providing Patients with Copies of Medical Records

The HIPAA Privacy Rule gave patients the right to obtain a copy of their medical records from their healthcare providers. Under HIPAA, copies of medical records should be provided to patients as soon as possible, but no later than 30 days from when the request is made. Even though compliance with the HIPAA Privacy Rule has been mandatory since April 14, 2003, there have been several cases of hospitals failing to provide patients with copies of their medical records. In 2011, the Department of Health and Human Services’ Office for Civil Rights (OCR) sent a message to healthcare providers about this aspect of HIPAA compliance when it issued a $4,300,000 civil monetary penalty to Cignet Health of Prince George’s County. Even though it has now been 15 years since compliance with the HIPAA Privacy Rule became mandatory, there is still widespread noncompliance when it comes to providing patients with copies of their medical records. According to a new study published in JAMA Network Open, healthcare providers are not providing patients with copies of their full medical records,...

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California HIV Patient PHI Breach Lawsuit Allowed to Move Forward
Oct08

California HIV Patient PHI Breach Lawsuit Allowed to Move Forward

A lawsuit filed by Lambda Legal on behalf of a victim of a data breach that saw the highly sensitive protected health information of 93 lower-income HIV positive individuals stolen by unauthorized individuals has survived a motion to dismiss. The former administrator of the California AIDS Drug Assistance Program (ADAP), A.J. Boggs & Company, submitted a motion to dismiss but it was recently rejected by the Superior Court of California in San Francisco. In the lawsuit, Lambda Legal alleges A.J. Boggs & Company violated the California AIDS Public Health Records Confidentiality Act, the California Confidentiality of Medical Information Act, and other state medical privacy laws by failing to ensure an online system was secure prior to implementing that system and allowing patients to enter sensitive information. A.J. Boggs & Company made its new online enrollment system live on July 1, 2016, even though it had previously received several warnings from nonprofits and the LA County Department of Health that the system had not been tested for vulnerabilities. It was...

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Claxton-Hepburn Medical Center Fires Several Employees for Inappropriate PHI Access
Sep27

Claxton-Hepburn Medical Center Fires Several Employees for Inappropriate PHI Access

Claxton-Hepburn Medical Center, a not-for-profit 115-bed community hospital in Ogdensburg, NY, has fired several employees for accessing patient health records without authorization. The PHI breaches were discovered during an internal investigation. It is unclear whether that investigation was launched following a complaint that had been received or if the patient privacy violations were uncovered during a routine audit of PHI access logs – A requirement of HIPAA. Claxton-Hepburn Medical Center has not publicly disclosed how many employees were terminated over the violations, only reporting that all employees who purposely committed the acts were terminated. It is also currently unclear exactly how many patients’ PHI was breached. Claxton-Hepburn Medical Center has confirmed that training is given to all employees on the first day of employment detailing the requirements of HIPAA and the importance of protecting the privacy of patients. All employees are made aware that accessing patient health information is only permitted when PHI needs to be viewed to complete work duties or...

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HIPAA Quiz Launched by Compliancy Group
Sep26

HIPAA Quiz Launched by Compliancy Group

A new HIPAA Quiz has been launched by the Compliancy Group, which serves as a quick and easy free tool to assess the current state of HIPAA compliance in an organization.   Healthcare organizations that have implemented policies and procedures to comply with the Health Insurance Portability and Accountability Act (HIPAA) Rules may think that they are fully compliant with all provisions of the HIPAA Privacy, Security, and Breach Notification Rules. However, HHS’ Office for Civil Rights (OCR) compliance audits and investigations into data breaches and complaints often reveal certain requirements of HIPAA have been missed or misinterpreted. OCR investigates all breaches of more than 500 records and so far in 2018, six financial penalties have been issued to HIPAA covered entities to resolve HIPAA violations. The average settlement/civil monetary penalty in 2018 is $1,491,166. State attorneys general also investigate data breaches and complaints and can also issue fines for noncompliance with HIPAA Rules. There have been five fines issued by state attorneys general in 2018 to resolve...

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Massachusetts Gynecologist Spared Jail Time for Criminal HIPAA Violation
Sep25

Massachusetts Gynecologist Spared Jail Time for Criminal HIPAA Violation

In April 2018, the former Massachusetts-based gynecologist Rita Luthra, 65, of Longmeadow, was convicted of criminally violating the HIPAA Privacy Rule and obstructing a federal investigation into a nationwide kickback scheme. At her sentencing on September 19, 2018, Luthra was spared jail time and a fine and was given one year of probation. Luthra was accused of being paid $23,500 to prescribe Warner Chilcott’s osteoporosis drugs, although Luthra maintained she had been paid the money as ‘speaker fees’ for speaking at medical educational events, which took place in her office, and for writing a research paper, although that paper was never finished. The jury found that Luthra lied to federal agents about money she had received from the pharmaceutical firm. Luthra also denied providing a pharmaceutical sales representative with access to patient health information in order to complete pre-authorization forms for insurance companies that were refusing to approve prescriptions for two osteoporosis drugs that Warner Chilcott was pushing. She also allegedly instructed her assistant to...

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UMass Memorial Health Care Pays $230,000 to Resolve Alleged HIPAA Violations
Sep24

UMass Memorial Health Care Pays $230,000 to Resolve Alleged HIPAA Violations

Mass Memorial Health Care has been fined $230,000 by the Massachusetts attorney general for HIPAA failures related to two data breaches that exposed the protected health information (PHI) of more than 15,000 state residents. A lawsuit was filed against UMass Memorial Health Care in which attorney general Maura Healey claimed UMass Memorial Medical Group Inc., and UMass Memorial Medical Center Inc., failed to implement sufficient measures to protect patients’ sensitive health information. In two separate incidents, employees accessed and copied patient health information without authorization and used that information to open cell phone and credit card accounts in the victims’ names. It was also alleged that UMass Memorial Medical Group Inc., and UMass Memorial Medical Center Inc., were both aware of employee misconduct, yet failed to properly investigate complaints related to data breaches and discipline the employees concerned in a timely manner. Both entities also failed to ensure that patients’ PHI was properly safeguarded. These failures violated Massachusetts data security...

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August 2018 Healthcare Data Breach Report
Sep21

August 2018 Healthcare Data Breach Report

August was a much better month for the healthcare industry with fewer data breaches reported than in July. In August, 28 healthcare data breaches were reported to the HHS’ Office for Civil Rights, a 17.86% month-over-month reduction in data breaches. There was also a major reduction in the number of healthcare records that were exposed or stolen. In August, 623,688 healthcare records were exposed or stolen – A 267.56% reduction from August, when 2,292,522 healthcare records were breached. Causes of Healthcare Data Breaches in August 2018 Hacking incidents dominated the breach reports in August, accounting for 53.57% of all reported data breaches and 95.73% of all records exposed or disclosed in August. Eight of the top ten breaches were the result of hacks, malware, or ransomware attacks. Insider breaches are a major problem in the healthcare industry, more so than other verticals. In August there were nine insider breaches – 32.14% of the healthcare data breaches in August. Those breaches involved the unauthorized access or impermissible disclosure of 18,488 healthcare...

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$999,000 in HIPAA Penalties for Three Hospitals for Boston Med HIPAA Violations
Sep20

$999,000 in HIPAA Penalties for Three Hospitals for Boston Med HIPAA Violations

Three hospitals that allowed an ABC film crew to record footage of patients as part of the Boston Med TV series have been fined $999,000 by the Department of Health and Human Services’ Office for Civil Rights (OCR) for violating Health Insurance Portability and Accountability Act (HIPAA) Rules. This is the second HIPAA violation case investigated by OCR related to the Boston Med TV series. On April 16, 2016, New York Presbyterian Hospital settled its HIPAA violation case with OCR for $2.2 million to resolve the impermissible disclosure of PHI to the ABC film crew during the recording of the series and for failing to obtain consent from patients. Fines for Boston Medical Center, Brigham and Women’s Hospital, & Massachusetts General Hospital Boston Medical Center (BMC) settled its HIPAA violations with OCR for $100,000. OCR investigators determined that BMC had impermissibly disclosed the PHI of patients to ABC employees during production and filming of the TV series, violating 45 C.F.R. § 164.502(a). Brigham and Women’s Hospital (BWH) settled its HIPAA violations...

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CMS: Fairview Southdale Hospital Videotaped Patients Without Knowledge or Consent
Sep17

CMS: Fairview Southdale Hospital Videotaped Patients Without Knowledge or Consent

The HHS’ Centers for Medicare and Medicaid Services (CMS) has investigated Fairview Southdale Hospital in Edina, MN over an alleged violation of patient privacy. The CMS confirmed that patients were videotaped during psychiatric evaluations in the emergency department without their knowledge or consent.  The hospital was cited for violating patient privacy. According to the Star Tribune, the CMS launched an investigation following a complaint from a patient who had been taken to the hospital for a psychiatric evaluation against her will in May 2017. The patient was escorted to the hospital as police officers were concerned about her state of mental health and feared she may cause harm to herself or others. After being released, the patient took legal action over her admission to the hospital and how she was treated by the police. As part of that lawsuit, the patient requested a copy of the security camera footage from the hospital. While the patient expected to receive a copy of the videotape from the front of the hospital showing her entering the facility, the videotape showed her...

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Texas Nurse Fired for Social Media HIPAA Violation
Sep13

Texas Nurse Fired for Social Media HIPAA Violation

A nurse at a Texas children’s hospital has been fired for violating Health Insurance Portability and Accountability Act (HIPAA) Rules by posting protected health information on a social media website. The pediatric ICU/ER nurse worked at Texas Children’s Hospital and posted a series of comments on Facebook about a rare case of measles at the hospital. The nurse was an anti-vaxxer and posted about the experience of seeing a boy at the hospital suffering from the disease – a disease that could have been prevented through vaccination. Her comments explained how the disease was much worse that she expected it to be, having not encountered anyone with the measles in the past.  She explained that it was a “rough” experience seeing the boy suffering from the disease. She also explained in one of her posts, “I think it’s easy for us non-vaxxers to make assumptions, but most of us have never and will never see one of these diseases,” according to the Houston Chronicle, which obtained screenshots of her Facebook posts. “By no means have I changed my vax stance, and I never will. But this...

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Hurricane Florence: OCR Issues Guidance on Appropriate Sharing of Health Information
Sep13

Hurricane Florence: OCR Issues Guidance on Appropriate Sharing of Health Information

On Wednesday, September 12, 2018, President Trump approved a request for a federal emergency declaration in the state of Virginia and made FEMA resources available for the state. The Secretary of the U.S. Department of Health and Human Services, Alex Azar, has also declared a Public Health Emergency in Virginia, North Carolina, and South Carolina. The Secretarial declaration eases certain HIPAA restrictions and helps Centers for Medicare & Medicaid Services’ (CMS) beneficiaries and their healthcare providers prepare for the possible impact of Hurricane Florence and provides greater flexibility to meet emergency health needs. During severe disasters and public emergencies healthcare providers face increased challenges and may struggle to continue to meet all requirements of the HIPAA Privacy Rule. In emergency situations, such as during hurricanes, the HIPAA Privacy Rule still applies; however, Alex Azar’s declaration of a Public Health Emergency means certain provisions of the Privacy Rule have been relaxed under the Project Bioshield Act of 2004 (PL 108-276) and section...

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Healthcare Organizations Reminded of Importance of Securing Electronic Media and Devices Containing ePHI
Sep06

Healthcare Organizations Reminded of Importance of Securing Electronic Media and Devices Containing ePHI

In its August 2018 cybersecurity newsletter, the Department of Health and Human Services’ Office for Civil Rights has reminded HIPAA-covered entities of the importance of implementing physical, technical, and administrative safeguards to ensure the confidentiality, integrity, and availability of electronic protected health information (ePHI) that is processed, transmitted, or stored on electronic media and devices. Electronic devices such as desktop computers, laptops, servers, smartphones, and tablets play a vital role in the healthcare, as do electronic media such as hard drives, zip drives, tapes, memory cards, and CDs/DVDs. However, the portability of many of those devices/media means they can easily be misplaced, lost, or stolen. Physical controls are therefore essential. Anyone with physical access to electronic devices or media, whether healthcare employees or malicious actors, potentially have the ability to view, change, or delete data. Device configurations could be altered or malicious software such as ransomware or malware could be installed. All of these actions...

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NY Attorney General Fines Arc of Erie County $200,000 for Security Breach
Sep04

NY Attorney General Fines Arc of Erie County $200,000 for Security Breach

The Arc of Erie County has been fined $200,000 by the New York Attorney General for violating HIPAA Rules by failing to secure the electronic protected health information (ePHI) of its clients. In February 2018, The Arc of Erie County, a nonprofit social services agency and chapter of the The Arc Of New York, was notified by a member of the public that some of its clients’ sensitive personal information was accessible through its website. The information could also be found through search engines. The investigation into the security breach revealed sensitive information had been accessible online for two and a half years, from July 2015 to February 2018 when the error was corrected. The forensic investigation into the security incident revealed multiple individuals from outside the United States had accessed the information on several occasions. The webpage should only have been accessible internally by staff authorized to view ePHI and should have required a username and password to be entered before access to the data could be gained. In total, 3,751 clients in New York had...

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Couple Sues McAlester Hospital Over Alleged Snooping and Impermissible Disclosure
Aug27

Couple Sues McAlester Hospital Over Alleged Snooping and Impermissible Disclosure

Following the accidental drowning of their adopted son, Denise and Wayne Russell were contacted by the child’s birth mother who made threats against their family. The phone call from the birth mother came shortly after their son was admitted to McAlester Regional Health Center following a tragic swimming pool accident. Their 2-year old child had fallen into the pool after the gate to the pool area had been accidentally left open. The parents administered CPR at the scene until the paramedics arrived and the child was rushed to hospital where he was later confirmed to have died. Shortly after their son died, the Russells received the telephone call from the birth mother. When asked how she knew about the accident and death of the child, she confirmed that she had been informed by the hospital. The birth month screamed at the Russells and made multiple threats, according to Denise Russell, including a threat to kill their other son. The situation became so bad that a protective order was filed against their son’s birth mother. The Russells had taken care of their adopted son Keon...

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Lawmakers Accuse Oklahoma Department of Veteran Affairs of Violating HIPAA Rules
Aug13

Lawmakers Accuse Oklahoma Department of Veteran Affairs of Violating HIPAA Rules

The Oklahoma Department of Veteran Affairs has been accused of violating Health Insurance Portability and Accountability Act (HIPAA) Rules by three Democrat lawmakers, who have also called for two top Oklahoma VA officials to be fired over the incident. The alleged HIPAA violation occurred during a scheduled internet outage, during which VA medical aides were prevented from gaining access to veterans’ medical records. The outage had potential to cause major disruption and prevent “hundreds” of veterans from being issued with their medications. To avoid this, the Oklahoma Department of Veteran Affairs allowed medical aides to access electronic medical records using their personal smartphones. In a letter to Oklahoma Governor Mary Fallin, Reps. Brian Renegar, Chuck Hoskin, and David Perryman called for the VA Executive Director Doug Elliot and the clinical compliance director Tina Williams to be fired over the alleged HIPAA violation. They claimed Elliot and Williams “have little regard for, and knowledge of, health care,” and allowing medical aides to access electronic medical...

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Healthcare Organizations Reminded of HIPAA Rules for Disposing of Electronic Devices
Aug07

Healthcare Organizations Reminded of HIPAA Rules for Disposing of Electronic Devices

In its July Cybersecurity Newsletter, the Department of Health and Human Services’ Office for Civil Rights has reminded HIPAA covered entities about HIPAA Rules for disposing of electronic devices and media. Prior to electronic equipment being scrapped, decommissioned, returned to a leasing company or resold, all electronic protected health information (ePHI) on the devices must be disposed of in a secure manner. HIPAA Rules for disposing of electronic devices cover all electronic devices capable of storing PHI, including desktop computers, laptops, servers, tablets, mobile phones, portable hard drives, zip drives, and other electronic storage devices such as CDs, DVDs, and backup tapes. Healthcare organizations also need to be careful when disposing of other electronic equipment such as fax machines, photocopiers, and printers, many of which store data on internal hard drives. These devices in particular carry a high risk of a data breach at the end of life as they are not generally thought of as devices capable of storing ePHI. If electronic devices are not disposed of securely...

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NIST/NCCoE Release Guide for Securing Electronic Health Records on Mobile Devices
Aug06

NIST/NCCoE Release Guide for Securing Electronic Health Records on Mobile Devices

The HIPAA Security Rule requires HIPAA-covered entities to ensure the confidentiality, integrity, and availability of electronic protected health information at all times. Healthcare organizations must ensure patients’ health is not endangered, their privacy is protected, and their identities are not compromised. A range of physical, technical, and administrative controls can be implemented to secure ePHI on servers and desktop computers, but ensuring the same level of security for mobile devices can be a major challenge. Mobile devices offer many benefits for healthcare providers. They can improve access to protected health information, ensure that data can be accessed anywhere, and they help healthcare providers improve coordination of care. However, when ePHI is stored on mobile devices such as laptops, tablets and mobile phones, or is transmitted using those devices, it is particularly vulnerable. Mobile devices are easy to lose, are often stolen, and data transmitted through mobile devices can also be vulnerable to interception. In healthcare, mobile device security is a major...

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HHS Secretary Alex Azar Promises Reforms to Federal Health Privacy Rules
Jul30

HHS Secretary Alex Azar Promises Reforms to Federal Health Privacy Rules

At a July 27 address at The Heritage Foundation, Secretary of the Department of Health and Human Services (HHS), Alex Azar, explained that the HHS will be undertaking several updates to health privacy regulations over the coming months, including updates to the Health Insurance Portability and Accountability Act (HIPAA) and 45 CFR Part 2 (Part 2) regulations. The process is expected to commence in the next couple of months. Requests for information on HIPAA and Part 2 will be issued, following which action will be taken to reform both sets of rules to remove obstacles to value-based care and support efforts to combat the opioid crisis. Rule changes are also going to be made to remove some of the barriers to data sharing which are currently hampering efforts by healthcare providers to expand the use of electronic health technology. These requests for information are part of a comprehensive review of current regulations that are hampering the ability of doctors, hospitals, and payers to improve the quality healthcare services and coordination of care while helping to reduce...

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Investigation Launched Over Snapchat Photo Sharing at M.M. Ewing Continuing Care Center
Jul19

Investigation Launched Over Snapchat Photo Sharing at M.M. Ewing Continuing Care Center

Certain employees of a Canandaigua, NY nursing home have been using their smartphones to take photographs and videos of at least one resident and have shared those images and videos with others on Snapchat – a violation of HIPAA and serious violation of patient privacy. The privacy breaches occurred at Thompson Health’s M.M. Ewing Continuing Care Center and involved multiple employees. Thompson Health has already taken action and has fired several workers over the violations. Now the New York Department of Health and the state attorney general’s office have got involved and are conducting investigations. The state attorney general’s Deputy Press Secretary, Rachel Shippee confirmed to the Daily Messenger that an investigation has been launched, confirming “The Medicaid Fraud Control Unit’s mission includes the protection of nursing home residents from abuse, neglect and mistreatment, including acts that violate a resident’s rights to dignity and privacy.” Thompson Health does not believe the images/videos were shared publicly and sharing was restricted to a group of employees at the...

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Federal Court Rules in Favor of Main Line Health in Age Discrimination Case Over HIPAA Violation
Jul09

Federal Court Rules in Favor of Main Line Health in Age Discrimination Case Over HIPAA Violation

In 2016, Radnor, PA-based Main Line Health Inc., terminated an employee for violating Health Insurance Portability and Accountability Act (HIPAA) Rules by accessing the personal records of a co-worker without authorization on two separate occasions. In such cases, when employee or patient records are accessed without authorization, employees face disciplinary action which can include termination. Gloria Terrell was one such employee who was terminated for violating company policies and HIPAA Rules. Main Line Health fired Terrell for “co-worker snooping.” Terrell filed an internal appeal over her termination and maintained she accessed the records of a co-worker in order to obtain a contact telephone number. Terrell said she needed to contact the co-worker to make sure a shift would be covered, and this constituted a legitimate business reason for the access as she was unable to find the phone list with employees’ contact numbers. After firing Terrell, Main Line Health appointed a significantly younger person to fill the vacant position. Terrell took legal action against Main Line...

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Healthcare Worker Charged with Criminally Violating HIPAA Rules
Jul03

Healthcare Worker Charged with Criminally Violating HIPAA Rules

A former University of Pittsburgh Medical Center patient information coordinator has been indicted by a federal grand jury over criminal violations of HIPAA Rules, according to an announcement by the Department of Justice on June 29, 2018. Linda Sue Kalina, 61, of Butler, Pennsylvania, has been charged in a six-count indictment that includes wrongfully obtaining and disclosing the protected health information of 111 patients. Kalina worked at the University of Pittsburgh Medical Center and the Allegheny Health Network between March 30, 2016 and August 14, 2017. While employed at the healthcare organizations, Kalina is alleged to have accessed the protected health information (PHI) of those patients without authorization or any legitimate work reason for doing so. Additionally, Kalina is alleged to have stolen PHI and, on four separate occasions between December 30, 2016, and August 11, 2017, disclosed that information to three individuals with intent to cause malicious harm. Kalina was arrested following an investigation by the Federal Bureau of Investigation. The case was taken up...

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OCR Draws Attention to HIPAA Patch Management Requirements
Jul03

OCR Draws Attention to HIPAA Patch Management Requirements

Healthcare organizations have been reminded of HIPAA patch management requirements to ensure the confidentiality, integrity, and availability of ePHI is safeguarded. Patch Management: A Major Challenge for Healthcare Organizations Computer software often contains errors in the code that could potentially be exploited by malicious actors to gain access to computers and healthcare networks. Software, operating system, and firmware vulnerabilities are to be expected. No operating systems, software application, or medical device is bulletproof. What is important is those vulnerabilities are identified promptly and mitigations are put in place to reduce the probability of the vulnerabilities being exploited. Security researchers often identify flaws and potential exploits. The bugs are reported to manufacturers and patches are developed to fix the vulnerabilities to prevent malicious actors from taking advantage. Unfortunately, it is not possible for software developers to test every patch thoroughly and identify all potential interactions with other software and systems and still...

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Unencrypted Hospital Pager Messages Intercepted and Viewed by Radio Hobbyist
Jun26

Unencrypted Hospital Pager Messages Intercepted and Viewed by Radio Hobbyist

Many healthcare organizations have now transitioned to secure messaging systems and have retired their outdated pager systems. Healthcare organizations that have not yet made the switch to secure text messaging platforms should take note of a recent security breach that saw pages from multiple hospitals intercepted by a ‘radio hobbyist’ in Missouri. Intercepting pages using software defined radio (SDR) is nothing new. There are various websites that explain how the SDR can be used and its capabilities, including the interception of private communications. The risk of PHI being obtained by hackers using this tactic has been well documented.  All that is required is some easily obtained hardware that can be bought for around $30, a computer, and some free software. In this case, an IT worker from Johnson County, MO purchased an antenna and connected it to his laptop in order to pick up TV channels. However, he discovered he could pick up much more. By accident, he intercepted pages sent by physicians at several hospitals. The man told the Kansas City Star he intercepted pages...

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District Court Ruling Confirms No Private Cause of Action in HIPAA
Jun25

District Court Ruling Confirms No Private Cause of Action in HIPAA

Patients who believe HIPAA Rules have been violated can submit a compliant to the Department of Health and Human Services’ Office for Civil Rights, but they do not have the right to take legal action, at least not for the HIPAA violation. There is no individual private cause of action under HIPAA law. Several patients have filed lawsuits over alleged HIPAA violations, although the cases have not proved successful. A recent case has confirmed once again that there is no private cause of action in HIPAA, and lawsuits filed solely on the basis of a HIPAA violation are extremely unlikely to succeed. Ms. Hope Lee-Thomas filed the lawsuit for an alleged HIPAA violation that occurred at Providence Hospital in Washington D.C., where she received treatment from LabCorp. Ms. Lee-Thomas, who represented herself in the action, claims that while at the hospital on June 15, 2017, a LabCorp employee instructed her to enter her protected health information at a computer intake station. Ms. Lee-Thomas told the LabCorp employee that the information was in full view of another person at a different...

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Overdose Prevention and Patient Safety Act Passed by House
Jun22

Overdose Prevention and Patient Safety Act Passed by House

The Overdose Prevention and Patient Safety Act – H.R. 6082 – aims to ease restrictions on the sharing of health records of patients with addictions, aligning 42 CFR Part 2 – Confidentiality of Substance Use Disorder Patient Records – with HIPAA. Currently, 42 CFR Part 2 only permits the disclosure of health records of patients with substance abuse disorder without written consent to medical staff in emergency situations, to specified individuals for research and program evaluations, or if required to do so by means of a court order. Under current regulations, a special release form must be signed by a patient authorizing the inclusion of substance abuse disorder information in their medical record. Preventing doctors from having access to a patient’s entire medical history means decisions could be taken without full understanding of their potential consequences. If details of substance abuse disorder can be accessed, doctors will be able to make more informed decisions which will help them to safely and effectively treat patients. The Overdose Prevention and Patient Safety...

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Is Rackspace HIPAA Compliant?
Jun21

Is Rackspace HIPAA Compliant?

The Windcrest, TX-based managed cloud computing company Rackspace offers public cloud and email hosting services, but can they be used by HIPAA-covered entities without violating HIPAA Rules? Is Rackspace HIPAA compliant? Will Rackspace Sign a Business Associate Agreement with HIPAA Covered Entities? Rackspace is aware that by allowing healthcare organizations to use its services, the company is classed as a HIPAA business associate and must agree to comply with the HIPAA Privacy and Security Rules. Rackspace has obtained HITRUST and HITRUST CSF certifications which demonstrate the company meets the data and privacy security standards demanded by HIPAA for managed public, private, and hybrid cloud environments. The company uses extended SSL encryption and meets PCR DSS data security requirements. The company provides assistance to healthcare companies to help them use its services and comply with HIPAA Rules and develop an approach that satisfies HIPAA Rules and meets their business needs. Rackspace will also sign a business associate agreement for its dedicated hosting services,...

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Washington Health System Suspends Several Employees for Inappropriate PHI Access
Jun21

Washington Health System Suspends Several Employees for Inappropriate PHI Access

Following the alleged inappropriate accessing of patient health records by employees, Washington Health System has taken the decision to suspend several employees while the privacy breach is investigated. While it has not been confirmed how many employees have been suspended, Washington Health System VP of strategy and clinical services, Larry Pantuso, issued a statement to the Observer Reporter indicating around a dozen employees have been suspended, although at this stage, no employees have been fired for inappropriate medical record access. The privacy breaches are believed to relate to the death of an employee of the WHS Neighbor Health Center. Kimberly Dollard, 57, was killed when an out of control car driven by Chad Spence, 43, rammed into the building where she worked. Spence and one other individual were admitted to the hospital after sustaining injuries in the accident. Pantuso did not confirm that this was the incident that prompted the employees to access patients’ medical records, although he did confirm that the alleged inappropriate access related to a “high profile...

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May 2018 Healthcare Data Breach Report
Jun19

May 2018 Healthcare Data Breach Report

April was a particularly bad month for healthcare data breaches with 41 reported incidents. While it is certainly good news that there has been a month-over-month reduction in healthcare data breaches, the severity of some of the breaches reported last month puts May on a par with April. There were 29 healthcare data breaches reported by healthcare providers, health plans, and business associates of covered entities in May – a 29.27% month-over month reduction in reported breaches. However, 838,587 healthcare records were exposed or stolen in those incidents – only 56,287 records fewer than the 41 incidents in April. In May, the mean breach size was 28,917 records and the median was 2,793 records. In April the mean breach size was 21,826 records and the median was 2,553 records. Causes of May 2018 Healthcare Data Breaches Unauthorized access/disclosure incidents were the most numerous type of breach in May 2018 with 15 reported incidents (51.72%). There were 12 hacking/IT incidents reported (41.38%) and two theft incidents (6.9%). There were no lost unencrypted electronic devices...

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OCR Announces $4.3 Million Civil Monetary Penalty for University of Texas MD Anderson Cancer Center
Jun19

OCR Announces $4.3 Million Civil Monetary Penalty for University of Texas MD Anderson Cancer Center

The Department of Health and Human Services’ Office for Civil Rights has announced its fourth largest HIPAA violation penalty has been issued to The University of Texas MD Anderson Cancer Center (MD Anderson). MD Anderson has been ordered to pay $4,348,000 in civil monetary penalties to resolve the HIPAA violations related to three data breaches experienced in 2012 and 2013. MD Anderson is an academic institution and a cancer treatment and research center based at the Texas Medical Center in Houston, TX. Following the submission of three breach reports in 2012 and 2013, OCR launched an investigation to determine whether the breaches were caused as a result of MD Anderson having failed to comply with HIPAA Rules. The breaches in question were the theft of an unencrypted laptop computer from the home of an MD Anderson employee and the loss of two unencrypted USB thumb drives, each of which contained the electronic protected health information (ePHI) of its patients. In total, the PHI of 34,883 patients was exposed and could potentially have been viewed by unauthorized individuals....

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3-Year Jail Term for VA Employee Who Stole Patient Data
Jun18

3-Year Jail Term for VA Employee Who Stole Patient Data

A former employee of the Veteran Affairs Medical Center in Long Beach, CA who stole the protected health information (PHI) of more than 1,000 patients has been sentenced to three years in jail. Albert Torres, 51, was employed as a clerk in the Long Beach Health System-run medical center – a position he held for less than a year. Torres was pulled over by police officers on April 12 after a check of his license plates revealed an anomaly – plates had been used on a private vehicle, which were typically reserved for commercial vehicles. The police officers found prescription medications which Torres’ did not have a prescription for and the Social Security numbers and other PHI of 14 patients in his vehicle. A subsequent search of Torres’ apartment revealed he had hard drives and zip drives containing the PHI of 1,030 patients and more than $1,000 in cleaning supplies that had been stolen from the hospital. After pleading guilty to several crimes, including identity theft and grand theft, Torres was sentenced to three years in state penitentiary on June 4. Sutter Health Fires...

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OCR Issues Guidance on Individual Authorization of Uses and Disclosures of PHI for Research
Jun15

OCR Issues Guidance on Individual Authorization of Uses and Disclosures of PHI for Research

The Department of Health and Human Services’ Office for Civil Rights has issued new guidance for HIPAA-covered entities to streamline HIPAA authorizations for uses of protected health information for research purposes, as required by the 21st Century Cures Act of 2016. Uses and Disclosure of PHI for Research The HIPAA Privacy Rule does permit covered entities to use patients’ PHI for research without obtaining individual authorizations under certain circumstances, such as if documented Institutional Review Board (IRB) or Privacy Board Approval has been obtained – see 45 CFR § 164.512(i)(1)(i) and (ii). However, in most cases, prior to using patients’ PHI for research, individual authorizations must be obtained from patients in writing. Without a valid authorization from a patient, their PHI can only be used or disclosed for purposes permitted by the Privacy Rule. The new guidance explains the content that must be included in individual authorizations to meet HIPAA requirements. OCR explains that individual authorizations must: Be written in plain language to ensure they can be...

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Is SendGrid HIPAA Compliant?
Jun14

Is SendGrid HIPAA Compliant?

SendGrid is an email marketing platform that allows companies to quickly and easily communicate their marketing messages to customers, but can the platform be used by healthcare organizations? Is SendGrid HIPAA compliant? HIPAA Compliant Email Services Providers of cloud-based email services are not exempt from compliance with HIPAA under the conduit exception rule. If a HIPAA-covered entity wants to use an email service to communicate with patients, no protected health information (PHI) can be included in the messages unless the requirements of HIPAA are satisfied. If PHI needs to be included in emails, the email service provider would be classed as a business associate and a business associate agreement (BAA) would need to be entered into by both parties. The business associate agreement (BAA) outlines the responsibilities of the business associate with respect to HIPAA and provides the covered entity with ‘reasonable assurances’ that HIPAA Rules will be followed by staff and the platform includes appropriate security controls to ensure the confidentiality, integrity, and...

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12-Month Suspension for Nurse Who Provided Patient Information to New Employer
Jun08

12-Month Suspension for Nurse Who Provided Patient Information to New Employer

The New York State Education Department has suspended the license of a nurse practitioner for violating the privacy of patients by providing their contact information to her new employer. In April 2015, Martha C. Smith-Lightfoot took a spreadsheet containing the personally identifiable information of approximately 3,000 patients of University of Rochester Medical Center (URMC) and gave that information to her new employer, Greater Rochester Neurology. The privacy violation was uncovered when several patients complained to URMC about being contacted by Greater Rochester Neurology about switching providers. Prior to leaving URMC, Smith-Lightfoot requested information on patients she has treated in order to ensure continuity of care.  URMC provider her with a spreadsheet that contained names, addresses, dates of birth, and diagnoses. URMC did not authorize Smith-Lightfoot to take the spreadsheet with her when she left employment. The provision of the patient list to Greater Rochester Neurology was an impermissible disclosure of PHI and a violation of the HIPAA Privacy Rule. When it...

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Lawsuits Filed Over Alleged HIPAA Violations
Jun05

Lawsuits Filed Over Alleged HIPAA Violations

Two lawsuits have recently been filed in relation to alleged breaches of Health Insurance Portability and Accountability Act (HIPAA) Rules, one by a former hospital employee and another by a patient whose privacy was allegedly violated by a CVS pharmacy employee. Former Employee of Mosaic Life Care Medical Center Takes Legal Action over Dismissal A former employee of Mosaic Life Care Medical Center in St. Joseph, MO is taking legal action over wrongful discharge and retaliation for her taking steps to avoid a violation of the False Claims Act. Debra Conard, 57, alleges she was wrongfully terminated for raising concerns about unlawful, unethical, and fraudulent billing practices. According to the lawsuit, in April 2017, Conard was instructed by hospital officials to release charges for billing even though the documentation did not support the claims. Multiple charges were required to be pushed through, which would induce payment by Medicare and other third parties, even though Conrad could not verify that the claims were correct. Conrad raised her concerns about potential violations...

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Colorado Governor Signs Data Protection Bill into Law
Jun05

Colorado Governor Signs Data Protection Bill into Law

Colorado Governor John Hickenlooper has signed a bill – HB 1128 – into law that strengthens protections for consumer data in the state of Colorado. The bipartisan bill, sponsored by Reps. Cole Wist (R) and Jeff Bridges (D) and Sens. Kent Lambert (R) and Lois Court (D), was unanimously passed by the Legislature. The bill will take effect from September 1, 2018. The bill requires organizations operating in the state of Colorado to implement reasonable security measures and practices to ensure the personal identifying information (PII) of state residents is protected. The bill also reduces the time for notifying the state attorney general about breaches of PII and introduces new rules for disposing of PII when it is no longer required. Personal information is classed as first name and last name or first initial and last name in combination with any of the following data elements (when not encrypted, redacted, or secured by another means that renders the information unreadable): Social Security number Student ID number Military ID number Passport number Driver’s license number or...

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Could Law Firms Targeting Patients in ER Rooms Using Geofencing Technology Violate HIPAA?
Jun01

Could Law Firms Targeting Patients in ER Rooms Using Geofencing Technology Violate HIPAA?

Questions are being raised about whether HIPAA Rules are being violated when attorneys send text messages and push notifications to patients who have visited emergency rooms and other medical facilities using geofencing technology. Marketers are using a range of clever tactics to sell products and services such as remarketing – The displaying of advertisements on websites to individuals who have previously viewed products on another website but not made a purchase. Similarly, the use of geofencing is growing in popularity. Geofencing is the creation of a digital fence around a specific location. When an individual crosses that invisible boundary, a push notification is sent to the users mobile phone. That location could be a store or any location. Retailers have been using the technology for some time, Google sends push notifications based on location, and now attorneys are getting in on the act. This tactic of targeting specific individuals is being offered by at least one digital marketing firm and the service is being offered to attorneys. In this case the geofence is around...

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Aetna Files Further Lawsuit in an Attempt to Recover Costs from 2017 HIV Status Privacy Breach
Jun01

Aetna Files Further Lawsuit in an Attempt to Recover Costs from 2017 HIV Status Privacy Breach

There have been further developments in the ongoing legal battles over a 2017 privacy breach experienced by Aetna involving the exposure of patients’ sensitive health information. A further lawsuit has been filed by the insurer in an attempt to recover the costs incurred as a result of the breach. Ongoing Legal Battles Over the Exposure of Patients’ HIV Statuses In 2017, the health insurer Aetna experienced a data breach that saw highly sensitive patient information impermissibly disclosed to other individuals. A mailing vendor sent letters to patients using envelopes with clear plastic windows and information about HIV medications were allegedly visible. The mailings related to HIV medications used to treat patients who had already contracted HIV and individuals who were taking drugs as pre-exposure prophylaxis. Approximately 12,000 patients received the mailing. Lawsuits were filed on behalf of patients whose HIV positive status was impermissibly disclosed, which were settled in January for $17.2 million. A settlement was agreed with the New York state attorney general for a...

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OCR Reminds Covered Entities Not to Overlook Physical Security Controls
May31

OCR Reminds Covered Entities Not to Overlook Physical Security Controls

The Department of Health and Human Services’ Office for Civil Rights (OCR) has reminded covered entities that HIPAA not only requires technical controls to be implemented to ensure the confidentiality, integrity, and availability of protected health information, but also appropriate physical security controls. Physical controls are often the simplest and cheapest forms of protection to keep PHI private and confidential, yet these security controls are often overlooked. Some physical security controls cost nothing – such as ensuring portable electronic devices (laptop computers, portable storage devices, and pen drives) are locked away when they are not in use. While this is a very basic form of security, it is one of the most effective ways of preventing theft and one that can prove incredibly costly if overlooked. OCR draws attention to a 2015 HIPAA breach settlement with Lahey Hospital and Medical Center. An unencrypted laptop computer was stolen from the Tufts Medical School affiliated teaching hospital resulting in the exposure 599 patients’ ePHI. The laptop computer was used...

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CMS Urged to Aggressively Enforce Compliance with HIPAA Administrative Simplifications
May25

CMS Urged to Aggressively Enforce Compliance with HIPAA Administrative Simplifications

The Department of Health and Human Services’ Office for Civil Rights is the primary enforcer of HIPAA Rules and has issued numerous financial penalties for HIPAA violations in response to complaints and data breaches. State attorneys general are also permitted to fine HIPAA-covered entities when violations of HIPAA Rules are discovered, and several state attorneys general have exercised that right. While the HHS’ Centers for Medicare & Medicaid Services is mandated to assist OCR with the enforcement of HIPAA Rules related to compliance with the HIPAA Administrative Simplifications, to date the CMS has not issued any fines. The Medical Group Management Association (MGMA) believes that should change and the CMS should start enforcing compliance with HIPAA Rules that aim to reduce the administrative burden on healthcare providers. In a recent letter to CMS, the MGMA explained it has received many complaints from members related to the failure of health plans to comply with HIPAA and ACA administrative simplification requirements. The lack of enforcement activity by the CMS in...

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OCR Plans to Share HIPAA Violation Settlements with Breach Victims
May23

OCR Plans to Share HIPAA Violation Settlements with Breach Victims

The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009 and includes a provision that calls for the Department of Health and Human Services to share a percentage of HIPAA settlements with victims of HIPAA violations and data breaches. This month has seen some progress in that area. The Department of Health and Human Services’ Office for Civil Rights has announced it is planning on issuing an advance notice of proposed rulemaking in November about sharing a percentage of the fines it collects through its HIPAA enforcement activities with the victims of data breaches. OCR officials have previously made it clear that steps will be taken to meet the requirements of this HITECH provision, but little progress has been made. This is not the first time that OCR has announced it plans to issue an advance notice of proposed rulemaking on the matter only for the advance notice of proposed rulemaking to be delayed. If OCR follows through on its plans this fall, feedback will be sought from the public and industry stakeholders on how it can achieve...

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Jury Must Decide Whether Psychiatrist was Sacked for a HIPAA Violation
May22

Jury Must Decide Whether Psychiatrist was Sacked for a HIPAA Violation

Boston-based Steward Healthcare System terminated a psychiatrist for violating HIPAA Rules but must now prove to a jury that was the case. The psychiatrist claims he was fired in retaliation over taking extended disability leave, not for a HIPAA violation. Dr. Alexander Lipin contracted pneumonia and requested extended disability leave under the Family Medical Leave Act (FMLA). Extended leave was granted by Steward Healthcare System and Lipin was due to return to work on March 2, 2016. However, Lipin was fired on February 23 while still on disability leave over a HIPAA violation, which his attorney, Kavita M. Goyal, claims was used as an excuse for the termination. Steward Healthcare System alleged Lipin had violated HIPAA Rules by providing patients’ protected health information to law enforcement. According to Steward Medical Group President, George Clairmont, the decision had been taken to fire Lipin over the HIPAA violation before he took leave. Clairmont also stated Lipin was fired after it was discovered he was working for Anna Jaques Hospital while on leave. Lipin sued...

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GAO: Medical Records Can be Difficult and Expensive to Obtain
May17

GAO: Medical Records Can be Difficult and Expensive to Obtain

A recent audit conducted by the Government Accountability Office (GAO) has shown patients still face many challenges obtaining copies of their health information and healthcare providers and insurers are struggling to meet HIPAA requirements – and in some cases – are violating HIPAA Rules. A 21st Century Cures Act provision required GAO to conduct a study on patient access to medical records. The audit involved interviews with stakeholders, vendors, provider organizations, patient advocates, and state and HHS officials. The audit was conducted in four states – Ohio, Kentucky, Rhode Island and Wisconsin – which were chosen, in part, due to the range of fees charged for providing patients with copies of their medical records. Under HIPAA, patients are permitted to request copies of their health records from their providers. Patients can request their health records in paper or digital form and the requests must be processed within 30 days. HIPAA-covered entities are allowed to charge a reasonable, cost-based fee for providing patients with copies of their health data. Patients obtain...

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DoD IG Discovers Serious Flaws in Navy and Air Force EHR and Security Systems and Potential HIPAA Violations
May09

DoD IG Discovers Serious Flaws in Navy and Air Force EHR and Security Systems and Potential HIPAA Violations

A Department of Defense Inspector General (DoDIG) audit of the electronic health record (EHR) and security systems at the Defense Health Agency (DHA), Navy, and Air Force has uncovered serious security vulnerabilities that could potentially be exploited to gain access to systems and protected health information (PHI). This is the second DoDIG report from recent audits of military training facilities (MTFs). The first report revealed the DHA and Army had failed to consistently implement security protocols to safeguard EHRs and systems that stored, processed, or transmitted PHI. The latest report, which covers the DHA, Navy, and Air Force, has revealed serious vulnerabilities in 11 different areas. Inconsistency of implementing security protocols to protect EHRs and PHI, and the ineffective administrative, technical, and physical safeguards deployed constitute violations of Health Insurance Portability and Accountability Act (HIPAA) Rules. Those violations could attract financial penalties of up to $1.5 million per violation category. The DoDIG visited three Navy and two Air Force...

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Class Action Lawsuit Claims UnityPoint Health Mislead Patients over Severity of Phishing Attack
May08

Class Action Lawsuit Claims UnityPoint Health Mislead Patients over Severity of Phishing Attack

A class action lawsuit has been filed in response to a data breach at UnityPoint Health that saw the protected health information (PHI) of 16,429 patients exposed and potentially obtained by unauthorized individuals. As with many other healthcare data breaches, PHI was exposed as a result of employees falling for phishing emails. UnityPoint Health discovered the security breach on February 15, 2018 and sent breach notification letters to affected patients two months later, on or around April 16, 2018. HIPAA-covered entities have up to 60 days following the discovery of a data breach to issue notifications to patients. Many healthcare organizations wait before issuing breach notifications and submitting reports of the incident to the Department of Health and Human Services’ Office for Civil Rights. Waiting for two months to issue notifications to breach victims could be viewed as a violation of HIPAA Rules. While the maximum time limit for reporting was not exceeded, the HIPAA Breach Notification Rule requires notifications to be sent ‘without unnecessary delay.’ The HHS’ Office for...

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Massachusetts Physician Convicted for Criminal HIPAA Violation
May04

Massachusetts Physician Convicted for Criminal HIPAA Violation

Criminal penalties for HIPAA violations are relatively rare, although the Department of Justice does pursue criminal charges for HIPAA violations when there has been a serious violation of patient privacy, such as an impermissible disclosure of protected health information for financial gain or malicious purposes. One such case has resulted in two criminal convictions – a violation of the Health Insurance Portability and Accountability Act and obstructing a criminal healthcare investigation. The case relates to the DOJ investigation of the pharmaceutical firm Warner Chilcott over healthcare fraud. In 2015, Warner Chilcott plead guilty to paying kickbacks to physicians for prescribing its drugs and for manipulating prior authorizations to induce health insurance firms to pay for prescriptions. The case was settled with the DOJ for $125 million. Last week, a Massachusetts gynecologist, Rita Luthra, M.D., 67, of Longmeadow, was convicted for violating HIPAA by providing a Warner Chilcott sales representative with access to the protected health information of patients for a period of...

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OCR Encourages Healthcare Organizations to Conduct a Gap Analysis
May01

OCR Encourages Healthcare Organizations to Conduct a Gap Analysis

In its April 2018 cybersecurity newsletter, OCR draws attention to the benefits of performing a gap analysis in addition to a risk analysis. The latter is required to identify risks and vulnerabilities that could potentially be exploited to gain access to ePHI, while a gap analysis helps healthcare organizations and their business associates determine the extent to which they are compliant with specific elements of the HIPAA Security Rule. The Risk Analysis HIPAA requires covered entities and their business associates to perform a comprehensive, organization-wide risk analysis to identify all potential risks to the confidentiality, integrity, and availability of ePHI – 45 CFR § 164.308(a)(1)(ii)(A). If a risk analysis is not performed, healthcare organizations cannot be certain that all potential vulnerabilities have been identified. Vulnerabilities would likely remain that could be exploited by threat actors to gain access to ePHI. While HIPAA does not specify the methodology that should be used when conducting risk analyses, OCR explained in its newsletter that risk...

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How to Defend Against Insider Threats in Healthcare
Apr26

How to Defend Against Insider Threats in Healthcare

One of the biggest data security challenges is how to defend against insider threats in healthcare. Insiders are responsible for more healthcare data breaches than hackers, making the industry unique. Verizon’s Protected Health Information Data Breach Report highlights the extent of the problem. The report shows 58% of all healthcare data breaches and security incidents are the result of insiders. Healthcare organizations also struggle to detect insider breaches, with many breaches going undetected for months or even years. One healthcare employee at a Massachusetts hospital was discovered to have been accessing healthcare records without authorization for 14 years before the privacy violations were detected, during which time the records of more than 1,000 patients had been viewed. Healthcare organizations must not only take steps to reduce the potential for insider breaches, they should also implement technological solutions, policies, and procedures that allow breaches to be detected rapidly when they do occur. What are Insider Threats? Before explaining how healthcare...

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Healthcare Compliance Programs Not In Line With Expectations of Regulators
Apr23

Healthcare Compliance Programs Not In Line With Expectations of Regulators

Healthcare compliance officers are prioritizing compliance with HIPAA Privacy and Security Rules, even though the majority of Department of Justice and the HHS Office of Inspector General enforcement actions are not for violations of HIPAA or security breaches, but corrupt arrangements with referral sources and false claims. There are more penalties issued by regulators for these two compliance failures than penalties for HIPAA violations. HIPAA enforcement by the HHS’ Office for Civil Rights has increased, yet the liabilities to healthcare organizations from corrupt arrangements with referral sources and false claims are far higher. Even so, these aspects of compliance are relatively low down the list of priorities, according to a recent survey of 388 healthcare professionals conducted by SAI Global and Strategic Management Services. The survey was conducted on compliance officers from healthcare organizations of all sizes, from small physician practices to large integrated hospital systems. The aim of the study was to identify the key issues faced by compliance officers and...

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Former Berkeley Medical Center Worker Gets 5 Years’ Probation for Identity Theft
Apr17

Former Berkeley Medical Center Worker Gets 5 Years’ Probation for Identity Theft

In federal court on Monday, Chief U.S. District Judge Gina M. Groh sentenced a former Berkeley Medical Center worker to 5 years’ probation for her role in an identity theft scam. In addition to probation, Angela Dawn Roberts, 42, of Stephenson, VA, must pay $22,000 in restitution. Angela Dawn Roberts, also known as Angela Dawn Lee, had been working for WVU University Healthcare since 2014. Roberts was employed to schedule appointments for patients at two medical centers – Berkeley Medical Center and Jefferson Medical Center – which provided her with access to patients’ protected health information. Roberts copied sensitive information onto paper, including names, birth dates, and Social Security numbers, and in some cases printed copies of identity documents. On January 19, 2017, Roberts was suspended following an internal investigation into data theft which was alleged to have occurred on June 27, 2016. She was fired on January 27, 2017 and was prosecuted for stealing patient health information. Approximately 7,000 patients whose information was accessed by Roberts were...

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Analysis of March 2018 Healthcare Data Breaches
Apr16

Analysis of March 2018 Healthcare Data Breaches

There has been a month-over-month increase in healthcare data breaches. In March 2018, 29 security incidents were reported by HIPAA covered entities compared to 25 incidents in February. Even though more data breaches were reported in March, there was a fall in the number of individuals impacted by breaches. March 2018 healthcare data breaches saw 268,210 healthcare records exposed – a 13.13% decrease from the 308,780 records exposed in incidents in February. Causes of March 2018 Healthcare Data Breaches March saw the publication of the Verizon Data Breach Investigations Report which confirmed the healthcare industry is the only vertical where more data breaches are caused by insiders than hackers. That trend continued in March. Unauthorized access/disclosures, loss of devices/records, and improper disposal incidents were behind 19 of the 29 incidents reported – 65.5% of all incidents reported in March. The main cause of healthcare data breaches in March 2018 was unauthorized access/disclosure incidents. 14 incidents were reported, with theft/loss incidents the second main cause...

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2 to 6 Year Jail Term for Receptionist Who Stole PHI from Dentist Office
Apr11

2 to 6 Year Jail Term for Receptionist Who Stole PHI from Dentist Office

A former receptionist at a New York dental practice has been sentenced to serve 2 to 6 years in state penitentiary for stealing the protected health information of hundreds of patients. Annie Vuong, 31, was given access to the computer system and dental records of patients in order to complete her work duties. Vuong abused the access rights and stole the PHI of more than 650 patients. That information was passed to her co-defendants who used the data to steal identities and make fraudulent purchases of high value items. Vuong was arrested on February 2, 2015, following a two-and-a-half-year investigation into identity theft by the New York District Attorney’s Office. The theft of data occurred between May and November 2012, when the PHI of 653 patients was taken from the dental office. The types of information stolen included names, birth dates, and Social Security numbers. That information was shared with co-defendant Devin Bazile in an email. Bazile used the information to obtain credit lines from Barclaycard in the victims’ names. Credit ranged from $2,000 to $7,000 per...

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HHS Files Motion to Dismiss Ciox Health Lawsuit
Apr10

HHS Files Motion to Dismiss Ciox Health Lawsuit

The Department of Health and Human Services has filed a motion to dismiss a lawsuit filed by the healthcare information management company Ciox Health claiming the lawsuit lacks standing. Early this year, Ciox Health filed a lawsuit challenging changes to HIPAA in 2013 and subsequent enforcement guidance issued by the HHS in 2016. The changes to the HIPAA Privacy Rule in 2013 in question placed a limit on the amount that could be charged by covered entities for providing patients with copies of their health records. The charges must be limited to a reasonable cost-based fee. In 2016, the HHS issued guidance for the public explaining the rulemaking and providing answers to commonly asked questions about medical record access. Ciox Health claims the changes threaten to upend the medical records industry and that the updates and guidance are ultra vires, arbitrary and capricious. Ciox Health is also seeking injunctive relief to stop the HHS from unlawfully enforcing the regulations. In its motion to dismiss the lawsuit, filed in the U.S. District Court in Washington, D.C., HHS...

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Lack of Security Awareness Training Leaves Healthcare Organizations Exposed to Cyberattacks
Apr09

Lack of Security Awareness Training Leaves Healthcare Organizations Exposed to Cyberattacks

A recent study conducted by the Ponemon Institute on behalf of Merlin International has revealed healthcare organizations are failing to provide sufficient security awareness training to their employees, which is hampering efforts to improve their security posture. Phishing is a major security threat and the healthcare industry is being heavily targeted. Phishing offers threat actors an easy way to bypass healthcare organizations’ security defenses. Threat actors are now using sophisticated tactics to evade detection by security solutions and get their emails delivered. Social engineering techniques are used to fool employees into responding to phishing emails and disclose their login credentials or install malware. Phishing is used in a high percentage of cyberattacks on healthcare organizations. Research conducted by Cofense (formerly PhishMe) suggests as many as 91% of cyberattacks start with a phishing email. While security solutions can be implemented to block the majority of phishing emails from being delivered to end users’ inboxes, it is not possible to block 100% of...

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HIPAA Compliance for Pharmacies
Apr06

HIPAA Compliance for Pharmacies

HIPAA is a federal law that establishes the acceptable uses and disclosures of protected health information (PHI), sets standards for the secure storage and transmission of PHI, and gives patients the right to obtain copies of their PHI. HIPAA compliance for pharmacies is not an option. The penalties for failing to comply with HIPAA can be severe. Key Elements of HIPAA Compliance for Pharmacies The combined text of HIPAA Rules published by the Department of Health and Human Services’ Office for Civil Rights is 115 pages, so covering all elements of HIPAA compliance for pharmacies is beyond the scope of this post; however, some of the key elements of HIPAA compliance for pharmacies have been outlined below. Conduct risk analyses – A comprehensive, organization wide risk analysis must be conducted to identify all risks to the confidentiality, integrity, and availability of ePHI. Any risks identified must be subjected to a HIPAA-compliant risk management process. A risk analysis is not a onetime checkbox item. Risk analyses must be conducted regularly, such as when there is a change...

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Virtua Medical Group Fined $418,000 for Violations of HIPAA and New Jersey Law
Apr05

Virtua Medical Group Fined $418,000 for Violations of HIPAA and New Jersey Law

Virtua Medical Group – A network of physicians affiliated to over 50 medical practices in New Jersey – has been financially penalized by the New Jersey Attorney General’s Office for failing to protect the privacy of more than 1,650 patients whose medical information was accessible online without the need for any authentication. The electronic protected health information was exposed as a result of a misconfigured server. The error occurred at a business associate of the medical group – Best Medical Transcription – which had been provided with audio files to transcribe medical notes. Best Medical Transcription was contracted to transcribe dictations of medical notes, reports, and letters from three New Jersey medical practices: Virtua Pain and Spine Specialists in Voorhees, Virtua Gynecological Oncology Specialists, and Virtua Surgical Group in Hainesport. The transcribed notes were uploaded to a password-protected FTP website; however, in January 2016 during a software upgrade on the FTP server, the password protection was accidentally removed allowing patient...

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What Happens if You Break HIPAA Rules?
Apr03

What Happens if You Break HIPAA Rules?

HIPAA requires covered entities to provide training to staff to ensure HIPAA Rules and regulations are understood Healthcare employees should be aware of the possible penalties for HIPAA violations, but what are those penalties and what happens if you break HIPAA Rules? What Happens if You Break HIPAA Rules? If you break HIPAA Rules there are four potential outcomes: The violation could be dealt with internally by an employer You could be terminated You could face sanctions from professional boards You could face criminal charges which include fines and imprisonment What happens if you break HIPAA Rules will depend on the severity of the violation. The actions of employers, professional boards, federal regulators, and the Department of Justice will depend on several factors: The nature of the violation Whether there was knowledge that HIPAA Rules were being violated, or by exercising due diligence, it should have been clear that HIPAA Rules were being violated Whether action was taken to correct the violation Whether there was malicious intent or HIPAA Rules were violated for...

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What is Considered Protected Health Information Under HIPAA?
Apr02

What is Considered Protected Health Information Under HIPAA?

Protected health information – or PHI – is often mentioned in relation to HIPAA and healthcare, but what is considered protected health information under HIPAA? What is Considered Protected Health Information Under HIPAA Law? If you work in healthcare or are considering doing business with healthcare clients that requires access to health data, you will need to know what is considered protected health information under HIPAA law. The HIPAA Security Rule demands that safeguards be implemented to ensure the confidentiality, integrity, and availability of PHI, while the HIPAA Privacy Rule places limits the uses and disclosures of PHI. Violate any of the provisions in the HIPAA Privacy and Security Rules and you could be financially penalized. There are even criminal penalties for HIPAA violations. Claiming ignorance of HIPAA law is not a valid defense. Under HIPAA, protected health information is considered to be individually identifiable information relating to the health status of an individual, the provision of healthcare, or individually identifiable information that is created,...

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What to Do if You Discover a HIPAA Violation in the Workplace
Apr02

What to Do if You Discover a HIPAA Violation in the Workplace

You suspect there has been a HIPAA violation in the workplace, should you report the violation? If so, how should you report the potential violation and who needs to be told? Is it Necessary to Report a HIPAA Violation in the Workplace? If you think you have accidentally violated HIPAA Rules or you believe a work colleague or your employer is failing to comply with HIPAA Rules, the potential violation(s) should be reported. Since the passing of the HIPAA Enforcement Rule, HIPAA-covered entities can be financially penalized for HIPAA violations. If an uncorrected HIPAA violation is discovered during an investigation of a complaint, a data breach or HIPAA audit, the HHS’ Office for Civil Rights may choose to pursue a financial settlement to resolve the violation. Such actions are far less likely when a violation has been discovered internally and corrected to prevent a recurrence. If a patient’s privacy has been violated, by reporting the violation internally you will allow your employer to take steps to reduce the potential for further harm and will be helping to ensure that similar...

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What is the Relationship Between HITECH, HIPAA, and Electronic Health and Medical Records?
Apr02

What is the Relationship Between HITECH, HIPAA, and Electronic Health and Medical Records?

The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in August 1996, and was updated by the HIPAA Privacy Rule in 2003 and the HIPAA Security Rule in 2005, but how did the Health Information Technology for Economic and Clinical Health (HITECH) Act change HIPAA and what is the relationship between HITECH, HIPAA, and electronic health and medical records? What is the Relationship Between HITECH and HIPAA and Medical Records? Title I of HIPAA is concerned with the portability of health insurance and protecting the rights of workers between jobs to ensure health insurance coverage is maintained, which have nothing to do with the HITECH Act. However, there is a strong relationship between HITECH and HIPAA Title II. Title II of HIPAA includes the administrative provisions, patient privacy protections, and security controls for health and medical records and other forms of protected health information (PHI). One of the main aims of the HITECH Act was to encourage the adoption of electronic health and medical records by creating financial incentives for...

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What is Protected by HIPAA?
Mar31

What is Protected by HIPAA?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an important legislative Act that requires healthcare organizations that conduct transactions electronically to develop and implement controls to ensure the privacy of patients and security of healthcare data is safeguarded, but specifically, what is protected by HIPAA? What is Protected by HIPAA and How Must PHI be Safeguarded? All HIPAA covered entities should be well aware of the types of data that must be safeguarded in order to comply with HIPAA Rules, but many patients are unsure exactly what is protected by HIPAA. The HIPAA Privacy Rule requires HIPAA covered entities and their business associates to protect virtually all individually identifiable health information that is created, stored, maintained, or transmitted by HIPAA covered entities – typically healthcare providers, health plans and healthcare clearinghouses – and their business associates. The HIPAA Privacy Rule refers to individually identifiable health information as ‘Protected Health Information’ which includes past, present, and future...

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Security Breaches in Healthcare in the Last Three Years
Mar30

Security Breaches in Healthcare in the Last Three Years

There have been 955 major security breaches in healthcare in the last three years that have resulted in the exposure/theft of 135,060,443 healthcare records. More than 41% of the population of the United States have had some of their protected health information exposed as a result of those breaches, which have been occurring at a rate of almost one a day over the past three years. There has been a steady rise in reported security beaches in healthcare in the last three years. In 2015 there were 270 data breaches involving more than 500 records reported to the Department of Health and Human Services’ Office for Civil Rights. The figure rose to 327 security breaches in 2016, and 342 security breaches in 2017. More healthcare security breaches are being reported than at any other time since HIPAA required covered entities to disclose data breaches, although the number of individuals affected by healthcare data breaches has been declining year-over year for the past three years. In 2015, a particularly bad year for healthcare industry data breaches, 112,107,579 healthcare records were...

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Is Uber Health HIPAA Compliant?
Mar29

Is Uber Health HIPAA Compliant?

This March, Uber officially launched Uber Health – A platform that makes arranging transport for patients more straightforward and cost effective. The service should benefit patients and providers alike, although questions have been raised about HIPAA and whether Uber Health is HIPAA compliant. What is Uber Health? Uber Health consists of an online dashboard that healthcare providers can use to schedule transport for their patients in advance. Provided the patient has a mobile phone, he/she will receive a notification about the collection and drop off location via text message. In contrast to the standard Uber service, Uber Health does not require the use of a smartphone app. By using Uber Health, healthcare providers can potentially reduce the number of no shows and ensure more patients turn up on time for their appointments. Rides can be scheduled when the patient is in a facility, ensuring they have transport arranged for follow up appointments. The service could also be used for caregivers and staff. The official launch of the platform comes after a trial on around 100...

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Legislation Changes and New HIPAA Regulations in 2018
Mar29

Legislation Changes and New HIPAA Regulations in 2018

The policy of two out for every new regulation introduced means there are likely to be few, if any, new HIPAA regulations in 2018. However, that does not mean it will be all quiet on the HIPAA front. HHS’ Office for Civil Rights (OCR) director Roger Severino has indicated there are some HIPAA changes under consideration. OCR is planning on removing some of the outdated and labor-intensive elements of HIPAA that provide little benefit to patients, although before HIPAA changes are made, OCR will seek feedback from healthcare industry stakeholders. As with previous updates, OCR will submit notices of proposed rulemaking and will seek comment on the proposed changes. Those comments will be carefully considered before any HIPAA changes are made. The full list of proposed changes to the HIPAA Privacy Rule have not been made public, although Severino did provide some insight into what can be expected in 2018 at a recent HIPAA summit in Virginia. Severino explained there were three possible changes to HIPAA regulations in 2018, the first relates to enforcement of HIPAA Rules by OCR. Since...

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Study Suggests Improper Disposal of PHI is Commonplace
Mar29

Study Suggests Improper Disposal of PHI is Commonplace

A recent study (published in JAMA) has highlighted just how frequently hospitals are disposing of PHI in an insecure manner. While the study was conducted in Canada, which is not covered by HIPAA, the results highlight an important area of PHI security that is often overlooked. Improper Disposal of PHI is More Common than Previously Thought Researchers at St. Michael’s Hospital in Toronto checked recycled paperwork at five teaching hospitals in Canada. Each of the five hospitals had policies covering the secure disposal of documents containing PHI and separate recycling bins were provided for general paperwork and documents containing sensitive information. The latter were shredded before disposal. Despite the document disposal policies, paperwork containing personally identifiable information (PII) and personal health information (PHI) were often incorrectly placed in the bins. The researchers identified 2,867 documents containing PII and 1,885 items containing personally identifiable health information in the standard recycling bins. 1,042 documents contained high sensitivity...

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HIPAA Rules on Contingency Planning
Mar27

HIPAA Rules on Contingency Planning

In its March 2018 cybersecurity newsletter, OCR explained HIPAA Rules on contingency planning and urged healthcare organizations to plan for emergencies to ensure a return to normal operations can be achieved in the shortest possible time frame. A contingency plan is required to ensure that when disaster strikes, organizations know exactly what steps must be taken and in what order. Contingency plans should cover all types of emergencies, such as natural disasters, fires, vandalism, system failures, cyberattacks, and ransomware incidents. The steps that must be taken for each scenario could well be different, especially in the case of cyberattacks vs. natural disasters. The plan should incorporate procedures to follow for specific types of disasters. Contingency planning is not simply a best practice. It is a requirement of the HIPAA Security Rule. Contingency planning should not be considered a onetime checkbox item necessary for HIPAA compliance. It should be an ongoing process with plans regularly checked, updated, and tested to ensure any deficiencies are identified and...

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Class Action Lawsuit Seeks Damages for Victims of CVS Caremark Data Breach
Mar26

Class Action Lawsuit Seeks Damages for Victims of CVS Caremark Data Breach

An alleged healthcare data breach that saw the protected health information of patients of CVS Caremark exposed has resulted in legal action against CVS, Caremark, and its mailing vendor, Fiserv. The lawsuit, which was filed in Ohio federal court on March 21, 2018, relates to an alleged privacy breach that occurred as a result of an error that affected a July/August 2017 mailing sent to approximately 6,000 patients. In July 2017, CVS Caremark was contracted to operate as the pharmacy benefits manager for the Ohio HIV Drug Assistance Program (PhDAP), and under that program, CVS Caremark provides eligible patients with HIV medications and communicates with them about prescriptions. In July/August 2017, CSV Caremark’s mailing vendor Fiserve sent letters to patients containing their membership cards and information about how they could obtain their HIV medications. In the lawsuit the complaint alleges HIV-related information was clearly visible through the plastic windows of the envelopes, allowing the information to be viewed by postal service workers, family members, and roommates....

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What Does HIPAA Protect?
Mar26

What Does HIPAA Protect?

The Health Insurance Portability and Accountability Act of 1996 is a set of standards that healthcare organizations must comply with, but what does HIPAA protect? What Does HIPAA Protect? HIPAA introduced rules that govern the uses and disclosures of health information (the HIPAA Privacy Rule) and physical, technical, and administrative safeguards that must be implemented to ensure the confidentiality, integrity, and availability of health information (the HIPA Security Rule). Essentially, these two aspects of HIPAA protect the privacy of patients and health plan members. HIPAA also helps protect patients from harm. In the event that health information is exposed, stolen, or impermissibly disclosed, patients and health plan members must be informed of the breach to allow them to take action to protect themselves from harm, such as identity theft and fraud. What is Protected Under HIPAA Law? The types of information protected under HIPAA includes all health information created, used, maintained or transmitted by a HIPAA-covered entity or a business associate of a HIPAA-covered...

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What is the Civil Penalty for Knowingly Violating HIPAA?
Mar26

What is the Civil Penalty for Knowingly Violating HIPAA?

What is the civil penalty for knowingly violating HIPAA Rules? What is the maximum financial penalty for a HIPAA violation and when are fines issued? In this post we answer these questions and explain about the penalties for violating HIPAA Rules What is HIPAA? The Health Insurance Portability and Accountability Act – HIPAA – is a federal law that applies to healthcare organizations and healthcare employees. HIPAA requires healthcare organizations to develop policies and procedures to protect the privacy of patients and implement safeguards to ensure the confidentiality, integrity, and availability of protected health information (PHI). HIPAA places restrictions on the uses of health data, who can be provides with copies of health information, and gives patients the right to obtain copies of their health data. HIPAA covered entities are typically healthcare providers, health plans, and healthcare clearinghouses. HIPAA also applies to vendors and suppliers (business associates) that require access to PHI to perform their contracted duties. As with other federal laws, there are...

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Can You Make WordPress HIPAA Compliant?
Mar23

Can You Make WordPress HIPAA Compliant?

WordPress is a convenient content management system that allows websites to be quickly and easily constructed. The platform is popular with businesses, but is it suitable for use in healthcare? Can you make WordPress HIPAA compliant? Before assessing whether it is possible to make WordPress HIPAA compliant, it is worthwhile covering how HIPAA applies to websites. HIPAA and Websites HIPAA does not specifically cover compliance with respect to websites, HIPAA requirements for websites are therefore a little vague. As with any other forms of electronic capture or transmission of ePHI, safeguards must be implemented in line with the HIPAA Security Rule to ensure the confidentiality, integrity, and availability of ePHI. Those requirements apply to all websites, including those developed from scratch or created using an off-the-shelf platform such as WordPress. Websites must incorporate administrative, physical, and technical controls to ensure the confidentiality of any protected health information uploaded to the website or made available through the site. HIPAA-covered entities must...

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Banner Health Anticipates Potential Financial Penalty from OCR over 2016 Cyberattack
Mar22

Banner Health Anticipates Potential Financial Penalty from OCR over 2016 Cyberattack

According to a financial report issued by Banner Health, OCR is investigating the colossal 2016 Banner Health data breach which saw the protected health information of 3.7 million patients exposed. The breach involved Banner Health facilities at 27 locations in Alaska, Arizona, California, Colorado, Nebraska, Nevada, and Wyoming and resulted in the exposure of highly sensitive protected health information including names, dates of birth, Social Security numbers, and health insurance information. The attackers gained access to the payment processing system used in its food and beverage outlets with a view to obtaining credit card numbers. However, once access to the network was gained, they also accessed servers containing PHI. Banner Health reports that it has cooperated with OCR’s investigation into the breach and has supplied information as requested. However, OCR was not satisfied with its response and the evidence supplied on its HIPAA compliance efforts. Specifically, OCR was not satisfied with the documentation supplied to demonstrate “past security assessment activities”...

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Jail Terms for HIPAA Violations by Employees
Mar22

Jail Terms for HIPAA Violations by Employees

The penalties for HIPAA violations by employees can be severe, especially those involving the theft of protected health information. HIPAA violations by employees can attract a fine of up to $250,000 with a maximum jail term of 10 years and a 2-year jail term for aggravated identity theft. This month there have been two notable cases of HIPAA violations by employees, one of which has resulted in a fine and imprisonment, with the other likely to result in a longer spell in prison when sentencing takes place in June. Jail Term for Former Transformations Autism Treatment Center Employee In February, a former behavioral analyst at the Transformations Autism Treatment Center (TACT) was discovered to have stolen the protected health information of patients following termination. Jeffrey Luke, 29, of Collierville, TN gained access to a TACT Google Drive account containing the PHI of patients following termination and downloaded the PHI of 300 current and former patients onto his personal computer. Approximately one month after Luke was terminated, TACT discovered patient information had...

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How to Become HIPAA Compliant
Mar21

How to Become HIPAA Compliant

If you would like to start doing business with healthcare organizations you will need to know how to become HIPAA compliant, what HIPAA compliance entails, and how you can prove to healthcare organizations that you have implemented all the required safeguards and privacy controls to ensure the confidentiality, integrity, and availability of any protected health information you will be provided with or given access to. How to Become HIPAA Compliant There are no shortcuts if you want to become HIPAA compliant. HIPAA compliance means implementing controls and safeguards to ensure the confidentiality, integrity, and availability of protected health information and developing policies and procedures in line with the Healthcare Insurance Portability and Accountability Act (1996), the HIPAA Privacy Rule (2000), the HIPAA Security Rule (2003), the Health Information Technology for Economic and Clinical Health Act (2009), and the Omnibus Final Rule (2013). To become HIPAA compliant, you will need to study the full text of HIPAA (45 CFR Parts 160, 162, and 164) – which the Department...

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Is Liquid Web HIPAA Compliant?
Mar20

Is Liquid Web HIPAA Compliant?

Healthcare organizations searching for a hosting solution may identify Liquid Web as a potential vendor, but is Liquid Web HIPAA compliant? Can its cloud services be used by HIPAA-covered entities for hosting applications and projects that include electronic protected health information? Any healthcare organization that wants to use the cloud to host applications that use the protected health information (PHI) of patients must select a vendor whose service includes safeguards to ensure the confidentiality, integrity, and availability of ePHI that meet the requirements of the HIPAA Security Rule. Cloud service providers, including hosting companies, are classed as business associates since they potentially have access to their clients’ data. While many cloud service providers claim they do not access customers’ data, they are still classed as business associates. HIPAA-covered entities and their business associates must therefore enter into a business associate agreement with the service provider before any ePHI is uploaded to the cloud. Liquid Web Business Associate Agreements...

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Healthcare Data Breach Statistics
Mar20

Healthcare Data Breach Statistics

We have compiled healthcare data breach statistics from October 2009 when the Department of Health and Human Services’ Office for Civil Rights first started publishing summaries of healthcare data breaches on its website. The healthcare data breach statistics below only include data breaches of 500 or more records as smaller breaches are not published by OCR. The breaches include closed cases and breaches still being investigated by OCR. Our healthcare data breach statistics clearly show there has been an upward trend in data breaches over the past 9 years, with 2017 seeing more data breaches reported than any other year since records first started being published. There have also been notable changes over the years in the main causes of breaches. The loss/theft of healthcare records and electronic protected health information dominated the breach reports between 2009 and 2015, although better policies and procedures and the use of encryption has helped reduce these easily preventable breaches. Our healthcare data breach statistics show the main causes of healthcare data breaches...

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Is Zendesk HIPAA Compliant?
Mar16

Is Zendesk HIPAA Compliant?

Is Zendesk HIPAA compliant? Can Zendesk products be used by healthcare organizations in the United States for communicating with patients? In this post we explore the Zendesk platform and assess whether it has the necessary privacy and security controls to comply with HIPAA and if the company’s products can be used in connection with electronic protected health information. What is Zendesk? Zendesk is a San Francisco based customer service software and support ticketing system provider used by more than 200,000 companies for managing customer queries, providing support, and building customer relationships. The platform incudes Zendesk Support – a call center and ticketing system; Zendesk Chat – a web and mobile messaging system, and the customer service analytics solution Zendesk Insights. Zendesk Privacy and Security Controls Zendesk has implemented physical security controls at its facilities to prevent unauthorized data access and has round the clock surveillance and uses multi-factor authentication. Its network is protected by firewalls, with DoS and DDoS prevention solutions...

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When Did HIPAA Take Effect?
Mar16

When Did HIPAA Take Effect?

The Health Insurance Portability and Accountability Act was a landmark piece of legislation that was originally intended to simplify the administration of healthcare, eliminate wastage and prevent healthcare fraud, and to ensure insurance coverage was not lost when employees were between jobs. When Did HIPAA Take Effect? HIPAA was signed into law by President Clinton on August 21, 1996, although HIPAA has been updated several times over the past 20 years and many new provisions have been incorporated to improve privacy protections and security to ensure health information remains confidential. The main updates to HIPAA are summarized below. The HIPAA Privacy Rule The HIPAA Privacy Rule was a major update to HIPAA and introduced many of the aspects for which HIPAA is known today. The HIPAA Privacy Rule defined ‘Protected Health Information (PHI), patients were given the right to obtain copies of their protected health information from HIPAA covered entities, and strict rules were introduced on the allowable uses and disclosures of PHI. When did the Privacy Rule of HIPAA Take...

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What Information is Protected Under HIPAA Law?
Mar15

What Information is Protected Under HIPAA Law?

One of the main aims of HIPAA is to protect the privacy of patients by ensuring certain types of information are safeguarded and not disclosed to unauthorized individuals, but what information is protected under HIPAA law? What Information is Protected Under HIPAA Law? HIPAA laws protect all individually identifiable health information that is held by or transmitted by a HIPAA covered entity or business associate. According to the Department of Health and Human Services’ Office for Civil Rights there are 18 identifiers that make health information personally identifiable. When these data elements are included in a data set, the information is considered protected health information and subject to the requirements of the HIPAA Privacy, Security and Breach Notification Rules. The following information is protected under HIPAA law: Names Addresses (including subdivisions smaller than state such as street, city, county, and zip code) Dates (except years) directly related to an individual, such as birthdays, admission/discharge dates, death dates, and exact ages of individuals older...

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Is Intercom HIPAA Compliant?
Mar15

Is Intercom HIPAA Compliant?

Intercom’s messaging software-as-a-service solutions are popular with businesses for chatting with potential customers. The solutions have potential for use in the healthcare industry for chatting with patients, but is Intercom HIPAA compliant? Can the company’s solutions be used in connection with electronic protected health information or would that constitute a violation of HIPAA Rules? Is Intercom Prepared to Sign a Business Associate Agreement? HIPAA covered entities and their businesses are only permitted to use software products and services in connection with electronic protected health information if there are safeguards in place to protect the confidentiality, integrity, and availability of ePHI. Any software platform must incorporate audit and access controls and data must be appropriately secured in transit and at rest. Before software-as-a-service can be used to send or store ePHI, a HIPAA covered entity must enter into a business associate agreement with the service provider in which the company’s responsibilities under HIPAA are explained. There are exceptions for...

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What is a HIPAA Violation?
Mar14

What is a HIPAA Violation?

Barely a day goes by without a news report of a hospital, health plan, or healthcare professional violating HIPAA, but what is a HIPAA violation and what happens when a violation occurs? What is a HIPAA Violation? The Health Insurance Portability and Accountability Act of 1996 is a landmark piece of legislation that was introduced to simplify the administration of healthcare, eliminate wastage, prevent healthcare fraud, and ensure that employees could maintain healthcare coverage when between jobs. There have been notable updates to HIPAA to improve privacy protections for patients and health plan members over the years which help to ensure healthcare data is safeguarded and the privacy of patients is protected. Those updates include the HIPAA Privacy Rule, HIPAA Security Rule, HIPAA Omnibus Rule, and the HIPAA Breach Notification Rule. A HIPAA violation is a failure to comply with any aspect of HIPAA standards and provisions detailed in detailed in 45 CFR Parts 160, 162, and 164. The combined text of all HIPAA regulations published by the Department of Health and Human Services...

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Is it a HIPAA Violation to Email Patient Names?
Mar14

Is it a HIPAA Violation to Email Patient Names?

We have been asked is it a HIPAA violation to email patient names and other protected health information? In answer to this and similar questions, we will clarify how HIPAA relates to email and explain some of the precautions HIPAA covered entities and healthcare employees should take to ensure compliance when using email to send electronic protected health information. Is it a HIPAA Violation to Email Patient Names? Patient names (first and last name or last name and initial) are one of the 18 identifiers classed as protected health information (PHI) in the HIPAA Privacy Rule. HIPAA does not prohibit the electronic transmission of PHI. Electronic communications, including email, are permitted, although HIPAA-covered entities must apply reasonable safeguards when transmitting ePHI to ensure the confidentiality and integrity of data. It is not a HIPAA violation to email patient names per se, although patient names and other PHI should not be included in the subject lines of emails as the information could easily be viewed by unauthorized individuals. Even when messages are protected...

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2018 HIPAA Changes and Enforcement Outlook
Mar13

2018 HIPAA Changes and Enforcement Outlook

Are there likely to be major 2018 HIPAA changes? What does this year have in store in terms of new HIPAA regulations? OCR Director Roger Severino has hinted there could be some 2018 HIPAA changes and that HIPAA enforcement in 2018 is unlikely to slowdown. Are Major 2018 HIPAA Changes Likely? The Trump administration has made it clear that there should be a decrease rather than an increase in regulation in the United States. In January 2017, Trump signed an executive order calling for a reduction in regulation, which was seen to be hampering America’s economic growth. At the time Trump said, “If there’s a new regulation, they have to knock out two. But it goes far beyond that, we’re cutting regulations massively for small business and for large business.” While Trump was not specifically referring to healthcare, it is clear we are currently in a period of deregulation. Trump’s words were recently echoed by Severino at the HIMSS conference who confirmed the HSS understands deregulation in some areas is required before further regulations can be introduced. Therefore, there are...

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Is Zoho HIPAA Compliant?
Mar13

Is Zoho HIPAA Compliant?

Many healthcare organizations would like to use Zoho tools and applications, but is Zoho HIPAA compliant? Can its tools and applications be used by U.S. healthcare organizations in conjunction with protected health information? In this post we explore whether Zoho supports HIPAA compliance for any of its cloud-based services. What is Zoho? Zoho is a Pleasanton, CA-based developer of cloud applications and web-based tools that includes email (Zoho Mail), a document editor (Zoho Docs), a customer relationship management platform (Zoho CRM), a spreadsheet editor (Zoho Sheet), a presentation editor (Zoho Show), a custom application builder (Zoho Creator), a project management platform (Zoho projects), live chat software (Zoho Chat), a bookkeeping service (Zoho Books), app integration platform (Zoho Flow), and an IoT management platform (WebNMS). The company is focused on providing innovative cloud-based solutions for businesses and has been developing applications since 1996. Many of its solutions are broadly comparable to those provided by Google (G Suite) and Microsoft (Office 365)....

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Is Office 365 HIPAA Compliant?
Mar12

Is Office 365 HIPAA Compliant?

Is Microsoft Office 365 HIPAA compliant? Can healthcare organizations use Office 365 and remain in compliance with HIPAA and HITECH Act Rules? What is Office 365? Office 365 is a suite of subscription products developed by Microsoft that includes Word, Excel, PowerPoint, OneNote, Outlook, Publisher, and Access. Office 365 for Healthcare Microsoft is willing to enter into a business associate agreement (BAA) with HIPAA covered entities for Office 365 and Microsoft Dynamics CRM Online, provided the latter is purchased through Volume Licensing Programs or the Dynamics CRM Online Portal. The Microsoft BAA also covers the use of the Microsoft Azure cloud platform. Microsoft does not demand that a BAA be obtained prior to use of Office 365, as the BAA is automatically made available to customers with an online service contract. However, HIPAA covered entities should obtain a BAA prior to use of Office 365 in conjunction with any electronic protected health information (ePHI). They should also specify an administrative contact. In the event of a security breach, the administrative contact...

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HIPAA Social Media Rules
Mar12

HIPAA Social Media Rules

HIPAA was enacted several years before social media networks such as Facebook were launched, so there are no specific HIPAA social media rules; however, there are HIPAA laws and standards that apply to social media use by healthcare organizations and their employees. Healthcare organizations must therefore implement a HIPAA social media policy to reduce the risk of privacy violations. There are many benefits to be gained from using social media. Social media channels allow healthcare organizations to interact with patients and get them more involved in their own healthcare. Healthcare organizations can quickly and easily communicate important messages or provide information about new services. Healthcare providers can attract new patients via social media websites. However, there is also considerable potential for HIPAA Rules and patient privacy to be violated on social media networks. So how can healthcare organizations and their employees use social media without violating HIPAA Rules? HIPAA and Social Media The first rule of using social media in healthcare is to never disclose...

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When Was HIPAA Enacted?
Mar09

When Was HIPAA Enacted?

How long has compliance with the Health Insurance Portability and Accountability Act (HIPAA) been necessary? When was HIPAA enacted and what were the compliance dates for the original act and its subsequent amendments? When was HIPAA Enacted? HIPAA was enacted on August 21, 1996 when President Bill Clinton added his signature and signed the legislation into law. One of the key aims of the legislation was to improve the portability and accountability of health insurance coverage – Ensuring employees retained health insurance coverage when between jobs. HIPAA combatted wastage in healthcare and helped to prevent fraud and abuse in healthcare delivery and health insurance. HIPAA also simplified the administration of healthcare. HIPAA was enacted and signed into law in 1996, but there have been major updates to HIPAA legislation over the years, notably the introduction of the HIPAA Privacy Rule, The HIPAA Security Rule, the incorporation of HITECH Act requirements and the HIPAA Omnibus Rule. These updates added many new provisions to HIPAA legislation and helped to ensure that patient...

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Is a HIPAA Violation Grounds for Termination?
Mar07

Is a HIPAA Violation Grounds for Termination?

Is a HIPAA violation grounds for termination? What actions are healthcare organizations likely to take if they discover an employee has violated HIPAA Rules? Since the introduction of the HIPAA Enforcement Rule, the HHS’ Office for Civil Rights has been able to pursue financial penalties for HIPAA violations. Organizations discovered to have violated HIPAA Rules or failed to have implemented policies and procedures in line with HIPAA Rules can face severe financial penalties. But what about individual employees who accidentally or deliberately violate HIPAA and patient privacy? Do Most Healthcare Organizations Consider a HIPAA Violation Grounds for Termination? Not all HIPAA violations are equal, although any violation of HIPAA Rules is a serious matter that warrants investigation and action by healthcare organizations. When a HIPAA violation is reported – by an employee, colleague or patient – healthcare organizations will investigate the incident and will attempt to determine whether HIPAA laws were violated, and if so, how the violation occurred, the implications for...

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What Happens if You Violate HIPAA?
Mar07

What Happens if You Violate HIPAA?

If you work in healthcare you should have a good working knowledge of HIPAA rules, exercise diligence, and ensure that HIPAA Rules are always followed, but what happens if you violate HIPAA? What are the likely repercussions for accidentally or knowingly violating HIPAA Rules? What happens if you violate HIPAA will depend on the type of violation, its severity, the harm caused to others, and the extent to which you knew that HIPAA Rules were being violated. Disciplinary Action and Termination If at the time of the violation you were unaware that you make a mistake, the violation was minor, and no harm has been caused, the violation may be dealt with internally. Verbal or written warnings may be issued and further training on HIPAA compliance would be appropriate. For more serious violations, especially in cases where HIPAA Rules have been knowingly violated, termination is likely. The violation may be reported to licensing boards who can place restrictions on licenses. Suspension and loss of license is a possibility. Civil Penalties The Department of Health and Human Services’...

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Is Google Calendar HIPAA Compliant?
Mar07

Is Google Calendar HIPAA Compliant?

Is Google Calendar HIPAA compliant? Can the time management and calendar scheduling service be used by healthcare organizations or would use of the service be considered a violation of HIPAA Rules? This post explores whether Google supports HIPAA compliance for the Google Calendar service.   Google Calendar was launched in 2006 and is part of Google’s G Suite of products and services. Google Calendar could potentially be used for scheduling appointments, which may require protected health information to be added. Uploading any protected health information to the cloud is not permitted by the HIPAA Privacy Rule unless certain HIPAA requirements have first been satisfied. A risk analysis must be conducted to assess potential risks to the confidentiality, integrity, and availability of ePHI. Risks must be subjected to a HIPAA-compliant risk management process and reduced to an acceptable level. Access controls must be implemented to ensure that ePHI can only be viewed by authorized individuals, appropriate security controls must be in place to prevent unauthorized disclosures, and an...

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EmblemHealth Fined $575,000 by NY Attorney General for HIPAA Breach
Mar07

EmblemHealth Fined $575,000 by NY Attorney General for HIPAA Breach

A 2016 mailing error by EmblemHealth that saw the Health Insurance Claim Numbers of 81,122 plan members printed on the outside of envelopes has resulted in a $575,000 settlement with the New York Attorney General. While all mailings include a unique patient identifier on the envelope, in this case the potential for harm was considerable as Health Insurance Claim numbers are formed using the Social Security numbers of plan members. Announcing the settlement, New York Attorney General Eric T. Schneiderman explained that Health Insurance Portability and Accountability Act (HIPAA) Rules require HIPAA covered entities to implement administrative, physical, and technical safeguards to ensure the confidentiality of patients’ and plan members’ protected health information. The error that saw Social Security numbers exposed violated HIPAA Rules. EmblemHealth failed to comply with “many standards and procedural specifications” required by HIPAA. Attorney General Schneiderman also said that printing Social Security numbers on the outside of envelopes violated New York General Business Law §...

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What is HIPAA Certification?
Mar06

What is HIPAA Certification?

Many vendors would like HIPAA certification to confirm they are fully compliant with HIPAA Rules and understand all aspects of the Health Insurance Portability and Accountability Act (HIPAA), but is it possible to obtain HIPAA certification to confirm HIPAA compliance? What is HIPAA Certification? In an ideal world, HIPAA certification would confirm that all aspects of HIPAA Rules are understood and being followed. If a third-party vendor such as a transcription company was HIPAA certified, it would make it easier for healthcare organizations looking for such as service to select an appropriate vendor. Many companies claim they have been certified as HIPAA compliant or in some cases, that they are ‘HIPAA Certified’. However, ‘HIPAA Certified’ is a misnomer. There is no official, legally recognized HIPAA compliance certification process or accreditation. There is a good reason why this is the case. HIPAA compliance is an ongoing process. An organization may be determined to be in compliance with HIPAA Rules today, but that does not mean that they will be tomorrow or at some point in...

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How to Report a HIPAA Violation Anonymously
Mar06

How to Report a HIPAA Violation Anonymously

In this post we explain how to report a HIPAA violation anonymously if you feel your (or someone else’s) privacy has been violated of if HIPAA Rules are not being followed in your organization. When Can an Alleged HIPAA Violation be Reported? Most healthcare organizations go to great lengths to ensure they are in compliance with HIPAA Rules, but occasionally HIPAA regulations are violated by management or employees. In such cases, a complaint can be lodged with the Department of Health and Human Services’ Office for Civil Rights (OCR) – the main enforcer of HIPAA Rules. However, complaints will only result in action being taken if the complaint is submitted within 180 days of the date of discovery that HIPAA Rules were violated. In limited cases, when there is ‘good cause’ that it was not possible to file a complaint within 180 days, an extension may be granted. Note that OCR cannot investigate any alleged violation of the HIPAA Privacy Rule that occurred before April 14, 2003 or Security Rule violations that occurred before April 20, 2005 because compliance with those...

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Is Google Slides HIPAA Compliant?
Mar05

Is Google Slides HIPAA Compliant?

Is Google Slides HIPAA compliant? Can Google Slides be used by healthcare organizations without violating HIPAA Rules? This post explores whether Google Slides is HIPAA compliant and whether it is possible to use the presentation editor in connection with electronic protected health information. Google Slides is a presentation editor that allows users to create slide shows, training material, and project presentations. It is an ideal option for users who do not regularly create slide shows or presentations and do not have a software package that offers the same functionality. Google Slides is available free of charge for consumers to use and is equivalent to Microsoft’s PowerPoint. Healthcare organizations that are looking to create training courses and slideshows that involve the use of data protected by HIPAA need to exercise caution. Use of Google Slides with electronic protected health information could potentially violate HIPAA Rules and patient privacy. That could all too easily result in a financial penalty. Google Slides is a web-based presentation program that is not...

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What Does HIPAA Cover?
Mar01

What Does HIPAA Cover?

It has been 22 years since the Health Insurance Portability and Accountability Act (HIPAA) was Introduced, but there is still some confusion about HIPAA, what the legislation does for patients, who is required to comply with HIPAA Rules, and what does HIPAA cover. Who Does HIPAA Cover? HIPAA is a federal law that introduced standards in healthcare relating to patient privacy and the protection of medical data. HIPAA covers healthcare providers, health plans, healthcare clearinghouses, and business associates of HIPAA-covered entities. HIPAA applies to most entities that fall into the above categories, except those that do not conduct transactions electronically. Healthcare providers include hospitals, clinics, physicians, nursing homes, pharmacies, chiropractors, dentists, and psychologists. Health plans include health insurers, company health plans, HMOs, and government programs that pay for healthcare such as Medicaid and Medicare. Healthcare clearinghouses are organizations that transform nonstandard health data into a standard format. A business associate is an individual or...

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Is Google Forms HIPAA Compliant?
Feb27

Is Google Forms HIPAA Compliant?

Google Forms is a convenient tool for creating surveys and gaining feedback from customers, but is it suitable for use by healthcare organizations? Is Google Forms HIPAA compliant or is its use likely to be a violation of HIPAA Rules? Before any cloud-based service can be used by HIPAA covered entities or their business associates in connection with PHI, it is first necessary to enter into a business associate agreement with the service provider. Without a business associate agreement in place, use of the service would be considered a HIPAA violation. Google and Business Associate Agreements with HIPAA Covered Entities Google is prepared to enter into a business associate agreement with HIPAA covered entities and their business associates and offers its own BAA in which Google provides satisfactory assurances – as required by HIPAA – that the Privacy, Security, and Breach Notification Rule requirements will be followed. The BAA does not cover all Google services, but Google Drive – of which Google Forms is part – is covered by the BAA. Obtaining a BAA from a service provider is...

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Is Google Sheets HIPAA Compliant?
Feb26

Is Google Sheets HIPAA Compliant?

Is Google Sheets HIPAA compliant? Can HIPAA-covered entities use Google Sheets to create, view, or share spreadsheets containing identifiable protected health information or would using Google Sheets violate HIPAA Rules? In this post we assess whether Google Sheets supports HIPAA compliance.  Under HIPAA Rules, healthcare organizations are required to implement safeguards to ensure the confidentiality, integrity, and availability of PHI. While it is straightforward to implement controls internally to keep data secure, oftentimes third parties are contracted to provide services that require access to PHI. They too must abide by HIPAA Rules covering privacy, security, and breach notifications. A third-party that requires access to PHI – or copies of health data – to perform services on behalf of a covered entity is considered a business associate. A covered entity and business associate must enter into a contract – a business associate agreement – in which the business associate agrees to comply with certain aspects of the HIPAA Privacy, Security, and Breach Notification...

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Is IBM Cloud HIPAA Compliant?
Feb23

Is IBM Cloud HIPAA Compliant?

Is IBM Cloud HIPAA compliant? Is the cloud platform suitable for healthcare organizations in the United States to host infrastructure, develop health applications and store files? In this post we assess whether the IBM Cloud supports HIPAA compliance and the platform’s suitability for use by healthcare organizations. IBM offers a cloud platform to help organizations develop their mobile and web services, build native cloud apps, and host their infrastructure along with a wide range of cloud-based services for the capture, analysis, and processing of data. The platform has already been adopted by many healthcare providers, payers, and health plans, and applications and portals have been developed to provide patients with better access to their health information. IBM Cloud Security IBM is a leader in the field of network and data security, and its expertise has meant its cloud platform is highly secure. Security is built into the core of all of the firm’s software and services to ensure that sensitive data remains confidential and cannot be accessed by unauthorized individuals. Its...

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Updated Colorado Data Breach Notification Advances: Reporting Period Cut to 30 Days
Feb22

Updated Colorado Data Breach Notification Advances: Reporting Period Cut to 30 Days

In January, a new data breach notification bill was introduced in Colorado that proposed updates to state laws to improve protections for residents affected by data breaches. The bill introduced a maximum time frame of 45 days for companies to notify individuals whose personal information was exposed or stolen as a result of a data breach. The definition of personal information was also updated to include a much wider range of information including data covered by HIPAA – medical information, health insurance information, and biometric data. Last week, Colorado’s House Committee on State, Veterans, and Military Affairs unanimously passed an updated version of the bill, which has now been passed to the Committee on Appropriations for consideration. The updated bill includes further new additions to the list of data elements classed as personal information – passport numbers, military, and student IDs. There has also been a shortening of the time frame organizations have to issue notifications. Instead of the 45 days proposed in the original bill, the time frame has been cut to just...

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Is the Google Cloud Platform HIPAA Compliant?
Feb22

Is the Google Cloud Platform HIPAA Compliant?

Is the Google Cloud Platform HIPAA compliant?  Is the Google Cloud Platform a suitable alternative to Azure and AWS for healthcare organizations? In this post we determine whether the Google Cloud platform is HIPAA compliant and if it can be used by healthcare organizations to build applications, host infrastructure, and store files containing protected health information. Healthcare organizations are increasingly taking advantage of cloud platforms. The healthcare cloud computing market was valued at $4.65 billion in 2016 and is expected to increase to more than $14.76 billion by 2022. Amazon AWS is still the leading platform with a market share of 62% according to KeyBlanc, with Microsoft Azure second on 20%, but Google is gaining ground, with a market share of around 12%. Amazon and Microsoft both offering platforms that support HIPAA compliance, but what about Google? Is the Google Cloud Platform HIPAA compliant? Will Google Sign a Business Associate Agreement Covering its Cloud Platform? Since the Omnibus Rule came into effect in September 2013, Google has been signing...

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Research Institutions Given Additional 6 Months to Comply with Updated Common Rule
Feb21

Research Institutions Given Additional 6 Months to Comply with Updated Common Rule

Updates to the Common Rule – The Federal Policy for the Protection of Human Subjects – that were initially due to come into effect on January 19, 2018 have been delayed by 6 months, giving research organizations more time to comply with the new provisions. The new compliance date is July 19, 2018, although the provision covering cooperative research still has a compliance date of Jan 20, 2020. Several healthcare organizations, including the American Medical Informatics Association (AMIA), the Associated of American Medical Colleges (AAMC), and the Association of American Universities (AAU), called for the compliance date to be pushed back due to uncertainty surrounding the final rule. A delay would allow institutions additional time to ensure compliance and would allow federal agencies more time to issue guidance to researchers to help them implement the updated regulations. 16 federal departments, including the Department of Health and Human Services, made revisions to the Common Rule. In a notice of proposed Rulemaking, the need for the delay to the compliance date was...

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Is SharePoint HIPAA Compliant?
Feb21

Is SharePoint HIPAA Compliant?

Is SharePoint HIPAA compliant? Does the platform incorporate all the required administrative and technical controls to meet HIPAA requirements? This post explores whether SharePoint supports HIPAA compliance and its suitability for use in the healthcare industry. What is SharePoint? SharePoint is a web-based document management and storage system and one of the leading collaborative platforms on the market, used by 78% of Fortune 500 companies. The platform is based on Microsoft’s OpenXML document standard and therefore integrates seamlessly with Microsoft Office. SharePoint offers many of the same functions as Google Drive and Dropbox, although SharePoint is a much more powerful platform and can also be used for internet portals, intranet sites and can form the basis of a CRM system. With such a wide range of functions it is naturally a good fit for healthcare organizations, but is SharePoint HIPAA compliant? Does the platform incorporate all the necessary functions and security controls required by HIPAA? Is SharePoint Covered by Microsoft’s Business Associate Agreement?...

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Is Yammer HIPAA Compliant?
Feb20

Is Yammer HIPAA Compliant?

Is Yammer HIPAA compliant? Does the platform incorporate all the necessary administrative and technical controls to meet HIPAA requirements? This post explores whether Yammer supports HIPAA compliance and assesses whether the platform can be used by healthcare organizations without violating HIPAA Rules. What is Yammer? Yammer has been a standalone social networking and collaboration platform since 2008. Its popularity and potential were noticed by Microsoft, which purchased the company in 2012. Today the platform is used by 85% of Fortune 500 companies. The freemium platform allows company employees to communicate with each other, collaborate on projects, share knowledge, and ask and get quick answers from co-workers.  Due to similarities in its architecture and functionality, it is often referred to as ‘Twitter for companies’. In contrast to other social media platforms, communications are private and are not published online. The platform can be kept as a strictly internal communication and collaboration tool, although it is also possible to use the platform to communicate with...

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What Covered Entities Should Know About Cloud Computing and HIPAA Compliance
Feb19

What Covered Entities Should Know About Cloud Computing and HIPAA Compliance

Healthcare organizations can benefit greatly from transitioning to the cloud, but it is essential to understand the requirements for cloud computing to ensure HIPAA compliance. In this post we explain some important considerations for healthcare organizations looking to take advantage of the cloud, HIPAA compliance considerations when using cloud services for storing, processing, and sharing ePHI, and we will dispel some of the myths about cloud computing and HIPAA compliance. Myths About Cloud Computing and HIPAA Compliance There are many common misconceptions about the cloud and HIPAA compliance, which in some cases prevent healthcare organizations from taking full advantage of the cloud, and in others could result in violations of HIPAA Rules. Some of the common myths about cloud computing and HIPAA compliance are detailed below: Use of a ‘HIPAA compliant’ cloud service provider will ensure HIPAA Rules are not violated False: A cloud service provider can incorporate all the necessary safeguards to ensure the service or platform can be used in a HIPAA compliant manner, but it is...

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Is Zoom a HIPAA Compliant Video and Web Conferencing Platform?
Feb19

Is Zoom a HIPAA Compliant Video and Web Conferencing Platform?

Zoom is a popular video and web conferencing platform that has been adopted by more than 750,000 businesses, but is the service suitable for use by healthcare organizations for sharing PHI. Is Zoom HIPAA compliant?   What is Zoom? Zoom is a cloud-based video and web conferencing platform that allows workers across multiple locations to take part in meetings, share files, and collaborate. The platform supports webinars and includes a business IM service. Zoom has already been adopted by many healthcare organizations around the globe who use the platform to consult with other providers and communicate with patients. However, in the United States, healthcare providers must comply with HIPAA Rules. Any software solution must incorporate a host of security protections to ensure protected health information (PHI) is safeguarded. Further, cloud-based platform providers are classed as a business associates and are also required to comply with HIPAA Rules if their platforms are to be used in conjunction with PHI. Zoom and HIPAA Compliance As a business associate, Zoom would be required to...

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Is WebEx HIPAA Compliant?
Feb18

Is WebEx HIPAA Compliant?

Is WebEx HIPAA compliant? Is the online meeting and web conferencing platform suitable for use by healthcare organizations or should the service be avoided? In this post we assess the security controls and features of the platform and determine whether use of WebEx could be considered a HIPAA violation. What is WebEx? WebEx is a web and video conferencing and collaboration platform that helps businesses connect with remote workers and partners as if they are in the same room. With tools such as WebEx, healthcare organizations can communicate quickly and easily with the workforce, no matter where employees are located. Regional operational meetings can be conducted, medical education can take place online, and healthcare employees can be trained on new processes and procedures. These platforms can also potentially be used for communicating with patients. However, before any collaboration tools can be used in connection with protected health information (PHI), healthcare organizations must be certain that the tools support HIPAA compliance. So how does WebEx fare in this regard? Is...

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Is Amazon CloudFront HIPAA Compliant?
Feb16

Is Amazon CloudFront HIPAA Compliant?

Is Amazon CloudFront HIPAA compliant and can the web service be used by HIPAA covered entities without violating HIPAA Rules? In this post we determine whether Amazon CloudFront supports HIPAA compliance or if it should be avoided by HIPAA-covered entities. What is Amazon CloudFront? Amazon CloudFront is a web service that allows users to speed up web content delivery over the Internet. Typically, when a website is accessed, the visitor experiences some latency accessing static and dynamic content. The reason for this is visitors will not make a direct connection to the content, instead they will be routed through a path to reach the server where the content can be accessed. The path can involve many routing points, will inevitably have an impact on the speed at which content can be accessed. By using a content delivery network such as Amazon CloudFront, it is possible to reduce latency and improve reliability and availability of web content. By delivering content via a network of data centers (edge locations), users are routed to the nearest location with the least latency, thus...

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Is Citrix ShareFile HIPAA Compliant?
Feb15

Is Citrix ShareFile HIPAA Compliant?

ShareFile was bought by Citrix Systems in 2011 and the platform is marketed as a suitable data sync, file sharing, and collaboration tool for the healthcare industry, but is Citrix ShareFile HIPAA compliant? What is Citrix ShareFile? Citrix ShareFile is a secure file sharing, data storage and collaboration tool that allows large files to be easily shared within a company, with remote workers, and with external partners. The solution allows any authorized individual to instantly access stored documents via desktops and mobile devices. For healthcare organizations this means the solution can be used to share large files such as DICOM images with researchers, remote healthcare workers, and business associates. The ShareFile patient portal can also be used to share PHI with patients. Is Citrix ShareFile HIPAA Compliant? Citrix will sign a business associate agreement with HIPAA covered entities and their business associates that covers the use of FileShare, although it is the responsibility of the covered entity to ensure that the solution is configured correctly and is used in a...

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Is eFileCabinet HIPAA Compliant?
Feb14

Is eFileCabinet HIPAA Compliant?

eFileCabinet is a document management and storage solution for businesses that offers on-site and cloud storage, but is the service suitable for the healthcare industry? Is eFileCabinet HIPAA compliant or will using the platform be considered a violation of HIPAA Rules? What are Document Management Systems? Document management systems allow organizations to carefully manage electronic documents and store them securely in one location. With huge volumes of documents being created, such systems take the stress out of document management and can help HIPAA covered entities share documents containing ePHI securely and avoid HIPAA violations. There are many document management systems on the market, but not all support HIPAA compliance, so what about eFileCabinet? Is eFileCabinet HIPAA compliant? eFileCabinet Security and Privacy Controls Security controls include the encryption of data in transit and at rest with 256-bit encryption. Sensitive data can be securely shared with third-parties and remote employees via the company’s SecureDrawer feature. SecureDrawer allows files to be...

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$100,000 Settlement Shows HIPAA Obligations Don’t End When a Business Closes
Feb14

$100,000 Settlement Shows HIPAA Obligations Don’t End When a Business Closes

HIPAA covered entities and their business associates must abide by HIPAA Rules, yet when businesses close the HIPAA obligations do not end. The HHS’ Office for Civil Rights (OCR) has made this clear with a $100,000 penalty for FileFax Inc., for violations that occurred after the business had ceased trading. FileFax is a Northbrook, IL-based firm that offers medical record storage, maintenance, and delivery services for HIPAA covered entities. The firm ceased trading during the course of OCRs investigation into potential HIPAA violations. An investigation was launched following an anonymous tip – received on February 10, 2015 – about an individual that had taken documents containing protected health information to a recycling facility and sold the paperwork. That individual was a “dumpster diver”, not an employee of FileFax. OCR determined that the woman had taken files to the recycling facility on February 6 and 9 and sold the paperwork to the recycling firm for cash. The paperwork, which included patients’ medical records, was left unsecured at the recycling facility. In...

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Is Box HIPAA Compliant?
Feb13

Is Box HIPAA Compliant?

Is Box HIPAA compliant? Can Box be used by healthcare organizations for the storage of documents containing protected health information or would doing so be a violation of HIPAA Rules? An assessment of the security controls of the Box cloud storage and content management service and its suitability for use in healthcare. What is Box? Box is a cloud storage and content management service that supports collaboration and file-sharing. Users can share files, invite others to view, edit or upload content. Box can be used for personal use; however, businesses need to sign up for either a business, enterprise, or elite account. Is Box Covered by the Conduit Exception Rule? The HIPAA conduit exception rule was introduced to allow HIPAA covered entities to use certain communications channels without having to obtain a business associate agreement. The conduit exception rule applies to telecoms companies and Internet service providers that act as conduits through which data flows. Cloud storage services are not covered under the HIPAA conduit exception rule, even if those entities claim...

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Timothy Noonan Becomes OCR’s Top HIPAA Enforcer, Replacing Deputy Director Iliana Peters
Feb12

Timothy Noonan Becomes OCR’s Top HIPAA Enforcer, Replacing Deputy Director Iliana Peters

After just 4 months in the position of deputy director for health information privacy at the Department of Health and Human Services’ Office for Civil Rights, Iliana Peters has departed for the private sector. Peters took over as deputy director following the departure of acting deputy director Deven McGraw in November, only to leave the post on February 2 to join the healthcare team at law firm Polsinelli. This is the third major change of staff at the Department of Health and Human Services in a little over four months. First, there was the departure of HHS Secretary Tom Price in late September, McGraw left in October to join health tech startup Citizen, and now Iliana Peters has similarly quit for the private sector. Peters has been working at the Office for Civil Rights for the past 12 years, including 5 years as a senior advisor. During her time at OCR Peters has worked closely with regional offices helping them enforce HIPAA Rules and has been instrumental in building up OCR’s HIPAA enforcement program. Peters has trained regional OCR staff on HIPAA enforcement and the...

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Is Ademero HIPAA Compliant?
Feb12

Is Ademero HIPAA Compliant?

Ademero is a document management software (DMS) provider whose platform helps businesses keep track of large quantities of documents and transition to a paperless environment, but is Ademero HIPAA compliant? Can its DMS be used by healthcare organizations without violating HIPAA Rules? Ademero and HIPAA The HIPAA Security Rule includes required and addressable implementation specifications. Any implementation specification that is required must be implemented to comply with HIPAA Rules. Addressable implementation specifications are not required, strictly speaking. Those implementation specifications include some flexibility. For instance, data encryption is not a required element, but that does not mean it can be ignored. If the decision is taken not to encrypt data that is acceptable provided that decision was based on a risk analysis and the decision not to use encryption is documented. Alternative controls must also be put in place that provide an equivalent level of protection. Software solutions that support HIPAA compliance will have appropriate controls in place to satisfy...

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Texas HB300 Compliance
Feb10

Texas HB300 Compliance

Texas HB300 (Texas House Bill 300) was signed into law by State governor Rick Perry in June 2011. The Bill made significant changes to state laws covering the privacy and security of protected health information (PHI) for individuals and organizations that assemble, collect, analyze, store, or transmit PHI. The Texas HB300 compliance date was September 1, 2012. Texas HB300 Introduced Stricter Privacy and Security Protections than HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA) already requires covered entities (healthcare providers, health plans, and healthcare clearinghouses) and business associates of HIPAA-covered entities to implement safeguards to ensure the confidentiality, integrity, and availability of PHI and protect the privacy of patients and health plan members. Texas HB300 takes those requirements a step further, introducing even stricter requirements for covered entities, which under the new laws, also includes individuals and organizations not covered by HIPAA Rules. The existing laws updated by Texas HB300 were: Texas Health Code,...

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What is HIPAA Authorization?
Feb09

What is HIPAA Authorization?

We are often asked to clarify certain elements of HIPAA Rules. One recent question relates to disclosures of protected health information (PHI) and medical records – ‘What is HIPAA authorization?’ What is HIPAA Authorization? The HIPAA Privacy Rule (effective since April 14, 2003) introduced standards covering allowable uses and disclosures of health information, including to whom information can be disclosed and under what circumstances protected health information can be shared. The HIPAA Privacy Rule permits the sharing of health information by healthcare providers, health plans, healthcare clearinghouses, business associates of HIPAA-covered entities, and other entities covered by HIPAA Rules under certain circumstances. In general terms, permitted uses and disclosures are for treatment, payment, or health care operations. HIPAA authorization is consent obtained from a patient or health plan member that permits a covered entity or business associate to use or disclose PHI to an individual/entity for a purpose that would otherwise not be permitted by the HIPAA Privacy Rule....

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Is HelloFax HIPAA Compliant?
Feb08

Is HelloFax HIPAA Compliant?

Is HelloFax HIPAA compliant? Can HelloFax be used by healthcare organizations to send files containing protected health information, or would doing so be considered a violation of HIPAA Rules? In this post we explore the protections in place and attempt to determine whether HelloFax can be considered a HIPAA compliant fax service. The HIPAA Conduit Exception and Fax Transmissions It is important to make a distinction between standard faxes and digital faxing services. Standard fax machines, those which are used to transmit a physical document from one fax machine to another, have long been used by healthcare organizations, and in many cases, to transmit documents containing protected health information. Transmissions are sent without first entering into a business associate agreement – or BAA – with telecommunications companies. That is because telecoms firms, such as AT&T, are covered by the HIPAA conduit exception rule. The HIPAA conduit exception is covered in more detail here, although in short, it details the types of communications services do not require a business...

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Is iCloud HIPAA Compliant?
Feb06

Is iCloud HIPAA Compliant?

Is iCloud HIPAA compliant? Can healthcare organizations use iCloud for storing files containing electronic protected health information (ePHI) or sharing ePHI with third-parties? This article assesses whether iCloud is a HIPAA compliant cloud service. Cloud storage services are a convenient way of sharing and storing data. Since files uploaded to the cloud can be accessed from multiple devices in any location with an Internet connection, information is always at hand when it is needed. There are many cloud storage services to choose from, many of which are suitable for use by healthcare providers for storing and sharing ePHI. They include robust access and authentication controls and data uploaded to and stored in the cloud is encrypted. Logs are also maintained so it is possible to tell who accessed data, when access occurred, and what users did with the data once access was granted. iCloud is a cloud storage service that owners of Apple devices can easily access through their iPhones, iPads, and Macs. iCloud has robust authentication and access controls, and data is encrypted in...

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Lawsuit Over HIPAA Breach by Mail Service Survives Motion to Dismiss
Feb02

Lawsuit Over HIPAA Breach by Mail Service Survives Motion to Dismiss

A mail service – Press America, Inc – used by a pharmacy benefit manager – CVS Pharmacy – is being sued over an accidental disclosure of 41 individuals’ protected health information. CVS Pharmacy is a business associate of a health plan and is contracted to provide a mail-order pharmacy service for the health plan. The mail service is a subcontractor of CVS Pharmacy, and both entities are bound by HIPAA Rules. CVS Pharmacy signed a business associate agreement with the health plan, and Press America did likewise with CVS Pharmacy as PHI was required in order to perform the mailings. CVS Pharmacy alleges the HIPAA Privacy Rule was violated by Press America when it inadvertently disclosed PHI to unauthorized individuals due to a mismailing incident. The disclosure of some plan members’ PHI was accidental, but the privacy breach violated a performance standard in the CVS Pharmacy’s contract with the health plan. By violating the performance standard, the CVS Pharmacy was required to pay the health plan $1.8 million. A lawsuit was filed by the CVS Pharmacy seeking...

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$3.5 Million Settlement to Resolve HIPAA Violations That Contributed to Five Data Breaches
Feb01

$3.5 Million Settlement to Resolve HIPAA Violations That Contributed to Five Data Breaches

The first HIPAA settlement of 2018 has been announced by the Department of Health and Human Services’ Office for Civil Rights (OCR). Fresenius Medical Care North America (FMCNA) has agreed to pay OCR $3.5 million to resolve multiple potential HIPAA violations that contributed to five separate data breaches in 2012. The breaches were experienced at five separate covered entities, each of which was owned by FMCNA. Those breached entities were: Bio-Medical Applications of Florida, Inc. d/b/a Fresenius Medical Care Duval Facility in Jacksonville, Florida (FMC Duval) Bio-Medical Applications of Alabama, Inc. d/b/a Fresenius Medical Care Magnolia Grove in Semmes, Alabama (FMC Magnolia Grove) Renal Dimensions, LLC d/b/a Fresenius Medical Care Ak-Chin in Maricopa, Arizona (FMC Ak-Chin) Fresenius Vascular Care Augusta, LLC (FVC Augusta) WSKC Dialysis Services, Inc. d/b/a Fresenius Medical Care Blue Island Dialysis (FMC Blue Island) Breaches Experienced by FMCNA HIPAA Covered Entities The five security breaches were experienced by the FMCNA covered entities over a period of four months...

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Aetna Agrees to Pay $1.15 Million Settlement to Resolve NY Attorney General Data Breach Case
Jan25

Aetna Agrees to Pay $1.15 Million Settlement to Resolve NY Attorney General Data Breach Case

Last July, Aetna sent a mailing to members in which details of HIV medications were clearly visible through the plastic windows of envelopes, inadvertently disclosing highly sensitive HIV information to individuals’ house mates, friends, families, and loved ones. Two months later, a similar privacy breach occurred. This time the mailing related to a research study regarding atrial fibrillation (AFib) in which the term IMACT-AFIB was visible through the window of the envelope. Anyone who saw the envelope could have deduced the intended recipient had an AFib diagnosis. The July breach triggered a class action lawsuit which was recently settled by Aetna for $17.2 million. Aetna must now also cover a $1.15 million settlement with the New York Attorney General to resolve violations of federal and state laws. Attorney General Schneiderman launched an investigation following the breach of HIV information in July, which violated the privacy of 2,460 Aetna members in New York. The September privacy breach was discovered during the course of that investigation. 163 New York Aetna members had...

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Kansas Attorney General Fines Healthcare Provider for Failing to Protect Patient Records
Jan25

Kansas Attorney General Fines Healthcare Provider for Failing to Protect Patient Records

The Topeka, KS-based healthcare company Pearlie Mae’s Compassion and Care LLC and its owners have been fined by the Kansas Attorney General for failing to protect patient and employee records. The owners have agreed to pay a civil monetary penalty of $8,750. The HITECH Act gave attorneys general the authority to enforce HIPAA rules and take action against HIPAA-covered entities and business associates that are discovered not to be in compliance with HIPAA regulations. Only a handful of state attorneys general have exercised those rights, with many opting to pursue privacy violations under state laws. In this case, Attorney General Derek Schmidt issued the civil monetary penalty for violations of the Wayne Owen Act, which is part of the Kansas Consumer Protection Act. Special agents of the Kansas attorney general’s office were assisting the Topeka Police Department execute a search warrant in June 2017 at the home of Ann Marie Kaiser, one of the owners of Pearlie Mae’s Compassion and Care. Kaiser’s home was used as an office location for the company. While at the property, the...

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Is Google Docs HIPAA Compliant?
Jan23

Is Google Docs HIPAA Compliant?

Is Google Docs HIPAA compliant? Is it permitted to upload documents containing protected health information to Google Docs, or would that violate HIPAA Rules? In this post we will assess Google Docs and determine whether Google is a HIPAA compliant and whether it can be used safely and securely by HIPAA-covered entities and business associates for sharing PHI. Does Google Docs Encrypt Data? In order for Google Docs to be HIPAA compliant, stored data must be encrypted. Data must also be encrypted during uploading and downloading. We can confirm that Google uses 128-bit or stronger Advanced Encryption Standard (AES) to protect data in transit to the platform, and between and in its data centers. Is Google Considered a Conduit? The Department of Health and Human Services has made it clear in recent guidance that cloud service providers are not – in the vast majority of cases – considered conduits, so the HIPAA Conduit Exception Rule does not apply. Instead, cloud service providers are classed as business associates, even if the service provider does not access data stored in customer...

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Is FaceTime HIPAA Compliant?
Jan19

Is FaceTime HIPAA Compliant?

Is FaceTime HIPAA compliant? Can FaceTime be used by HIPAA covered entities to communicate protected health information (PHI) without violating HIPAA Rules? In this article we will examine the protections in place to keep transmitted information secure, whether Apple will sign a business associate agreement for FaceTime, and if a BAA is necessary. Will Apple Sign A BAA for FaceTime? An extensive search of the Apple website has revealed no sign that Apple will sign a business associate agreement with healthcare organizations for any of its services. The only mention of its services in relation to HIPAA-covered entities is in relation to iCloud, which Apple clearly states should not be used by healthcare providers or their business associates to create, receive, maintain or transmit PHI. Since Apple is not prepared to sign a business associate agreement for FaceTime, that would indicate FaceTime is not a HIPAA compliant service. However, business associate agreements only need to be signed by business associates. So, is Apple a business associate? The HIPAA Conduit Exception Rule The...

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The HIPAA Conduit Exception Rule and Transmission of PHI
Jan19

The HIPAA Conduit Exception Rule and Transmission of PHI

The HIPAA Conduit Exception Rule is a source of confusion for many HIPAA covered entities, but it is essential that this aspect of HIPAA is understood. Failure to correctly classify a service provider as a conduit or a business associate could see HIPAA Rules violated and a significant financial penalty issued for noncompliance. The HIPAA Omnibus Final Rule and Business Associates On January 25, 2013, the HIPAA Omnibus Final Rule was issued. The HIPAA Omnibus Final Rule introduced a swathe of updates to HIPAA Rules, including the incorporation of the Health Information Technology for Economic and Clinical Health (HITECH) Act. HIPAA Omnibus Final Rule included an update to the definition of a business associate. Prior to January 25, 2013, a business associate was a person or entity that creates, receives, or transmits protected health information (PHI) on behalf of a covered entity. The Omnibus rule added ‘maintains’ to that definition. That meant companies that store electronic information – or physical records – are considered business associates. The Omnibus Rule also...

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Deadline for Reporting 2017 HIPAA Data Breaches Approaches
Jan17

Deadline for Reporting 2017 HIPAA Data Breaches Approaches

The deadline for reporting 2017 HIPAA data breaches to the Department of Health and Human Services’ Office for Civil Rights is fast approaching. HIPAA-covered entities have a maximum of 60 days from the discovery of a data breach to report security incidents to OCR and notify affected patients. Smaller breaches of PHI do not need to be reported to OCR within this time frame, instead covered entities can delay reporting those breaches to OCR until the end of the calendar year. The maximum allowable time for reporting breaches impacting fewer than 500 individuals is 60 days from the end of the year in which the breach was experienced. The final day for reporting 2017 HIPAA data breaches to OCR is therefore March 1, 2018. A HIPAA data breach is defined as an “acquisition, access, use, or disclosure” of unsecured protected health information (PHI) that is not permitted by the HIPAA Privacy Rule. Unsecured PHI is defined as PHI that is “not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology,”...

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HHS Sued by CIOX Health Over Unlawful HIPAA Regulations
Jan16

HHS Sued by CIOX Health Over Unlawful HIPAA Regulations

The Department of Health and Human Services is being sued by CIOX Health, a medical record retrieval company, over updates to HIPAA laws that place restrictions on the amount that can be charged to patients for providing them with copies of their medical records. CIOX Health claims the HIPAA Omnibus Rule updates in 2013, “unlawfully, unreasonably, arbitrarily and capriciously,” restrict the fees that can be charged by providers and their business associates for providing copies of the health information stored on patients. Changes to HIPAA Rules not only placed a limit on the fees, but also expanded the types of information that must be provided to patients, on request. Accessing some of that information, in particular health information that is not stored in electronic medical records, is costly. Yet, even though the costs of processing some requests are high, HIPAA limits charges to $6.50 according to the lawsuit. CIOX Health argues that this flat rate fee is an arbitrary figure that bears no relation to the actual cost of honoring patient requests for copies of their...

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Achieving HIPAA Compliant File Sharing In and Outside the Cloud
Jan12

Achieving HIPAA Compliant File Sharing In and Outside the Cloud

HIPAA compliant file sharing consists of more than selecting the right technology to ensure the security, integrity and confidentiality of PHI at rest or in transit. Indeed, you could implement the most HIPAA compliant file sharing technology available and still be a long way short of achieving HIPAA compliance. It is not the technology that is at fault. Many Covered Entities and Business Associates fail to configure the technology properly or train employees how to use the technology in compliance with HIPAA. According to a recent IBM X-Force Threat Intelligence Report, 46% of data breaches in the healthcare industry are attributable to “inadvertent actors”. Of the remaining 54% of data breaches in the healthcare industry, 29% are attributable to “outsiders”, while the remaining 25% are the work of “malicious insiders”. Therefore, if a Covered Entity implements HIPAA compliant file sharing technology, but fails to configure it properly, train employees how to use it compliantly, or introduce mechanisms to monitor access to PHI, it may only be 29% of the way towards achieving HIPAA...

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What is Individually Identifiable Health Information?
Jan11

What is Individually Identifiable Health Information?

What is individually identifiable health information and what must HIPAA-covered entities do to the information before it can be shared for reasons not detailed in the permitted uses and disclosures of the HIPAA Privacy Rule? What is Individually Identifiable Health Information? Before answering the question, what is individually identifiable health information, it is necessary to define health information. HIPAA defines health information as any information created or received by a HIPAA-covered entity (healthcare provider, health plan, or healthcare clearinghouse) or business associate of a HIPAA-covered entity. Health information includes past, present, and future information about mental and physical health and the condition of an individual, the provision of healthcare to an individual, and information related to payment for healthcare, again in the past, present, or future. Health information also includes demographic information about an individual. Individually identifiable health information is a subset of health information, and as the name suggests, is health information...

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What is Protected Health Information?
Jan10

What is Protected Health Information?

The latest article in our HIPAA basics series answers the question what is protected health information? The Health Insurance Portability and Accountability Act (HIPAA) requires covered entities to implement safeguards to ensure the confidentiality, integrity, and availability of protected health information, but what is protected health information? First, it is worthwhile explaining two other important terms detailed in HIPAA regulations: A covered entity and a business associate. A covered entity is a healthcare provider, health plan, or healthcare clearinghouse which transmits health data electronically for transactions that the U.S. Department of Health and Human Services has adopted standards. A business associate is an organization or individual who performs services on behalf of a HIPAA-covered entity that requires access to, or the use of, protected health information. What is Protected Health Information? Protected health information is the term given to health data created, received, stored, or transmitted by HIPAA-covered entities and their business associates in...

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Is Azure HIPAA Compliant?
Jan05

Is Azure HIPAA Compliant?

Is Azure HIPAA compliant? Can Microsoft’s cloud services be used by HIPAA covered entities without violating HIPAA Rules? Many healthcare organizations are considering moving some of their services to the cloud, and a large percentage already have. The cloud offers considerable benefits and can help healthcare organizations lower their IT costs, but what about HIPAA? HIPAA does not prohibit healthcare organizations from taking advantage of cloud services; however, it does place certain restrictions on the services that can be used, at least as far as protected health information is concerned. Most healthcare organizations will consider the three main providers of cloud services. Amazon Web Services (AWS), Google Cloud Platform (GCP), and Microsoft Azure. We have already covered AWS HIPAA compliance here, but what about Azure? Is Azure HIPAA compliant? Is Azure HIPAA Compliant? Before any cloud service can be used by healthcare organizations, they must first enter into a business associate agreement with the service provider. Under HIPAA Rules, cloud service providers are considered...

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Largest Healthcare Data Breaches of 2017
Jan04

Largest Healthcare Data Breaches of 2017

This article details the largest healthcare data breaches of 2017 and compares this year’s breach tally to the past two years, which were both record-breaking years for healthcare data breaches. 2015 was a particularly bad year for the healthcare industry, with some of the largest healthcare data breaches ever discovered. There was the massive data breach at Anthem Inc., the likes of which had never been seen before. 78.8 million healthcare records were compromised in that single cyberattack, and there were also two other healthcare data breaches involving 10 million or more records. 2015 was the worst ever year in terms of the number of healthcare records exposed or stolen. 2016 was a better year for the healthcare industry in terms of the number of healthcare records exposed in data breaches. There was no repeat of the mega data breaches of the previous year. Yet, the number of incidents increased significantly. 2016 was the worst ever year in terms of the number of breaches reported by HIPAA-covered entities and their business associates. So how have healthcare organizations...

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HHS Publishes Final Rule on Confidentiality of Substance Use Disorder Patient Records
Jan03

HHS Publishes Final Rule on Confidentiality of Substance Use Disorder Patient Records

The Department of Health and Human Services has published its final rule on the Confidentiality of Substance Use Disorder Patient Records, altering Substance Abuse and Mental Health Services Administration (SAMHSA) regulations. The aim of the update is to better align regulations with advances in healthcare delivery in the United States, while ensuring patient’s privacy is protected when treatment for substance abuse disorders is sought. The final rule addresses the permitted uses and disclosures of patient identifying information for healthcare operations, payment, audits and evaluations. The last substantial changes to the Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR part 2) regulations were in 1987. In 2016, SAMHSA submitted a Notice of Proposed Rulemaking in the Federal Register proposing updates to 42 CFR part 2. The proposed updates reflected the development of integrated health care models and the use of electronic exchange of patient information, while still ensuring patient privacy was protected to prevent improper disclosures. After considering public...

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CMS Clarifies Position on Use of Text Messages in Healthcare
Jan03

CMS Clarifies Position on Use of Text Messages in Healthcare

In November, the Centers for Medicare and Medicaid Services (CMS) explained in emails to healthcare providers that the use of text messages in healthcare is prohibited due to concerns about security and patient privacy. SMS messages are not secure. The CMS was concerned that the use of text messages in healthcare will lead to the exposure of sensitive patient data and could threaten the integrity of medical records. While this is understandable as far as SMS messages are concerned, many secure messaging applications satisfy all the requirements of HIPAA – e.g. transmission security, access and authentication controls, audit controls, and safeguards to ensure the integrity of PHI. The use of secure messaging platforms was raised with the CMS by some hospitals; however, the position of the CMS, based on the emails, appeared to be a total ban on the use of text messages in healthcare, even the use of secure messaging platforms. In the emails, the CMS said, “After meeting with vendors regarding these [secure messaging] products, it was determined they cannot always ensure the privacy...

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2017 HIPAA Enforcement Summary
Dec28

2017 HIPAA Enforcement Summary

Our 2017 HIPAA enforcement summary details the financial penalties paid by healthcare organizations to resolve HIPAA violation cases investigated by the Department of Health and Human Services’ Office for Civil Rights (OCR) and state attorneys general. 2017 saw OCR continue its aggressive pursuit of financial settlements for serious violations of HIPAA Rules. There have been 9 HIPAA settlements and one civil monetary penalty in 2017. In total, OCR received $19,393,000 in financial settlements and civil monetary penalties from covered entities and business associates to resolve HIPAA violations discovered during the investigations of data breaches and complaints. Last year, there were 12 settlements reached with HIPAA-covered entities and business associates, and one civil monetary penalty issued. In 2016, OCR received $25,505,300 from covered entities to resolve HIPAA violation cases. Summary of 2017 HIPAA Enforcement by OCR Listed below are the 2017 HIPAA enforcement activities of OCR that resulted in financial penalties for HIPAA-covered entities and their business associates....

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What is Considered PHI Under HIPAA?
Dec28

What is Considered PHI Under HIPAA?

In a healthcare environment, you are likely to hear health information referred to as protected health information or PHI, but what is considered PHI under HIPAA? What is Considered PHI Under HIPAA Rules? Under HIPAA Rules, PHI is considered to be any identifiable health information that is used, maintained, stored, or transmitted by a HIPAA-covered entity – A healthcare provider, health plan or health insurer, or a healthcare clearinghouse – or a business associate of a HIPAA-covered entity, in relation to the provision of healthcare or payment for healthcare services. It is not only past and current health information that is considered PHI under HIPAA Rules, but also future information about medical conditions or physical and mental health related to the provision of care or payment for care. PHI is health information in any form, including physical records, electronic records, or spoken information. Therefore, PHI includes health records, health histories, lab test results, and medical bills. Essentially, all health information is considered PHI when it includes individual...

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Is Google Voice HIPAA Compliant?
Dec28

Is Google Voice HIPAA Compliant?

Google Voice is a popular telephony service, but is Google Voice HIPAA compliant or can it be used in a HIPAA compliant way? Is it possible for healthcare organizations – or healthcare employees – to use the service without violating HIPAA Rules? Is Google Voice HIPAA Compliant? Google Voice is a popular and convenient telephony service that includes voicemail, voicemail transcription to text, the ability to send text messages free of charge, and many other useful features. It is therefore unsurprising that many healthcare professionals would like to use the service at work, as well as for personal use. In order for a service to be used in healthcare in conjunction with any protected health information (PHI) it must be possible to use it in a HIPAA compliant way. That means the service must be covered by the conduit exemption rule – which was introduced when the HIPAA Omnibus Final Rule came into effect – or it must incorporate a range of controls and safeguards to meet the requirements of the HIPAA Security Rule. As with SMS, faxing and email, Google Voice is not...

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