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HIPAA compliance news

Is Slack HIPAA Compliant?
Nov17

Is Slack HIPAA Compliant?

Slack is a powerful communication tool for improving collaboration, but is Slack HIPAA compliant? Can Slack be used by healthcare organizations for sharing protected health information without risking a HIPAA violation? Is Slack HIPAA Compliant? There has been considerable confusion about the use of Slack in healthcare and whether Slack is HIPAA compliant. Since its launch, Slack has not been HIPAA compliant, although steps have been taken to develop a version of the platform that can be used by healthcare organizations. That version is called Slack Enterprise Grid. Earlier this year, Geoff Belknap, Chief Security Officer at Slack, said “our team has spent over a year investing our time and effort into meeting the rigorous security needs of our customers who work in highly regulated industries.” Slack Enterprise Grid was announced at the start of 2017. Slack Enterprise Grid is not the same as Slack. It has been built on different code, and has been developed specifically for use by companies with more than 500 employees. Slack Enterprise Grid incorporates several security features...

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October 2017 Healthcare Data Breaches
Nov16

October 2017 Healthcare Data Breaches

In October 2017, there were 27 healthcare data breaches reported to the Department of Health and Human Services’ Office for Civil Rights. Those data breaches resulted in the theft/exposure of 71,377 patient and plan member records. October saw a significant fall in the number of reported breaches compared to September, and a major fall in the number of records exposed. October saw a major reduction in the number of breached records, with the monthly total almost 85% lower than September and almost 88% lower than the average number of records breached over the preceding three months. Healthcare providers were the worst hit in October with 19 reported data breaches. There were six data breaches reported by health plans and at least two incidents involved business associates of HIPAA-covered entities. October 2017 Healthcare Data Breaches by Covered Entity Type Main Causes of October 2017 Healthcare Data Breaches Unauthorized access/disclosures were the biggest causes of healthcare data breaches in October. There were 14 breaches reported involving unauthorized access/disclosures, 8...

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5 Year Jail Term Upheld for Clinic Worker Who Stole PHI
Nov15

5 Year Jail Term Upheld for Clinic Worker Who Stole PHI

A clinic worker who stole the protected health information of mentally ill patients and sold the data to identity thieves has failed to get his 5-year jail term reduced. Jean Baptiste Alvarez, 43, of Aldan, PA, stole daily census sheets from the Kirkbride Center, a 267-bed behavioral health care facility in Philadelphia. The census sheets contained all the information needed to steal the identities of patients and submit fraudulent tax returns in their names – Names, Social Security numbers, dates of birth and other personally identifiable information. Alvarez had the opportunity to steal the data undetected, as the floor where the sheets were kept did not have security cameras. Alvarez was paid $1,000 per census sheet by his to-co-conspirators, who used the information to submit 164 fraudulent tax returns in the names of the patients, resulting in a loss of $232,612 in tax revenue for the IRS. In early 2016, Alvarez was found guilty of conspiracy to defraud, misuse of Social Security numbers, and aggravated identity theft. The latter carried a minimum sentence of 2 years. The...

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How to Handle A HIPAA Privacy Complaint
Nov14

How to Handle A HIPAA Privacy Complaint

Healthcare providers need to be prepared to deal with a HIPAA privacy complaint from a patient. In order for an efficient response to be conducted, policies should be developed covering the complaints procedure and staff must be trained to handle HIPAA privacy complaints correctly. Patients must also be clearly informed how they can make a HIPAA privacy complaint if they feel that their privacy has been violated or HIPAA Rules have been breached. This should be clearly stated in your Notice of Privacy Practices. A HIPAA Privacy Complaint Should be Taken Seriously When a HIPAA privacy complaint is filed, it is important that it is dealt with quickly and efficiently. Fast action will help to reassure patients that that you treat all potential privacy and security violations seriously. While patients may be annoyed or upset that an error has been made, in many cases, patients are not looking to cause trouble. They want the issue to be investigated, any risks to be mitigated, the problem to be addressed to ensure it does not happen again, and in many cases, they seek an apology. If the...

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Is Google Hangouts HIPAA Compliant?
Nov14

Is Google Hangouts HIPAA Compliant?

Is Google Hangouts HIPAA compliant? Can Google Hangouts be used by healthcare professionals to transmit and receive protected health information (PHI)? Is Google Hangouts HIPAA Compliant? Healthcare organizations frequently ask about Google services and HIPAA compliance, and one product in particular has caused some confusion is Google Hangouts. Google Hangouts is the latest incarnation of the Hangouts video chat system, and has taken the place of Huddle (Google+ Messenger). Google Hangouts is a cloud-based communication platform that incorporates four different elements: Video chat, SMS, VOIP, and an instant messaging service. Google will sign a business associate agreement for G Suite, which currently covers the following Google core services Gmail Calendar Google Drive (Includes Google Docs, Google Sheets, Google Slides, and Google Forms) Apps Script Keep Sites Jamboard Google Cloud Search Vault (If applicable) Google Hangouts (Chat messaging) Hangouts Meet The Business Associate Agreement does not cover Google Groups, Google Contacts, and Google+, none of which can be used in...

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President Trump Nominates Alex Azar for HHS Secretary
Nov13

President Trump Nominates Alex Azar for HHS Secretary

Former Deputy Secretary of the Department of Health and Human Services, Alex Azar, is tipped to take over from former Secretary Tom Price after receiving the presidential nomination for the role. Azar previously served as general counsel to the HHS and Deputy Secretary during the George W. Bush administration. President Trump confirmed on Twitter that he believes Azar is the man for the job, tweeting “Happy to announce, I am nominating Alex Azar to be the next HHS Secretary. He will be a star for better healthcare and lower drug prices!” The position of Secretary of the Department of Health and Human Services was vacated by former Secretary Tom Price in September, following revelations about his controversial use of military aircraft and expensive charter flights to travel around the country. While there were several potential candidates tipped to receive the nomination, including commissioner of the Food and Drug Administration, Scott Gottlieb, and administrator of the Centers for Medicare and Medicaid Services, Seema Verma, President Trump has made a controversial choice. Alex...

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In What Year Was HIPAA Passed into Legislature?
Nov13

In What Year Was HIPAA Passed into Legislature?

The Health Insurance Portability and Accountability Act or HIPAA was passed into legislature on August 21, 1996, when Bill Clinton added his signature to the bill. Initially, the purpose of HIPAA was to improve portability and continuity of health insurance coverage, especially for employees that were between jobs. HIPAA also standardized amounts that could be saved in pre-tax medical savings accounts, prohibited tax-deduction of interest on life insurance loans, enforced group health plan requirements, simplified the administration of healthcare with standard codes and practices, and introduced measures to prevent healthcare fraud. Many of the details of the five titles of HIPAA took some time to be developed, and several years passed before HIPAA Rules became enforceable. The HIPAA Enforcement Rule, which allows the Department of Health and Human Services’ Office for Civil Rights to impose financial penalties for noncompliance with HIPAA Rules, was not passed until February 16, 2006 – A decade after HIPAA was first introduced. There have been several important dates in the past...

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What is a Limited Data Set Under HIPAA?
Nov07

What is a Limited Data Set Under HIPAA?

A limited data set under HIPAA is a set of identifiable healthcare information that the HIPAA Privacy Rule permits covered entities to share with certain entities for research purposes, public health activities, and healthcare operations without obtaining prior authorization from patients, if certain conditions are met. In contrast to de-identified protected health information, which is no longer classed as PHI under HIPAA Rules, a limited data set under HIPAA is still identifiable protected information. Therefore it is still subject to HIPAA Privacy Rule regulations. A HIPAA limited data set can only be shared with entities that have signed a data use agreement with the covered entity. The data use agreement allows the covered entity to obtain satisfactory assurances that the PHI will only be used for specific purposes, that the PHI will not be disclosed by the entity with which it is shared, and that the requirements of the HIPAA Privacy Rule will be followed. The data use agreement, which must be accepted prior to the limited data set being shared, should outline the following:...

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Can A Patient Sue for A HIPAA Violation?
Nov07

Can A Patient Sue for A HIPAA Violation?

Can a patient sue for a HIPAA violation? There is no private cause of action in HIPAA, so it is not possible for a patient to sue for a HIPAA violation. Even if HIPAA Rules have clearly been violated by a healthcare provider, and harm has been suffered as a direct result, it is not possible for patients to seek damages, at least not for the violation of HIPAA Rules. So, if it is not possible for a patient to sue for a HIPAA violation, does that mean legal action cannot be taken against a covered entity when HIPAA has clearly been violated? While HIPAA does not have a private cause of action, it is possible for patients to take legal action against healthcare providers and obtain damages for violations of state laws. In some states, it is possible to file a lawsuit against a HIPAA covered entity on the grounds of negligence or for a breach of an implied contract, such as if a covered entity has failed to protect medical records. In such cases, it will be necessary to prove that damage or harm has been caused as a result of negligence or the theft of unsecured personal information....

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When Should You Promote HIPAA Awareness?
Nov06

When Should You Promote HIPAA Awareness?

All employees must receive training on HIPAA Rules, but when should you promote HIPAA awareness? How often should HIPAA retraining take place? HIPAA-covered entities, business associates and subcontractors are all required to comply with HIPAA Rules, and all workers must receive training on HIPAA. HIPAA training should ideally be provided before any employee is given access to PHI. Training should cover the allowable uses and disclosures of PHI, patient privacy, data security, job-specific information, internal policies covering privacy & security, and HIPAA best practices. The penalties for HIPAA violations, and the consequences for individuals discovered to have violated HIPAA Rules, must also be explained. If employees do not receive training, they will not be aware of their responsibilities and privacy violations are likely to occur. Additional training must also be provided whenever there is a material change to HIPAA Rules or internal policies with respect to PHI, following the release of new guidance, or implementation of new technology. HIPAA Training Cannot be a...

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Is G Suite HIPAA Compliant?
Nov03

Is G Suite HIPAA Compliant?

Is G Suite HIPAA compliant? Can G Suite be used by HIPAA-covered entities without violating HIPAA Rules? Google has developed G Suite to include privacy and security protections to keep data secure, and those protections are of a sufficiently high standard to meet the requirements of the HIPAA Security Rule. Google will also sign a business associate agreement (BAA) with HIPAA covered entities. So, is G Suite HIPAA compliant? G Suite can be used without violating HIPAA Rules, but HIPAA compliance is more about the user than the cloud service provider. Making G Suite HIPAA Compliant (by default it isn’t) As with any secure cloud service or platform, it is possible to use it in a manner that violates HIPAA Rules. In the case of G Suite, all the safeguards are in place to allow HIPAA covered entities to use G Suite in a HIPAA compliant manner, but it is up to the covered entity to ensure that G Suite is configured correctly. It is possible to use G Suite and violate HIPAA Rules. Obtain a BAA from Google One important requirement of HIPAA is to obtain a signed, HIPAA-compliant...

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What Happens if a Nurse Violates HIPAA?
Nov03

What Happens if a Nurse Violates HIPAA?

What happens if a nurse violates HIPAA Rules? How are HIPAA violations dealt with and what are the penalties for individuals that accidentally or deliberately violate HIPAA and access, disclose, or share protected health information (PHI) without authorization?   The Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules must be followed by all covered entities and their business associates. The failure to comply with HIPAA Rules can result in significant penalties for HIPAA covered entities. Business associates of covered entities can also be fined directly for HIPAA violations, but what about individual healthcare workers such as nurses? What happens if a nurse violates HIPAA Rules? What are the Penalties if a Nurse Violates HIPAA? Accidental HIPAA violations by nurses happen, even when care is taken to follow HIPAA Rules. While all HIPAA violations can potentially result in disciplinary action, most employers would accept that accidental violations are bound to occur from time to time. In many cases, minor violations of HIPAA...

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Survey Reveals Sharing EHR Passwords is Commonplace
Nov02

Survey Reveals Sharing EHR Passwords is Commonplace

While data on the practice of password sharing in healthcare is limited, one survey suggests the practice of sharing EHR passwords is commonplace, especially with interns, medical students, and nurses. The research was conducted by Ayal Hassidim, MD of the Hadassah-Hebrew University Medical Center, Jerusalem, and also involved researchers from Duke University, Harvard Medical School, Ben Gurion University of the Negev, and Hadassah-Hebrew University Medical Center. The study was conducted on 299 medical students, nurses, medical residents, and interns and the results of the survey were recently published in Healthcare Informatics Research. The information stored in EHRs is sensitive and must be protected. Regulations such as HIPAA control access to that information. All individuals that require access to the information in EHR systems must be issued with a unique user ID and password. Any attempts to access protected health information must be logged to allow healthcare organizations to monitor for unauthorized access. If login credentials are shared with other individuals, it is...

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Tips for Reducing Mobile Device Security Risks
Nov01

Tips for Reducing Mobile Device Security Risks

An essential part of HIPAA compliance is reducing mobile device security risks to a reasonable and acceptable level. As healthcare organizations turn to mobiles devices such as laptop computers, mobile phones, and tablets to improve efficiency and productivity, many are introducing risks that could all too easily result in a data breach and the exposure of protected health information (PHI). As the breach reports submitted to the HHS’ Office for Civil Rights show, mobile devices are commonly involved in data breaches. Between January 2015 and the end of October 2017, 71 breaches have been reported to OCR that have involved mobile devices such as laptops, smartphones, tablets, and portable storage devices. Those breaches have resulted in the exposure of 1,303,760 patients and plan member records. 17 of those breaches have resulted in the exposure of more than 10,000 records, with the largest breach exposing 697,800 records. The majority of those breaches could have easily been avoided. The Health Insurance Portability and Accountability Act (HIPAA) Security Rule does not demand...

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Who Do You Report HIPAA Violations To?
Nov01

Who Do You Report HIPAA Violations To?

The Health Insurance Portability and Accountability Act (HIPAA) requires HIPAA-covered entities and their business associates to implement safeguards to ensure the privacy of patients is protected and protected health information (PHI) is secured, but what happens when those rules are violated? Who do you report HIPAA violations to? Who do You Report HIPAA Violations To? If you suspect that HIPAA Rules have been violated by a HIPAA covered entity – Healthcare providers, health plans, healthcare clearinghouses, business associates of covered entities and their subcontractors – it is important for the violation to be reported to allow an investigation to take place. HIPAA violations frequently occur as a result of human error, a misunderstanding of HIPAA regulations, or in some cases, deliberate or willful violations of HIPAA Rules occur. A covered entity or business associate may not be aware that a HIPAA violation has occurred, and should be given the opportunity to correct errors and prevent similar violations from occurring in the future. How Can Healthcare Employees Report...

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HHS Privacy Chief Deven McGraw Departs OCR: Iliana Peters Now Acting Deputy
Oct31

HHS Privacy Chief Deven McGraw Departs OCR: Iliana Peters Now Acting Deputy

Deven McGraw, the Deputy Director for Health Information Privacy at the Department of Health and Human Services’ Office for Civil Rights (OCR) has stepped down and left OCR. McGraw vacated the position on October 19, 2017. McGraw has served as Deputy Director for Health Information Privacy since July 2015, replacing Susan McAndrew. McGraw joined OCR from Manatt, Phelps & Phillips, LLP where she co-chaired the company’s privacy and data security practice. McGraw also served as Acting Chief Privacy Officer at the Office of the National Coordinator for Health IT (ONC) since the departure of Lucia Savage earlier this year. In July, ONC National Coordinator Donald Rucker announced that following cuts to the ONC budget, the Office of the Chief Privacy Officer would be closed out, with the Chief Privacy Officer receiving only limited support. It therefore seems an opportune moment for Deven McGraw to move onto pastures new. OCR’s Iliana Peters has stepped in to replace McGraw in the interim and will serve as Acting Deputy Director until a suitable replacement for McGraw can be found....

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Who Does HIPAA Apply To?
Oct31

Who Does HIPAA Apply To?

Health Insurance Portability and Accountability Act (HIPAA) Rules cover the allowable uses and disclosures of protected health information secure and data security, but who does HIPAA apply to? Which types of organizations must implement HIPAA compliance programs? Who Does HIPAA Apply to? HIPAA applies to healthcare providers, health plans, and healthcare clearinghouses if those organizations transmit health data electronically in connection with transactions for which the Department of Health and Human Services has adopted standards. Healthcare providers that are typically required to comply with HIPAA Rules includes hospitals, health clinics, nursing homes, doctors, dentists, pharmacies, chiropractors, and psychologists. Health plans include HMO’s, health insurance providers, company health plans, government programs that pay for health care such as Medicaid and Medicare, and veterans’ health programs. Self-insured companies that provide health coverage to their employees are also required to comply with HIPAA Rules. Healthcare clearinghouses include entities that process...

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OCR Clarifies HIPAA Rules on Sharing Patient Information on Opioid Overdoses
Oct28

OCR Clarifies HIPAA Rules on Sharing Patient Information on Opioid Overdoses

The U.S. Department of Health and Human Services’ Office for Civil Rights has cleared confusion about HIPAA Rules on sharing patient information on opioid overdoses. The HIPAA Privacy Rule permits healthcare providers to share limited PHI in certain emergency and dangerous situations. Those situations include natural disasters and during drug overdoses, if sharing information can prevent or lessen a serious and imminent threat to a patient’s health or safety. Some healthcare providers have misunderstood the HIPAA Privacy Rule provisions, and believe permission to disclose information to the patient’s loved ones or caregivers must be obtained from the patient before any PHI can be disclosed. In an emergency or crisis situation, such as during a drug overdose, healthcare providers are permitted to share limited PHI with a patient’s loved ones and caregivers without permission first having been obtained from the patient. During an opioid overdose, healthcare providers can share health information with the patient’s family members, close friends, and caregivers if: The healthcare...

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Is AWS HIPAA Compliant?
Oct27

Is AWS HIPAA Compliant?

Is AWS HIPAA compliant? Amazon Web Services has all the protections to satisfy the HIPAA Security Rule and Amazon will sign a business associate agreement with healthcare organizations. So, is AWS HIPAA compliant? Yes. And No. AWS can be HIPAA compliant, but it is also easy to make configuration mistakes that will leave protected health information (PHI) unprotected and accessible by unauthorized individuals, violating HIPAA Rules. Amazon Will Sign a Business Associate Agreement for AWS Amazon is keen for healthcare organizations to use AWS, and as such, a business associate agreement will be signed. Under that agreement, Amazon will support the security, control, and administrative processes required under HIPAA. Previous, under the terms of the AWS BAA, the AWS HIPAA compliance program required covered entities and business associates to use Amazon EC2 Dedicated Instances or Dedicated Hosts to process Protected Health Information (PHI), although that is now no longer the case. As part of its efforts to help healthcare organizations use AWS safely and securely without violating...

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How to Report a HIPAA Violation
Oct26

How to Report a HIPAA Violation

It is important for all healthcare employees to know how to report a HIPAA violation, the correct person to direct the complaint to, and whether the incident should be directed to the Department of Health and Human Services’ Office for Civil Rights (OCR). Potential HIPAA violations must be investigated internally by HIPAA covered entities and their business associates to determine the severity of the breach, the risk to individuals impacted by the incident, and to ensure action is taken promptly to correct the violation and mitigate risk. The sooner a potential HIPAA violation is reported, the easier it will be to limit the potential harm that may be caused and to prevent further violations of HIPAA Rules. How to Report a HIPAA Violation Internally When healthcare professionals suspect a colleague or their employer has violated HIPA Rules, the incident should be reported to a supervisor, your organization’s Privacy Officer, or to the individual responsible for HIPAA compliance in your organization. Accidental HIPAA violations occur even when great care is taken by employees. The...

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The Most Common HIPAA Violations You Should Be Aware Of
Oct26

The Most Common HIPAA Violations You Should Be Aware Of

The most common HIPAA violations that have resulted in financial penalties are the failure to perform an organization-wide risk analysis to identify risks to the confidentiality, integrity, and availability of protected health information (PHI); the failure to enter into a HIPAA-compliant business associate agreement; impermissible disclosures of PHI; delayed breach notifications; and the failure to safeguard PHI. The settlements pursued by the Department of Health and Human Services’ Office for Civil Rights (OCR) are for egregious violations of HIPAA Rules. Settlements are also pursued to highlight common HIPAA violations to raise awareness of the need to comply with specific aspects of HIPAA Rules. This article covers five of the most common HIPAA violations that have resulted in settlements with covered entities and their business associates over the past few years. Are Data Breaches HIPAA Violations? Data breaches are now a fact of life. Even with multi-layered cybersecurity defenses, data breaches are still likely to occur from time to time. OCR understands that healthcare...

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New Tool Helps Healthcare Organizations Find HIPAA Compliant Business Associates
Oct25

New Tool Helps Healthcare Organizations Find HIPAA Compliant Business Associates

Healthcare organizations are only permitted to use business associates that agree to comply with HIPAA Rules and sign a business associate agreement, but finding HIPAA compliant business associates can be a challenge. Searching for HIPAA compliant business associates is time consuming, although identifying vendors willing to follow HIPAA Rules is only part of the process. Business associate agreements must then be assessed, often incurring legal fees, and healthcare organizations must obtain assurances from new business associate that appropriate safeguards have been implemented to ensure the confidentiality, integrity, and availability of any PHI they provide. It is also challenging for vendors that wish to take advantage of the opportunities in the healthcare industry. They must be able to demonstrate they have implemented appropriate safeguards and need to provide reassurances that their products and services support HIPAA-compliance. A solution has now been developed that resolves the issues for both parties and streamlines the process of finding HIPAA compliant business...

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Who Enforces HIPAA?
Oct25

Who Enforces HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) introduced many new rules for healthcare organizations, but who enforces HIPAA? Which federal departments are responsible for ensuring HIPAA Rules are followed by covered entities and their business associates? Who Enforces HIPAA? The primary enforcer of HIPAA Rules is the Department of Health and Human Services’ Office for Civil Rights (OCR). However, since the incorporation of the Health Information Technology for Economic and Clinical Health (HITECH) Act into HIPAA in 2009, state attorneys general were also given the power to enforce HIPAA Rules. The Centers for Medicare and Medicaid Services (CMS) also have some powers, and are primarily responsible for enforcing the HIPAA administrative simplification regulations. The U.S. Food and Drug Administration (FDA) can also enforce HIPAA with respect to medical devices and may take action against healthcare organizations in certain situations. HIPAA Enforcement by the HHS’ Office for Civil Rights As the main enforcer of HIPAA Rules, the Office for Civil Rights...

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Who Should HIPAA Complaints be Directed to Within the Covered Entity?
Oct23

Who Should HIPAA Complaints be Directed to Within the Covered Entity?

Who should HIPAA complaints be directed to within the covered entity? Any healthcare employee who believes they have witnessed a HIPAA violation should report the incident internally. Typically, the person to report the violation to is your Privacy Officer, if your organization has appointed one. Reporting Potential HIPAA Violations Internally During your HIPAA training, you should have been told who should HIPAA complaints be directed to within the covered entity, and the procedures to follow for making complaints about potential HIPAA violations. Generally speaking, the HIPAA violation should be reported to the person in your organization who is responsible for HIPAA compliance, which is typically your Privacy Officer or CISO. You may feel more comfortable reporting the incident to your supervisor. All HIPAA violations, even HIPAA violations that seem relatively minor, should be reported. They could be indicative of a wider problem, so it is important they are investigated internally. Accidental HIPAA violations should also be reported. It is better to own up to a minor HIPAA...

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Is Microsoft Outlook HIPAA Compliant?
Oct20

Is Microsoft Outlook HIPAA Compliant?

The latest in our series of posts on HIPAA compliant software and email services for healthcare organizations explores whether Microsoft Outlook is HIPAA compliant. Is Microsoft Outlook HIPAA Compliant? Software or an email platform can never be fully HIPAA compliant, as compliance is not so much about the technology but how it is used. That said, software and email services can support HIPAA compliance. In order for an email service to support HIPAA compliance, it must include a range of security features to ensure that any information uploaded to and transmitted through the service can be done so securely, without risking the exposure or the interception of sensitive data. The platform provider must also be prepared to sign a business associate agreement with HIPAA-covered entities, and by doing so, agree to comply with the requirements of the HIPAA, Privacy, Security, and Breach Notification Rules. Microsoft has already taken steps toward making many of its services suitable for healthcare providers by agreeing to enter into a business associate agreement. Crucially for...

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What are the HIPAA Administrative Simplification Regulations?
Oct20

What are the HIPAA Administrative Simplification Regulations?

The HIPAA Administrative Simplification Regulations – detailed in 45 CFR Part 160, Part 162, and Part 164 – require healthcare organizations to adopt national standards, often referred to as electronic data interchange or EDI standards. The purpose of these regulations is to save time and costs by streamlining the paperwork required for processes such as billing, verifying patient eligibility, and sending and receiving payments. HIPAA Administrative Simplification Standards The HIPAA Administrative Simplification Regulations include four standards covering transactions, identifiers, code sets, and operating rules. By adopting these standards and switching from paperwork to electronic transactions, healthcare organizations can reduce the paperwork burden, receive payments faster, obtain information more rapidly, and easily check the status of claims. The regulations require HIPAA covered entities – healthcare providers, health plans, healthcare clearinghouses, and business associates of covered entities – to adopt standards for transactions involving the electronic exchange of...

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Termination for Nurse HIPAA Violation Upheld by Court
Oct19

Termination for Nurse HIPAA Violation Upheld by Court

A nurse HIPAA violation alleged by a patient of Norton Audubon Hospital culminated in the termination of the registered nurse’s employment contract. The nurse, Dianna Hereford, filed an action in the Jefferson Circuit Court alleging her employer wrongfully terminated her contract on the grounds that a HIPAA violation had occurred, when she claims she had always ‘strictly complied with HIPAA regulations.’ The incident that resulted in her dismissal was an alleged impermissible disclosure of PHI. Hereford had been assigned to the Post Anesthesia Care Unit at Norton Audubon Hospital and was assisting with a transesophageal echocardiogram. At the time of the alleged HIPAA violation, the patient was in an examination area that was closed off with a curtain. Hereford was present along with a physician and an echocardiogram technician. Alleged Improper Disclosure of Sensitive Health Information Before the procedure took place, Hereford performed a ‘Time-Out’ to ensure the patient understood what the procedure would entail, checked to make sure the site of the procedure was clearly marked...

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Healthcare Data Breaches in September Saw Almost 500K Records Exposed
Oct19

Healthcare Data Breaches in September Saw Almost 500K Records Exposed

Protenus has released its Breach Barometer report which shows there was a significant increase in healthcare data breaches in September. The report includes healthcare data breaches reported to the Department of Health and Human Services’ Office for Civil Rights and security incidents tracked by databreaches.net. The latter have yet to appear on the OCR ‘Wall of Shame.’ In total, Protenus/databreaches.net tracked 46 healthcare data breaches in September. While the total number of breach victims has not been confirmed for all incidents, at least 499,144 healthcare records are known to have been exposed or stolen. The number of records exposed or stolen in four of the month’s breaches has yet to be disclosed. The high number of incidents makes September the second worst month of 2017 for healthcare industry data breaches. Only June was worse, when 52 data breaches were reported. In August, 33 data breaches were reported by healthcare organizations. The report confirms the worst incident of the month was a ransomware attack that saw the records of 128,000 individuals made...

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De-identification of Protected Health Information: How to Anonymize PHI
Oct18

De-identification of Protected Health Information: How to Anonymize PHI

Healthcare organizations and their business associates that want to share protected health information must do so in accordance with the HIPAA Privacy Rule, which limits the possible uses and disclosures of PHI, but de-identification of protected health information means HIPAA Privacy Rule restrictions no longer apply. HIPAA Privacy Rule restrictions only covers individually identifiable protected health information. If you de-identify PHI so that the identity of individuals cannot be determined, and re-identification of individuals is not possible, PHI can be freely shared. The de-identification of protected health information enables HIPAA covered entities to share health data for large-scale medical research studies, policy assessments, comparative effectiveness studies, and other studies and assessments without violating the privacy of patients or requiring authorizations to be obtained from each patient prior to data being disclosed. HIPAA-Compliant De-identification of Protected Health Information HIPAA-compliant de-identification of protected health information is possible...

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What Are Covered Entities Under HIPAA?
Oct18

What Are Covered Entities Under HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) applies to HIPAA-covered entities and their business associates, but what are covered entities under HIPAA, and what sort of companies are classed as business associates? Covered Entities Under HIPAA Covered entities under HIPAA are individuals or entities that transmit protected health information for transactions for which the Department of Health and Human Services has adopted standards (see 45 CFR 160.103). Transactions include transmission of healthcare claims, payment and remittance advice, healthcare status, coordination of benefits, enrollment and disenrollment, eligibility checks, healthcare electronic fund transfers, and referral certification and authorization. Covered entities under HIPAA include health plans, healthcare providers, and healthcare clearinghouses. Health plans include health insurance companies, health maintenance organizations, government programs that pay for healthcare (Medicare for example), and military and veterans’ health programs. Healthcare clearinghouses are organizations that...

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What is the Purpose of HIPAA?
Oct18

What is the Purpose of HIPAA?

The Health Insurance Portability and Accountability Act – or HIPAA as it is better known – is an important legislative Act affecting the U.S. healthcare industry, but what is the purpose of HIPAA? Healthcare professionals often complain about the restrictions of HIPAA – Are the benefits of the legislation worth the extra workload? What is the Purpose of HIPAA? HIPAA was first introduced in 1996. In its earliest form, the legislation helped to ensure that employees would continue to receive health insurance coverage when they were between jobs. The legislation also required healthcare organizations to implement controls to secure patient data to prevent healthcare fraud, although it took several years for the rules for doing so to be penned. HIPAA also introduced several new standards that were intended to improve efficiency in the healthcare industry, requiring healthcare organizations to adopt the standards to reduce the paperwork burden. Code sets had to be used along with patient identifiers, which helped pave the way for the efficient transfer of healthcare data between...

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Q3, 2017 Healthcare Data Breach Report
Oct16

Q3, 2017 Healthcare Data Breach Report

In Q3, 2017, there were 99 breaches of more than 500 records reported to the Department of Health and Human Services’ Office for Civil Rights (OCR), bringing the total number of data breaches reported in 2017 up to 272 incidents. The 99 data breaches in Q3, 2017 saw 1,767,717 individuals’ PHI exposed or stolen. So far in 2017, the records of 4,601,097 Americans have been exposed or stolen as a result of healthcare data breaches. Q3 Data Breaches by Covered Entity Healthcare providers were the worst hit in Q3, reporting a total of 76 PHI breaches. Health plans reported 17 breaches and there were 6 data breaches experienced by business associates of covered entities. There were 31 data breaches reported in July, 29 in August, and 39 in September. While September was the worst month for data breaches, August saw the most records exposed – 695,228. The Ten Largest Healthcare Data Breaches in Q3, 2017 The ten largest healthcare data breaches reported to OCR in Q3, 2017 were all the result of hacking/IT incidents. In fact, 36 out of the 50 largest healthcare data breaches in...

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What Federal Department Regulates HIPAA?
Oct16

What Federal Department Regulates HIPAA?

Healthcare providers, health plans, healthcare clearinghouses, and business associates of those organizations must comply with the Health Insurance Portability and Accountability Act (HIPAA), but what federal department regulates HIPAA and takes action against organizations that fail to comply with HIPAA Rules? What Federal Department Regulates HIPAA? HIPAA is regulated by the Department of Health and Human Services’ Office for Civil Rights (OCR). Since the introduction of the HIPAA Enforcement Rule in March 2006, OCR was given the power to investigate complaints about HIPAA violations. OCR was also given the right to issue civil monetary penalties if HIPAA-covered entities were found to have violated HIPAA Rules. While OCR had the power to issue financial penalties, it is relatively rare for HIPAA violations to result in financial penalties. Over the years since the Enforcement Rule was passed, OCR has steadily increased enforcement of HIPAA Rules, although it has only been in the past four years that financial penalties for HIPAA violations have become more common. Since the...

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Is Skype HIPAA Compliant?
Oct13

Is Skype HIPAA Compliant?

Text messaging platforms such as Skype are a convenient way of quickly communicating information, but is Skype HIPAA compliant? Can Skype be used to send text messages containing electronic protected health information (ePHI) without risking violating HIPAA Rules? There is currently some debate surrounding Skype and HIPAA compliance. Skype includes security features to prevent unauthorized access of information transmitted via the platform and messages are encrypted. But does Skype satisfy all requirements of HIPAA Rules? This article will attempt to answer the question, Is Skype HIPAA compliant? Is Skype a Business Associate? Is Skype a HIPAA business associate? That is a matter that has been much debated. Skype could be considered an exception under the Conduit Rule – being merely a conduit through which information flows. If that is the case, a business associate agreement would not be necessary. However, a business associate agreement is necessary if a vendor creates, receives, maintains, or transmits PHI on behalf of a HIPAA-covered entity or one of its business associates....

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How to Secure Patient Information (PHI)
Oct13

How to Secure Patient Information (PHI)

HIPAA requires healthcare organizations of all sizes to secure protected health information (PHI), but how can covered entities secure patient information? If you are asked how you secure patient information, could you provide an answer? How Can You Secure Patient Information? HIPAA requires healthcare organizations and their business associates to implement safeguards to ensure the confidentiality, integrity, and availability of PHI, although there is little detail provided on how to secure patient information in HIPAA regulations. This is intentional, as the pace that technology is advancing is far greater than the speed at which HIPAA can be updated. If details were included, they would soon be out of date. Technology is constantly changing and new vulnerabilities are being discovered in systems and software previously thought to be secure. Securing patient information is therefore not about implementing security solutions and forgetting about them. To truly secure patient information you must regularly review your security controls, update policies and procedures, maintain...

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How Should You Respond to an Accidental HIPAA Violation?
Oct12

How Should You Respond to an Accidental HIPAA Violation?

The majority of HIPAA covered entities, business associates, and healthcare employees take great care to ensure HIPAA Rules are followed, but what happens when there is accidental HIPAA violation? How should healthcare employees, covered entities, and business associates respond? How Should Employees Report an Accidental HIPAA Violation? Accidents happen. If a healthcare employee accidentally views the records of a patient, if a fax is sent to an incorrect recipient, an email containing PHI is sent to the wrong person, or any other accidental disclosure of PHI has occurred, it is essential that the incident is reported to your Privacy Officer. Your Privacy Officer will need to determine what actions need to be taken to mitigate risk and reduce the potential for harm. The incident will need to be investigated, a risk assessment may need to be performed, and a report of the breach may need to be sent to the Department of Health and Human Services’ Office for Civil Rights (OCR). You should explain that a mistake was made and what has happened. You will need to explain which patient’s...

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Why is HIPAA Important?
Oct12

Why is HIPAA Important?

The Health Insurance Portability and Accountability Act (HIPAA) is a landmark piece of legislation, but why is HIPAA important? What changes did HIPAA introduce and what are the benefits to the healthcare industry and patients? HIPAA was introduced in 1996, primarily to address one particular issue: Insurance coverage for individuals that are between jobs. Without HIPAA, employees faced a loss of insurance coverage when they were between jobs. A second goal of HIPAA was to prevent healthcare fraud and ensure that all ‘protected health information’ was appropriately secured and to restrict access to health data to authorized individuals. Why is HIPAA Important for Healthcare Organizations? HIPAA introduced a number of important benefits for the healthcare industry to help with the transition from paper records to electronic copies of health information. HIPAA has helped to streamline administrative healthcare functions, improve efficiency in the healthcare industry, and ensure protected health information is shared securely. The standards for recording health data and electronic...

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Do Medical Practices Need to Monitor Business Associates for HIPAA Compliance?
Oct11

Do Medical Practices Need to Monitor Business Associates for HIPAA Compliance?

Should covered entities monitor business associates for HIPAA compliance or is it sufficient just obtain a signed, HIPAA-compliant business associate agreement? If a business associate provides reasonable assurances to a covered entity that HIPAA Rules are being followed, and errors are made by the BA that result in the exposure, theft, or accidental disclosure of PHI, the covered entity will not be liable for the BA’s HIPAA violations – provided the covered entity has entered into a business associate agreement with its business associate. It is the responsibility of the business associate to ensure compliance with HIPAA Rules. The failure of a business associate to comply with HIPAA Rules can result in financial penalties for HIPAA violations for the business associate, not the covered entity. A covered entity should ‘obtain satisfactory assurances’ that HIPAA Rules will be followed prior to disclosing PHI. While covered entities are not required by HIPAA to monitor business associates for HIPAA compliance, they should obtain proof that their business associate has performed an...

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Proposed Rule for Certification of Compliance for Health Plans Withdrawn by HHS
Oct10

Proposed Rule for Certification of Compliance for Health Plans Withdrawn by HHS

In January 2014, the HHS proposed a new rule for certification of compliance for health plans. The rule would have required all controlling health plans (CHPs) to submit a range of documentation to HHS to demonstrate compliance with electronic transaction standards set by the HHS under HIPAA Rules. The main aim of the proposed rule – Administrative Simplification: Certification of Compliance for Health Plans – was to promote more consistent testing processes for CHPs. The HHS has now announced that the proposed rule has now been withdrawn. Had the proposed rule made it to the final rule stage, CHPs would have been required to demonstrate compliance with HIPAA administration simplification standards for three electronic transactions: Eligibility for a health plan, health care claim status, and health care electronic funds transfers (EFT) and remittance advice. The failure to comply with the new rule would have resulted in financial penalties for CHPs. Most employers’ health plans were handled by their insurance carriers, so the proposed rule would not have affected them...

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53% of Businesses Have Misconfigured Secure Cloud Storage Services
Oct09

53% of Businesses Have Misconfigured Secure Cloud Storage Services

The healthcare industry has embraced the cloud. Many healthcare organizations now use secure cloud storage services to host web applications or store files containing electronic protected health information (ePHI). However, just because secure cloud storage services are used, it does not mean data breaches will not occur, and neither does it guarantee compliance with HIPAA. Misconfigured secure cloud storage services are leaking sensitive data and many organizations are unaware sensitive information is exposed. A Business Associate Agreement Does Not Guarantee HIPAA Compliance Prior to using any cloud storage service, HIPAA-covered entities must obtain a signed business associate agreement from their service providers. Obtaining a signed, HIPAA-compliant business associate agreement prior to the uploading any ePHI to the cloud is an important element of HIPAA compliance, but a BAA alone will not guarantee compliance. ePHI can easily be exposed if cloud storage services are not configured correctly. As Microsoft explains, “By offering a BAA, Microsoft helps support your HIPAA...

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Is WhatsApp HIPAA Compliant?
Oct06

Is WhatsApp HIPAA Compliant?

When WhatsApp announced it was introducing end-to-end encryption, it opened up the prospect of healthcare organizations using the platform as an almost free secure messaging app, but is WhatsApp HIPAA compliant? Many healthcare employees have been asking if WhatsApp is HIPAA compliant, and some healthcare professionals are already using the text messaging app to send protected health information (PHI). However, while WhatsApp does offer far greater protection than SMS messages and some other text messaging platforms, we believe WhatsApp is not a HIPAA compliant messaging platform. Why Isn’t WhatsApp HIPAA Compliant? First, it is important to point out that no software platform or messaging app can be truly HIPAA compliant, because HIPAA compliance is not about software. It is about users. Software can support HIPAA compliance and incorporate all the necessary safeguards to ensure the confidentiality, integrity, and availability of ePHI, but those controls can easily be undone by users. HIPAA does not demand that encryption is used. Provided an alternate, equivalent measure is...

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Does HIPAA Require Identity Theft Protection Services to Be Offered to Data Breach Victims?
Oct06

Does HIPAA Require Identity Theft Protection Services to Be Offered to Data Breach Victims?

The HIPAA Breach Notification Rule requires covered entities to issue notifications to individuals after their ePHI has been exposed or stolen, but what about credit monitoring and identity theft protection services? Must they be offered? HIPAA does not stipulate whether credit monitoring and identity theft protection services should be provided to individuals impacted by a data breach. The decision whether or not to provide those services is left to the discretion of the covered entity. However, following a breach of unsecured protected health information, HIPAA-covered entities are required to provide breach victims with details of the steps that should be taken to mitigate risk and protect themselves from harm. Those steps include obtaining a credit report from credit reporting agencies – Equifax, Experian, and TransUnion. The credit reporting bureaus must provide consumers with a free credit report once every 12 months if requested. Breach victims should be instructed to monitor their accounts for any sign of fraudulent activity and should be told what to do if suspicious...

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OCR Clarifies HIPAA Rules on Disclosures to Family, Friends and Other Individuals
Oct05

OCR Clarifies HIPAA Rules on Disclosures to Family, Friends and Other Individuals

The recent attack in Las Vegas has prompted the Department of Health and Human Services’ Office for Civil Rights to clarify HIPAA Rules on disclosures to family, friends and other individuals. Following Hurricane Irma and Hurricane Maria, OCR issued a partial waiver of certain provisions of the HIPAA Privacy Rule in the disaster areas of both hurricanes. OCR sometimes, but not always, issued such a waiver after a natural disaster when a public health emergency has been declared. However, OCR did not issue a HIPAA Privacy Rule waiver after the attack in Las Vegas, and neither was a waiver issued following the Orlando nightclub shootings in 2016. OCR does not usually issue waivers of HIPAA Rules following shootings and other man-made disasters. Healthcare organizations involved in the treatment of victims of the Las Vegas shootings were required to continue to follow the provisions of the HIPAA Privacy Rule. In its reminder about HIPAA Rules on disclosures to family, friends and other individuals, OCR explained that the HIPAA Privacy Rule allows healthcare organizations to disclose...

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What are the HIPAA Breach Notification Requirements?
Oct04

What are the HIPAA Breach Notification Requirements?

All HIPAA covered entities must familiarize themselves with the HIPAA breach notification requirements and develop a breach response plan that can be implemented as soon as a breach of unsecured protected health information is discovered. While most HIPAA covered entities should understand the HIPAA breach notification requirements, organizations that have yet to experience a data breach may not have a good working knowledge of the requirements of the Breach Notification Rule. Vendors that have only just started serving healthcare clients may similarly be unsure of the reporting requirements and actions that must be taken following a breach. The issuing of notifications following a breach of unencrypted protected health information is an important element of HIPAA compliance. The failure to comply with HIPAA breach notification requirements can result in a significant financial penalty. With this in mind, we have compiled a summary of the HIPAA breach notification requirements for covered entities and their business associates. Summary of the HIPAA Breach Notification Requirements...

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How Employees Can Help Prevent HIPAA Violations
Oct03

How Employees Can Help Prevent HIPAA Violations

Healthcare organizations and their business associates must comply with the HIPAA Privacy, Security, and Breach Notifications Rules and implement safeguards to prevent HIPAA violations. However, even with controls in place to reduce the risk of HIPAA violations, data breaches still occur. In most industries, it is hackers and other cybercriminals that are responsible for the majority of security breaches, but in healthcare it is insiders. While healthcare organizations can take steps to improve their defenses and implement technologies to identify breaches rapidly when they occur, healthcare employees also need to help prevent HIPAA violations. Employees Can Help to Prevent HIPAA Violations Healthcare privacy breaches often occur as a result of carelessness or a lack of understanding of HIPAA Rules. Healthcare organizations should therefore ensure employees receive full training on HIPAA and know the allowable uses and disclosures of PHI and to secure ePHI at all times. Refresher training sessions should also be provided regularly to ensure HIPAA Rules are not forgotten. Employees...

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What Does HIPAA Mean?
Oct01

What Does HIPAA Mean?

What does HIPAA mean? HIPAA is an acronym of the Health Insurance Portability and Accountability Act – A legislative act that was signed into law in the United States by Bill Clinton on August 21, 1996. Initially, HIPAA was introduced to reform the healthcare industry and had two main aims: To ensure that when employees were between jobs, they would still be able to maintain healthcare coverage – The P in HIPAA – Portability. The second aim was to ensure the security and confidentiality of health information – The first A in HIPAA – Accountability. HIPAA includes standards that were intended to simplify healthcare transactions, in particular, with respect to electronic data transmission. These included the use of specific code sets and identifiers. Over the past two decades, HIPAA has been transformed and now includes many new rules that healthcare organizations must follow to ensure the privacy of patients is protected, sensitive data is kept secure at all times, and in the event of a data breach, affected individuals are notified. Major revisions of HIPAA Rules took place in 2003...

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Is OneDrive HIPAA Compliant?
Sep30

Is OneDrive HIPAA Compliant?

Many covered entities want to take advantage of cloud storage services, but can Microsoft OneDrive be used? Is OneDrive HIPAA compliant? Many healthcare organizations are already using Microsoft Office 365 Business Essentials, including exchange online for email. Office 365 Business Essentials includes OneDrive Online, which is a convenient platform for storing and sharing files. Microsoft Supports HIPAA-Compliance There is certainly no problem with HIPAA-covered entities using OneDrive. Microsoft supports HIPAA-compliance and many of its cloud services, including OneDrive, can be used without violating HIPAA Rules. That said, before OneDrive – or any cloud service – can be used to create, store, or send files containing the electronic protected health information of patients, HIPAA-covered entities must obtain and sign a HIPAA-compliant business associate agreement (BAA). Microsoft was one of the first cloud service providers to agree to sign a BAA with HIPAA-covered entities, and offers a BAA through the Online Services Terms. The BAA includes OneDrive for Business, as well...

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Why Dental Offices Should be Worried About HIPAA Compliance
Sep28

Why Dental Offices Should be Worried About HIPAA Compliance

In 2015, Dr. Joseph Beck became the first dentist to be fined for a HIPAA violation, which sent a warning to dental offices about HIPAA compliance.  Until that point, dental offices had avoided fines for noncompliance with HIPAA Rules. The penalty was not issued by the Department of Health and Human Services’ Office for Civil Rights (OCR), but by the Office of the Indiana attorney general. The fine of $12,000 was for the alleged mishandling of the protected health information of 5,600 patients. Since then, many settlements have been reached with covered entities for HIPAA violations. No further penalties have been issued to dental offices, although there is nothing to stop OCR or state attorneys general from fining dental offices for failing to comply with HIPAA Rules and settlements for alleged HIPAA violations are now being reached much more frequently than in 2015. Last year was a record year for settlements and 2017 has continued where 2016 left off. The probability of HIPAA violations being discovered has also increased. OCR has already commenced the much-delayed second phase...

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HIPAA Compliance and Cloud Computing Platforms
Sep27

HIPAA Compliance and Cloud Computing Platforms

Before cloud services can be used by healthcare organizations for storing or processing protected health information (PHI) or for creating web-based applications that collect, store, maintain, or transmit PHI, covered entities must ensure the services are secure. Even when a cloud computing platform provider has HIPAA certification, or claims their service is HIPAA-compliant or supports HIPAA compliance, the platform cannot be used in conjunction with ePHI until a risk analysis – See 45 CFR §§ 164.308(a)(1)(ii)(A) – has been performed. A risk analysis is an essential element of HIPAA compliance for cloud computing platforms. After performing a risk analysis, a covered entity must establish risk management policies in relation to the service – 45 CFR §§ 164.308(a)(1)(ii)(B). Any risks identified must be managed and reduced to a reasonable and appropriate level. It would not be possible to perform a comprehensive, HIPAA-compliant risk analysis unless the covered entity fully understands the cloud computing environment and the service being offered by the platform...

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HITRUST/AMA Launch Initiative to Help Small Healthcare Providers with HIPAA Compliance
Sep27

HITRUST/AMA Launch Initiative to Help Small Healthcare Providers with HIPAA Compliance

HITRUST has announced it has partnered with the American Medical Association (AMA) for a new initiative that will help small healthcare providers with HIPAA compliance, cybersecurity, and cyber risk management. Small healthcare providers can be particularly vulnerable to cyberattacks, as they typically lack the resources to devote to cybersecurity and do not tend to have the budgets available to hire skilled cybersecurity staff. This week has underscored the need for small practices to improve their cybersecurity defenses, with the announcement of two cyberattacks on small healthcare providers by the hacking group TheDarkOverlord. Recent ransomware attacks have also shown that healthcare organizations of all sizes are likely to be attacked. Organizations of all sizes must practice good cyber hygiene and have the right defenses in place to improve resilience against ever changing cyber threats. HITRUST and AMA will be hosting 2-hour workshops where physicians and other healthcare staff will be educated on key areas of risk management, HIPAA compliance, and cybersecurity, with the...

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HHS Issues Partial HIPAA Privacy Rule Waiver in Hurricane Maria Disaster Zone
Sep22

HHS Issues Partial HIPAA Privacy Rule Waiver in Hurricane Maria Disaster Zone

The U.S. Department of Health and Human Services has already issued two partial waivers of HIPAA sanctions and penalties in areas affected by hurricanes this year. Now a third HIPAA waiver has been issued, this time in the Hurricane Maria disaster area in Puerto Rico and the U.S. Virgin Islands. As was the case with the waivers issued in relation to Hurricane Harvey and Hurricane Irma, the waiver only applies to covered entities in areas where a public health emergency has been declared, only for 72 hours following the implementation of the hospital’s disaster protocol, and only for specific provisions of the HIPAA Privacy Rule: The requirements to obtain a patient’s agreement to speak with family members or friends involved in the patient’s care. See 45 CFR 164.510(b). The requirement to honor a request to opt out of the facility directory. See 45 CFR 164.510(a). The requirement to distribute a notice of privacy practices. See 45 CFR 164.520. The patient’s right to request privacy restrictions. See 45 CFR 164.522(a). The patient’s right to request confidential...

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The Compliancy Group Helps Imperial Valley Family Care Medical Group Pass HIPAA Audit
Sep20

The Compliancy Group Helps Imperial Valley Family Care Medical Group Pass HIPAA Audit

The Department of Health and Human Services’ Office for Civil Rights commenced the second round of HIPAA compliance audits late last year. The audit program consists of desk-based audits of HIPAA-covered entities and business associates, followed by a round of in-depth audits involving site visits. The desk audits have been completed, with the site audits put on hold and expected to commence in early 2018. Only a small number of covered entities have been selected to be audited as part of the second phase of compliance audits; however, covered entities that have escaped an audit may still be required to demonstrate they are in compliance with HIPAA Rules. In addition to the audit program, any HIPAA-covered entities that experiences a breach of more than 500 records will be investigated by OCR to determine whether the breach was the result of violations of HIPAA Rules. OCR also investigates complaints submitted through the HHS website. The first round of HIPAA compliance audits in 2011/2012 did not result in any financial penalties being issued, but that may not be the case for the...

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OCR Launches Information is Powerful Medicine Campaign to Encourage Patients to Access Their Health Data
Sep13

OCR Launches Information is Powerful Medicine Campaign to Encourage Patients to Access Their Health Data

The Department of Health and Human Services’ Office for Civil Rights has launched a new campaign to raise awareness of patients’ right to access their health information and the benefits of doing so. The “Information is Powerful Medicine” campaign informs patients that they have the right to obtain copies of their health data and tells them to “Get it. Check it. Use it.” The benefits to patients are clear. If they obtain copies of the health information they can check their medical records for errors and correct any mistakes. Having access to health data helps patients to make better decisions about their health care and discuss their health more fully with their providers. Armed with their health data, patients can do more to stay healthy. Patients are advised that the HIPAA Privacy Rule allows them to obtain a physical or electronic copy of their health data and that their provider should provide the information as requested within 30 days. It has been explained that they may be charged a nominal fee for obtaining a copy of their health data. Patients are also informed that...

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Limited HIPAA Waiver Granted to Hospitals in Irma Disaster Zone
Sep12

Limited HIPAA Waiver Granted to Hospitals in Irma Disaster Zone

A public health emergency has been declared in areas of the U.S. Virgin Islands, Puerto Rico, and Florida affected by Hurricane Irma. As was the case in Texas and Louisiana after Hurricane Harvey, the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) has announced a limited waiver of HIPAA Privacy Rule sanctions and penalties for hospitals affected by Irma. OCR has stressed that the HIPAA Privacy and Security Rules have not been suspended and covered entities must continue to follow HIPAA Rules; however, certain provisions of the Privacy Rule have been waived under the Project Bioshield Act of 2014 and Section 1135(b) of the Social Security Act. In the event that a hospital in the disaster zone does not comply with the following aspects of the HIPAA Privacy Rule, penalties and sanctions will be waived: 45 CFR 164.510(b) – Obtain a patient’s agreement to speak with family members or friends involved in the patient’s care 45 CFR 164.510(a) – Honor requests to opt out of the facility directory. 45 CFR 164.520 – Distribute a notice of...

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OCR Stresses Need for Covered Entities to Prepare for Hurricanes and Other Natural Disasters
Sep08

OCR Stresses Need for Covered Entities to Prepare for Hurricanes and Other Natural Disasters

Hospitals in Texas and Louisiana had to ensure medical services continued to be provided during and after Hurricane Harvey, without violating HIPAA Rules. Questions were raised about when it is permitted to share health information with patients’ friends and family, the media and the emergency services and how the Privacy Rule applies in emergencies. The Department of Health and Human Services’ Office for Civil Rights responded by issuing guidance to covered entities on the HIPAA Privacy Rule and disclosures of patient health information in emergency situations to help healthcare organizations protect patient privacy and avoid violating HIPAA Rules. Allowable disclosures are summarized in this document. Hot on the heels of hurricane Harvey comes hurricane Irma, closely followed by hurricane Jose. Hospitals in other parts of the United States will have to cope with the storm and its aftermath and still comply with HIPAA Rules. OCR has taken the opportunity to remind covered entities of the need to prepare. OCR has explained that the HIPAA Privacy Rule was carefully created to ensure...

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OCR Head Expects Major HIPAA Settlement for a Big, Juicy, Egregious Breach in 2017
Sep06

OCR Head Expects Major HIPAA Settlement for a Big, Juicy, Egregious Breach in 2017

Roger Severino, the Director of the Department of Health and Human Services’ Office for Civil Rights (OCR) has stated his main enforcement priority for 2017 is to find a “big, juicy, egregious” HIPAA breach and to use it as an example for other healthcare organizations on the dangers of failing to follow HIPAA Rules. When deciding on which cases to pursue, OCR considers the opportunity to use the case as an educational tool to remind covered entities of the need to comply with specific aspects of HIPAA Rules. At the recent ‘Safeguarding Health Information’ conference run by OCR and NIST, Severino explained that “I have to balance that law enforcement instinct with the educational component that we do.” Severino went on to say, “I really want to make sure people come into compliance without us having to enforce. I want to underscore that.” Severino did not explain what aspect of noncompliance with HIPAA Rules OCR is hoping to highlight with its next big, juicy settlement, although no healthcare organization is immune to a HIPAA penalty if they are found to have violated HIPAA...

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HHS Issues Partial Waiver of Sanctions and Penalties for Privacy Rule Violations in Hurricane Harvey Disaster Zone
Aug31

HHS Issues Partial Waiver of Sanctions and Penalties for Privacy Rule Violations in Hurricane Harvey Disaster Zone

During emergencies such as natural disasters, complying with all HIPAA Privacy Rule provisions can be a challenge for hospitals and can potentially have a negative impact on patient care and disaster relief efforts. In emergency situations, HIPAA Rules still apply. The HIPAA Privacy Rule allows patient information to be shared to help with disaster relief efforts and ensure patients get the care they need. The Privacy Rule permits covered entities to share patient information for treatment purposes, for public health activities, to disclose patient information to family, friends and others involved in a patient’s care, to prevent or lessen a serious and imminent threat to the health and safety of a person or the public and, under certain circumstances, allows covered entities to share limited information with the media and other individuals not involved in a patient’s care (45 CFR 164.510(a)). In such cases, any disclosures must be limited to the minimum necessary information to accomplish the purpose for which the information is being disclosed. However, disasters often call for a...

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Want to Prevent Data Breaches? Time to Go Back to Basics
Aug15

Want to Prevent Data Breaches? Time to Go Back to Basics

Intrusion detection systems, next generation firewalls, insider threat management solutions and data encryption will all help healthcare organizations minimize risk, prevent security breaches, and detect attacks promptly when they do occur. However, it is important not to forget the security basics. The Office for Civil Rights Breach portal is littered with examples of HIPAA data breaches that have been caused by the simplest of errors and security mistakes. Strong security must start with the basics, as has recently been explained by the FTC in a series of blog posts. The blog posts are intended to help businesses improve data security, prevent data breaches and avoid regulatory fines. While the blog posts are not specifically aimed at healthcare organizations, the information covered is relevant to organizations of all sizes in all industry sectors. The blog posts are particularly relevant for small to medium sized healthcare organizations that are finding data security something of a challenge. The blog posts are an ideal starting point to ensure all the security basics are...

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Delaying Breach Notifications is a Violation of the Breach Notification Rule
Aug11

Delaying Breach Notifications is a Violation of the Breach Notification Rule

The HIPAA Breach Notification Rule (45 CFR §§ 164.400-414) requires covered entities to notify the HHS’ Office for Civil Rights of a breach of unsecured protected health information and send notification letters to affected individuals without unreasonable delay and no later than 60 days after the discovery of the breach. As last year’s monthly Breach Barometer reports from Protenus have shown, many covered entities have struggled to comply with the HIPAA Breach Notification Rule and have disclosed their breaches to OCR after the deadline has passed. This year has seen a major improvement in reporting times. The Protenus 2017 Breach Barometer Mid-Year Review shows that between January and June, it took an average of 54.5 days from the discovery of a breach to notify OCR. A look back at the Breach Barometer report for January shows just how much the situation has improved. In January, there were 31 data breaches disclosed. 40% of those breaches were reported later than the 60-day deadline. The improvement in breach reporting time is likely due, in part, to the decision by OCR to...

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Protenus Provides Insight into 2017 Healthcare Data Breach Trends
Aug03

Protenus Provides Insight into 2017 Healthcare Data Breach Trends

Protenus, in conjunction with Databreaches.net, has produced its Breach Barometer mid-year review. The report covers all healthcare data breaches reported over the past 6 months and provides valuable insights into 2017 data breach trends. The Breach Barometer is a comprehensive review of healthcare data breaches, covering not only the data breaches reported through the Department of Health and Human Services’ Office for Civil Rights’ breach reporting tool, but also media reports of incidents and public findings. Prior to inclusion in the report, all breaches are independently confirmed by databreaches.net. The Breach Barometer reports delve into the main causes of data breaches reported by healthcare providers, health plans and their business associates. In a webinar on Wednesday, Protenus Co-Founder and president Robert Lord and Dissent of databreaches.net discussed the findings of the mid-year review. Lord explained that between January and June 2017 there have been 233 reported data breaches. Those breaches have impacted 3,159,236 patients. The largest reported breach in the...

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Nuance Communications Decides Not to Report NotPetya Attack to OCR
Aug02

Nuance Communications Decides Not to Report NotPetya Attack to OCR

As the Department of Health and Human Services’ Office for Civil Rights has previously explained in its ransomware guidance, if ePHI is encrypted, ransomware attacks are usually HIPAA breaches and are reportable incidents. OCR says out in its ransomware guidance that “Whether or not the presence of ransomware would be a breach under the HIPAA Rules is a fact-specific determination,” going on to explain that the definition of a breach in HIPAA is “the acquisition, access, use, or disclosure of PHI in a manner not permitted under the [HIPAA Privacy Rule] which compromises the security or privacy of the PHI.” A ransomware attack qualifies as a HIPAA breach because the actions of the attackers have resulted in the acquisition of PHI, in the sense that unauthorized individuals have taken control of the data. The only time that a breach report – and notifications to patients – would not be required would be if the covered entity can demonstrate “a low probability that the PHI has been compromised.” OCR suggest covered entities can make that determination after a risk assessment has...

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How Often Should Healthcare Employees Receive Security Awareness Training?
Aug01

How Often Should Healthcare Employees Receive Security Awareness Training?

Security awareness training is a requirement of HIPAA, but how often should healthcare employees receive security awareness training? Recent Phishing and Ransomware Attacks Highlight Need for Better Security Awareness Training Phishing is one of the biggest security threats for healthcare organizations. Cybercriminals are sending phishing emails in the millions in an attempt to get end users to reveal sensitive information such as login credentials or to install malware and ransomware. While attacks are often ransom, healthcare employees are also being targeted with spear phishing emails. In December last year, anti-phishing solution provider PhishMe released the results of a study showing 91% of cyberattacks start with a phishing email. Spear phishing campaigns rose 55% last year, ransomware attacks increased by 400% and business email compromise (BEC) losses were up by 1,300%. In recent weeks, there have been several phishing attacks reported to the Department of Health and Human Services’ Office for Civil Rights. Those attacks have resulted in email accounts being compromised....

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Only One Third of Patients Use Patient Portals to View Health Data
Jul27

Only One Third of Patients Use Patient Portals to View Health Data

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits patients to access the health information held by their providers, yet relatively few patients are exercising that right, according to a recent U.S. Government Accountability Office (GAO) report, at least through patient portals. The Medicare Electronic Health Record Incentive Program encouraged healthcare providers to transition from paper to electronic medical records and now almost 90% of patients of participating providers have access to patient portals where they can view their health data. Even though patients have been provided with access, fewer than a third of patients are using patient portals to view their health information. GAO looked at patient health information access from the patients’ perspective, conducting interviews with patients to find out why they are not taking advantage of this valuable resource. Out of the healthcare organizations that participated in the Medicare EHR Program, 88% of hospitals and 87% of professionals offered patients access to their health information...

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OCR Data Breach Portal Update Highlights Breaches Under Investigation
Jul25

OCR Data Breach Portal Update Highlights Breaches Under Investigation

Last month, the Department of Health and Human Services confirmed it was mulling over updating its data breach portal – commonly referred to as the OCR ‘Wall of Shame’. Section 13402(e)(4) of the HITECH Act requires OCR to maintain a public list of breaches of protected health information that have impacted more than 500 individuals. All 500+ record data breaches reported to OCR since 2009 are listed on the breach portal. The data breach list contacts a wide range of breaches, many of which occurred through no fault of the covered entity and involved no violations of HIPAA Rules. OCR has received some criticism for its breach portal for this very reason, most recently from Rep. Michael Burgess (R-Texas) who said the breach portal was ‘unnecessarily punitive’ in its current form. For example, burglaries will occur even with reasonable physical security in place and even with appropriate controls in place, rogue healthcare employees will access PHI out of curiosity or with malicious intent on occasion, with some considering it unfair for those breaches to remain on public display...

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Model HIPAA-Compliant PHI Access Request Form Released by AHIMA
Jul21

Model HIPAA-Compliant PHI Access Request Form Released by AHIMA

The American Healthcare Information Management Association (AHIMA) has announced it has released a model PHI access request form for healthcare providers to give to patients who want to exercise their right under HIPAA to obtain copies of their health data. The model PHI access request form is compliant with HIPAA regulations and can be easily customized to suit the needs of each healthcare organization. AHIMA claims that until now, a model PHI access request form was not available to healthcare providers. HIPAA-covered entities have had to develop their own forms and there is considerable variation in the forms used by different healthcare organizations. Patients with multiple healthcare providers often find the process of obtaining their health data confusing. AHIMA has listened to feedback from its members and industry stakeholders who explained that the process of accessing medical records was often confusing for patients. Even some healthcare organizations are confused about what is permitted and not permitted under HIPAA Rules when it comes to providing access to health data....

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Is Google Drive HIPAA Compliant?
Jul21

Is Google Drive HIPAA Compliant?

Google Drive is a useful tool for sharing documents, but can those documents contain PHI? Is Google Drive HIPAA compliant? Is Google Drive HIPAA Compliant? The answer to the question, “Is Google Drive HIPAA compliant?” is yes and no. HIPAA compliance is less about technology and more about how technology is used. Even a software solution or cloud service that is billed as being HIPAA-compliant can easily be used in a manner that violates HIPAA Rules. G Suite – formerly Google Apps, of which Google Drive is a part – does support HIPAA compliance. The service does not violate HIPAA Rules provided HIPAA Rules are followed by users. G Suite incorporates all of the necessary controls to make it a HIPAA-compliant service and can therefore be used by HIPAA-covered entities to share PHI (in accordance with HIPAA Rules), provided the account is configured correctly and standard security practices are applied. The use of any software or cloud platform in conjunction with protected health information requires the vendor of the service to sign a HIPAA-compliant business...

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Are You Blocking Ex-Employees’ PHI Access Promptly?
Jul19

Are You Blocking Ex-Employees’ PHI Access Promptly?

A recent study commissioned by OneLogin has revealed many organizations are not doing enough to prevent data breaches by ex-employees. Access to computer systems and applications is a requirement while employed, but many organizations are failing to block access to systems promptly when employees leave the company, even though ex-employees pose a significant data security risk. Blocking access to networks and email accounts when an employee is terminated or otherwise leaves the company is one of the most basic security measures, yet all too often the process is delayed. 600 IT employees who had some responsibility for security in their organization were interviewed for the study and approximately half of respondents said they do not immediately terminate ex-employees’ network access rights. 58% said it takes longer than a day to delete ex-employees’ login credentials. A quarter of respondents said it can take up to a week to block access, while more than one in five respondents said it can take up to a month to deprovision ex-employees. That gives them plenty of time to gain access...

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Funding for ONC Office of the Chief Privacy Officer to be Withdrawn in 2018
Jul18

Funding for ONC Office of the Chief Privacy Officer to be Withdrawn in 2018

The cuts to the budget of the Office of the National Coordinator for Health Information Technology (ONC) mean the agency must make some big changes, one of which will be the withdrawal of funding for the Office of the Chief Privacy Officer. ONC National Coordinator Don Rucker, M.D., has confirmed that the office will be closed out in fiscal year 2018. Deven McGraw, the Deputy Director for Health Information Privacy, has been serving as Acting Chief Privacy Officer until a permanent replacement for Lucia Savage is found, following her departure in January. It is now looking highly unlikely that a permanent replacement will be sought. One of the key roles of the Chief Privacy Officer is to ensure that privacy and security standards are addressed and health data is appropriately protected. The Chief Privacy Officer also advises the National Coordinator for Health IT on privacy and security policies covering electronic health information. However, Rucker does not believe it is necessary for the ONC to have an office dedicated to privacy and security as other agencies in the HHS could...

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Is Dropbox HIPAA Compliant?
Jul14

Is Dropbox HIPAA Compliant?

Healthcare organizations can benefit from using Dropbox, but is Dropbox HIPAA compliant? Can the service be used to store and share protected health information? Is Dropbox HIPAA Compliant? Dropbox is a popular file hosting service used by many organizations to share files, but what about protected health information? Is Dropbox HIPAA compliant? Dropbox claims it now supports HIPAA and HITECH Act compliance but that does not mean Dropbox is HIPAA compliant. No software or file sharing platform can be HIPAA compliant as it depends on how the software or platform is used. That said, healthcare organizations can use Dropbox to share or store files containing protected health information without violating HIPAA Rules. The Health Insurance Portability and Accountability Act requires covered entities to enter into a business associate agreement (BAA) with an entity before any protected health information (PHI) is shared. Dropbox is classed as a business associate so a BAA is required. Dropbox will sign a business associate agreement with HIPAA-covered entities. To avoid a HIPAA...

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ONC Offers Help for Covered Entities on Medical Record Access for Patients
Jul13

ONC Offers Help for Covered Entities on Medical Record Access for Patients

The Health Insurance Portability and Accountability Act’s (HIPAA) Privacy Rule requires covered entities to give medical record access for patients on request. Patients should be able to obtain a copy of their health records in paper or electronic form within 30 days of submitting the request. Last year, the Department of Health and Human Services’ Office for Civil Rights (OCR) issued guidance for covered entities on providing patients with access to their medical records. A series of videos was also released to raise awareness of patients’ rights under HIPAA to access their records. In theory, providing access to medical records should be a straightforward process. In practice, that is often not the case. Patients often have difficulty accessing their electronic health data with many healthcare organizations unable to easily provide health records electronically. Patient portals often provide information for patients, although the information available via patient portals can be incomplete or inaccurate. When patients need to obtain their health information to give to other...

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OCR Draws Attention to Risks from File Sharing Tools and Cloud Computing
Jul03

OCR Draws Attention to Risks from File Sharing Tools and Cloud Computing

File sharing and collaboration tools offer many benefits to HIPAA-covered entities, although the tools can also introduce risks to the privacy and security of electronic health information.  Many companies use these tools, including healthcare organizations, yet they can easily lead to the exposure or disclosure of sensitive data. The Department of Health and Human Services’ Office for Civil Rights has recently issued a reminder to covered entities and business associates of the potential risks associated with file sharing and collaboration tools, explaining the risks these services can introduce and how covered entities can use these services and remain in compliance with HIPAA Rules. While file sharing tools and cloud computing services may incorporate all the necessary protections to ensure data is secured and cannot be accessed by unauthorized individuals, over the past few years there have been numerous cases where human error has resulted in misconfigurations. Those errors have led to data breaches. A Metalogix survey conducted by the Ponemon Institute revealed that one in...

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World’s Largest Data Breach Settlement Agreed by Anthem
Jun26

World’s Largest Data Breach Settlement Agreed by Anthem

The largest data breach settlement in history has recently been agreed by the health insurer Anthem Inc. Anthem experienced the largest healthcare data breach ever reported in 2015, with the cyberattack resulting in the theft of 78.8 million records of current and former health plan members. The breach involved names, addresses, Social Security numbers, email addresses, birthdates and employment/income information. A breach on that scale naturally resulted in many class-action lawsuits, with more than 100 lawsuits consolidated by a Judicial Panel on Multidistrict Litigation. Now, two years on, Anthem has agreed to settle the litigation for $115 million. If approved, that makes this the largest data breach settlement ever – Substantially higher than $18.5 million settlement agreed by Target after its 41 million-record breach and the $19.5 million paid to consumers by Home Depot after its 50-million record breach in 2014. After experiencing the data breach, Anthem offered two years of complimentary credit monitoring services to affected plan members. The settlement will, in...

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Delayed Breach Notification Sees CoPilot Fined $130,000 by NY AG
Jun19

Delayed Breach Notification Sees CoPilot Fined $130,000 by NY AG

A data breach that occurred in October 2015 should have seen affected individuals notified within 2 months, yet it took CoPilot Provider Support Services Inc., until January 2017 to issue breach notifications. An administration website maintained by CoPilot was accessed by an unauthorized individual on October 26, 2015. That individual also downloaded the data of 221,178 individuals. The stolen data included names, dates of birth, phone numbers, addresses, and medical insurance details. The individual suspected of accessing the website and downloading data was a former employee. CoPilot contacted the FBI in February 2016 to receive help with the breach investigation and establish the identity of the unauthorized individual. However, notifications were not sent by CoPilot until January 18, 2017. CoPilot says the delay was due to the time taken for the FBI to investigate the breach; however, since CoPilot was aware that reimbursement-related records had been stolen, notifications should have been sent sooner. Further, law enforcement did not instruct CoPilot to delay the issuing of...

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OCR’s Wall of Shame Under Review by HHS
Jun16

OCR’s Wall of Shame Under Review by HHS

Since 2009, the Department of Health and Human Services’ Office for Civil Rights has been publishing summaries of healthcare data breaches on its website. The data breach list is commonly referred to as OCR’s ‘Wall of Shame’. The data breach list only provides a brief summary of data breaches, including the name of the covered entity, the state in which the covered entity is based, covered entity type, date of notification, type of breach, location of breach information, whether a business associate was involved and the number of individuals affected. The list includes all reported data breaches, including those which occurred due to no fault of the healthcare organization. The list is not a record of HIPAA violations. Those are determined during OCR investigations of breaches. Making brief details of the data breaches available to the public is an ‘unnecessarily punitive’ measure, according to Rep. Michael Burgess (R-Texas), who recently criticized OCR about its data breach list. Burgess was informed at a cybersecurity hearing last week that HHS secretary Tom Price is currently...

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OCR Issues Guidance on the Correct Response to a Cyberattack
Jun12

OCR Issues Guidance on the Correct Response to a Cyberattack

Last week, the Department of Health and Human Services’ Office for Civil Rights issued new guidance to covered entities on the correct response to a cyberattack. OCR issued a quick response checklist and accompanying infographic to explain the correct response to a cyberattack and the sequence of actions that should be taken. Responding to an ePHI Breach Preparation is key. Organizations must have response and mitigation procedures in place and contingency plans should exist that can be implemented immediately following the discovery a cyberattack, malware or ransomware attack. The first stage of the response is to take immediate action to prevent any impermissible disclosure of electronic protected health information. In the case of a network intrusion, unauthorized access to the network – and data – must be blocked and steps taken to prevent data from being exfiltrated. Healthcare organizations may have staff capable of responding to such an incident, although third party firms can be contracted to assist with the response. Smaller healthcare organizations may have little choice...

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Recent Employee Snooping Incidents Highlight Need for Access Controls and Alerts
Jun02

Recent Employee Snooping Incidents Highlight Need for Access Controls and Alerts

Ransomware, malware and unaddressed software vulnerabilities threaten the confidentiality, integrity and availability of PHI, although healthcare organizations should take steps to deal with the threat from within. This year has seen numerous cases of employees snooping and accessing medical records without authorization. The HIPAA Security Rule 45 CFR §164.312(b) requires covered entities to “Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information,” while 45 CFR §164.308(a)(1)(ii)(D) requires covered entities to “Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.” Logs create an audit trail that can be followed in the event of a data breach or privacy incident. Those logs can be checked to discover which records have been accessed without authorization. If those logs are monitored continuously, privacy breaches can be identified quickly and action taken to...

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OCR Reminds Covered Entities of Security Incident Definition and Notification Requirements
Jun01

OCR Reminds Covered Entities of Security Incident Definition and Notification Requirements

The ransomware attacks and healthcare IT security incidents last month have prompted the Department of Health and Human Services’ Office for Civil Rights to issue a reminder to covered entities about HIPAA Rules on security breaches. In its May 2017 Cyber Newsletter, OCR explains what constitutes a HIPAA security incident, preparing for such an incident and how to respond when perimeters are breached. HIPAA requires all covered entities to implement technical controls to safeguard the confidentiality, integrity and availability of electronic protected health information (ePHI). However, even when covered entities have sophisticated, layered cybersecurity defenses and are fully compliant with HIPAA Security Rule requirements, cyber-incidents may still occur. Cybersecurity defenses are unlikely to be 100% effective, 100% of the time. Prior to the publication of OCR guidance on ransomware attacks last year, there was some confusion about what constituted a security incident and reportable HIPAA breach. Many healthcare organizations had experienced ransomware attacks, yet failed to...

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HIPAA Enforcement Update Provided by OCR’s Iliana Peters
May25

HIPAA Enforcement Update Provided by OCR’s Iliana Peters

Office for Civil Rights Senior Advisor for HIPAA Compliance and Enforcement, Iliana Peters, has given an update on OCR’s enforcement activities in a recent Health Care Compliance Association ‘Compliance Perspectives’ podcast. OCR investigates all data breaches involving the exposure of theft of more than 500 healthcare records. OCR also investigates complaints about potential HIPAA violations. Those investigations continue to reveal similar non-compliance issues. Peters said many issues come up time and time again. Peters confirmed that cases are chosen to move on to financial settlements when they involve particularly egregious HIPAA violations, but also when they relate to aspects of HIPAA Rules that are frequently violated. The settlements send a message to healthcare organizations about specific aspects of HIPAA Rules that must be addressed. Peters said one of the most commonly encountered problems is the failure to conduct a comprehensive, organization-wide risk assessment and ensure any vulnerabilities identified are addressed through a HIPAA-compliant risk management...

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OCR and ONC Face Major Budget Cuts
May24

OCR and ONC Face Major Budget Cuts

On Tuesday this week, the Trump administration revealed its 2018 fiscal budget with the Department of Health and Human Services’ Office for Civil Rights (OCR) and Office of the National Coordinator for Health Information Technology (ONC) both facing major cuts to their operational budgets. The ONC faces the largest budget cut, with its $60 million per year cut by 36% for the coming financial year. ONC would need to lose 26 members of staff, with such a large budget cut likely to force the agency to reconsider its priorities. OCR faces a budget cut of 13%, reducing funding from $38 million to $33 million likely requiring the loss of 16 staff. The fiscal 2018 budget is not set in stone and changes are likely to be made before the budget is passed by Congress. However, the Trump administration has previously stated the desire to shave $15.1 billion from the Department of Health and Human Services budget and cuts are therefore inevitable. OCR has many roles, although as the main enforcer of HIPAA Rules, those budget cuts could affect the agency’s HIPAA enforcement activities. OCR has...

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Impermissible Disclosure of HIV Status to Employer Results in $387,000 HIPAA Penalty
May24

Impermissible Disclosure of HIV Status to Employer Results in $387,000 HIPAA Penalty

The Department of Health and Human Services’ Office for Civil Rights (OCR) has announced a new HIPAA settlement to resolve violations of the HIPAA Privacy Rule. St. Luke’s-Roosevelt Hospital Center Inc., has paid OCR $387,200 to resolve potential HIPAA violations discovered during an OCR investigation of a complaint about an impermissible disclosure of PHI. In September 2014, OCR received a complaint about a potential privacy violation involving a patient of St. Luke’s Spencer Cox Center for Health. In the complaint, it was alleged that a member of St Luke’s staff violated the privacy of a patient by faxing protected health information to the individual’s employer. The information in the fax was highly sensitive, including the patient’s sexual orientation, HIV status, sexually transmitted diseases, mental health diagnosis, details of physical abuse suffered, medical care and medications. Instead of faxing the information, the data should have been sent to a personal post box as requested. The investigation revealed that the incident was not the only time that the HIPAA Privacy Rule...

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HIPAA and Ransomware: Healthcare Organizations Reminded of HIPAA Rules Relating to Ransomware
May19

HIPAA and Ransomware: Healthcare Organizations Reminded of HIPAA Rules Relating to Ransomware

Following the recent WannaCry ransomware attacks, the Department of Health and Human Services has been issuing cybersecurity alerts and warnings to healthcare organizations on the threat of attack and steps that can be taken to reduce risk. The email alerts were sent soon after the news of the attacks on the UK’s NHS first started to emerge on Friday May 12, and continued over the course of the week. The alerts provided timely and pertinent information for U.S. healthcare organizations allowing them to take rapid action to counter the threat. While the Office for Civil Rights has previously sent monthly emails to healthcare organizations warning of new threats in its cybersecurity newsletters, the recent alerts were sent much more rapidly and frequently, with four email alerts and conference calls made with industry stakeholders alerting them to the imminent threat. Whether this was a one off in response to a specific and imminent major threat or the HHS plans to issue more timely alerts remains to be seen. However, the rapid communication of the ransomware threat almost certainly...

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HIPAA Compliance Best Practices
May16

HIPAA Compliance Best Practices

Questions and Answers to Improve Security and Avoid Penalties By Bill Becker Even after 14 years, public and private sector organizations are still routinely found out of compliance with the Health Insurance Portability and Accountability Act (HIPAA). Security management processes are among the weakest links in compliance. In this article, we’ll look at some of the basics that covered entities and their business partners need to follow to ensure that they are not hit with financial or other penalties. For the uninitiated, HIPAA regulates the use and disclosure of certain information held by health plans, health insurers, and medical service providers that engage in many types of transactions. Enforcement of HIPAA Privacy and Security Rules falls to the Department of Health and Human Services’ Office for Civil Rights (OCR). Enforcement of compliance began in 2005, with OCR becoming responsible for Security Rule enforcement four years later. Since April 2003, over 150,000 HIPAA Privacy Rule complaints have been investigated by OCR. 98% (or 147,826) of the complaints have been...

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Memorial Hermann Health System Hit with $2.4 Million HIPAA Fine
May11

Memorial Hermann Health System Hit with $2.4 Million HIPAA Fine

Memorial Hermann Health System has agreed to settle potential HIPAA Privacy Rule violations with the Department of Health and Human Services’ Office for Civil Rights (OCR) for $2.4 million. The settlement stems from an impermissible disclosure on a press release issued by MHHS in September 2015. Memorial Hermann Health System (MHHS) is a 16-hospital health system based in Southeast Texas, serving patients in the Greater Houston area. In September, a patient visited a MHHS clinic and presented a fraudulent identification card to hospital staff. The fraudulent ID card was identified as such by hospital staff, law enforcement was notified and the patient was arrested. The hospital disclosed the name of the patient to law enforcement, which is allowable under HIPAA Rules. However, the following action taken by the hospital was a violation of the HIPAA Privacy Rule. MHHS issued a press release about the incident but included the patients name in the title of the press release. That press release was approved before release by MHHS senior management, even though naming the patient...

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HIMSS Privacy and Security Forum Offers Insight into Healthcare Cyber Threat Landscape
May03

HIMSS Privacy and Security Forum Offers Insight into Healthcare Cyber Threat Landscape

Next week, the HIMSS Privacy and Security Forum will be taking place in San Francisco. The two-day conference provides an opportunity for CISOs, CIOs and other healthcare leaders to obtain valuable information from security experts on the latest cybersecurity threats, along with practical advice on how to mitigate risk. More than 30 speakers will be attending the event and providing information on a broad range of healthcare cybersecurity topics, including securing IoT devices, preventing phishing and ransomware attacks, creating compliant security relationships and effective strategic communication and risk management. The conference will include keynote speeches from George Decesare, Senior VP and Chief Technology Risk Officer at Kaiser Permanente, Jane Harper, Director of Privacy & Security Risk Management at the Henry Ford Health System, CERT’s Matt Trevors, and M.K. Palmore, FBI San Francisco’s Assistant Special Agent in Charge of the SF Cyber Branch. George Decesare leads Kaiser Permanente’s cybersecurity, technology risk and compliance programs and identity and access...

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MDLive Faces Class Action Lawsuit Over Alleged Patient Privacy Violations
Apr26

MDLive Faces Class Action Lawsuit Over Alleged Patient Privacy Violations

A class action lawsuit has been filed against the telemedicine company MDLive claiming the company violated the privacy of patients by disclosing sensitive medical information to a third party without informing or obtaining consent from patients. App users are required to enter in a range of sensitive information into the MDLive app; however, the complainant alleges that during the first 15 minutes of use, the app takes an average of 60 screenshots and that those screenshots are sent to an Israeli company called Test Fairy, which conducts quality control tests for MDLive. The lawsuit alleges patients are not informed that their information is disclosed to a third-party company, and that all data entered into the app can be viewed by MDLive employees, even though there is no reason for those employees to be able to view the data. Users of the app enter their medical information during setup in order to find local healthcare providers. The types of information entered by users includes sensitive data such as health conditions, recent medical procedures, behavioral health histories,...

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Wireless Health Services Provider Settles HIPAA Violations with OCR for $2.5 Million
Apr24

Wireless Health Services Provider Settles HIPAA Violations with OCR for $2.5 Million

2016 was a record year for HIPAA settlements, but 2017 is looking like it will see last year’s record smashed. There have already been six HIPAA settlements announced so far this year, and hot on the heels of the $31,000 settlement announced last week comes another major HIPAA fine. A $2.5 million settlement has been agreed with CardioNet to resolve potential HIPAA violations. CardioNet is a Pennsylvania-based provider of remote mobile monitoring and rapid response services to patients at risk for cardiac arrhythmias. Settlement have previously been agreed with healthcare providers, health plans, and business associates of covered entities, but this is the first-time OCR has settled potential HIPAA violations with a wireless health services provider. While OCR has not previously fined a wireless health services provider for violating HIPAA Rules, the same cannot be said of the violations discovered. Numerous settlements have previously been agreed with covered entities after OCR discovered risk analysis and risk management failures. In this case, the settlement relates to a data...

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Patient Records Must be Disclosed by Organ Procurement Organization, Rules Supreme Court Judge
Apr21

Patient Records Must be Disclosed by Organ Procurement Organization, Rules Supreme Court Judge

A New York Supreme Court Judge has recently ruled that patient records held by the New York Organ Donor Network must be turned over to a plaintiff and that the request cannot be denied based on HIPAA. Patrick McMahon claims he was fired from his position of Transplant Coordinator by the New York Organ Donor Network following complaints he made about organ harvesting from four patients who were still showing clear signs of life and had not been declared legally dead. The New York Organ Donor Network maintains the plaintiff was fired for poor performance while he was still a probationary employee. The allegations about the procurement of organs have been denied. McMahon requested the New York Organ Donor Network turn over the medical records of the four patients as they are ‘material and necessary’ to show the patients showed signs of brain activity at the time the organs were harvested.  The New York Organ Donor Network had previously denied McMahon’s request, instead providing contact details of the patients’ next of kin, informing McMahon that he needed to obtain consent forms...

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OCR Settlement Highlights Importance of Obtaining Signed Business Associate Agreements
Apr21

OCR Settlement Highlights Importance of Obtaining Signed Business Associate Agreements

The Department of Health and Human Services’ Office for Civil Rights has sent another warning to HIPAA-covered entities about the need to obtain signed, HIPAA-compliant business associate agreements with all vendors prior to disclosing any protected health information. Yesterday, OCR announced it has agreed to settle potential violations of the Health Insurance Portability and Accountability Act with The Center for Children’s Digestive Health (CCDH); a small 7-center pediatric subspecialty practice based in Park Ridge, Illinois. On August 13, 2015, OCR conducted a HIPAA compliance review of CCDH following an investigation of FileFax Inc., which was contracted by CCDH to store inactive patient records. The FileFax investigation revealed the company had not signed a business associate agreement prior to being provided with patients’ PHI. The subsequent compliance review of CCDH similarly revealed that no signed business associate agreement existed. CCDH had therefore impermissibly disclosed patients’ PHI to FileFax in violation of HIPAA Rules. CCDH had provided paper records relating...

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$400,000 HIPAA Penalty Agreed with Denver FQHC for Security Management Process Failures
Apr13

$400,000 HIPAA Penalty Agreed with Denver FQHC for Security Management Process Failures

The Department of Health and Human Services’ Office for Civil Rights (OCR) has taken action against a Denver, CO-based federally-qualified health center (FQHC) for security management process failures that contributed to the organization experiencing a data breach in 2011. Metro Community Provider Network (MCPN) has agreed to pay OCR $400,000 and adopt a robust corrective action plan to resolve all HIPAA compliance issues identified during the OCR investigation. The incident that triggered the OCR investigation was a phishing attack that occurred on December 5, 2011. A hacker sent phishing emails to (MCPN) personnel, the responses to which enabled that individual to gain access to employees’ email accounts. Those accounts contained the electronic protected health information of 3,200 patients. OCR investigates all breaches of more than 500 patient records to determine whether healthcare organizations have experienced a breach as a direct result of violations of HIPAA Rules. OCR notes that MCPN took the necessary action following the breach to prevent further phishing attacks from...

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Roger Severino Named New Director of HHS’ Office for Civil Rights
Mar27

Roger Severino Named New Director of HHS’ Office for Civil Rights

The Department of Health and Human Services’ Office for Civil Rights has a new leader. The Trump Administration has chosen former civil rights trial attorney Roger Severino to lead the HIPAA enforcement efforts of the Office for Civil Rights. Severino joins OCR from the Heritage Foundation’s DeVos Center for Religion and Civil Society, Institute for Family, Community, and Opportunity, where he served as Director since May 2015. A formal announcement about the appointment of the new OCR Director has yet to be issued; however, the Heritage Foundation has confirmed that Severino is no longer on the staff and his name has been added to the HHS website. A spokesperson for OCR has also confirmed that Severino will be the new director and Severino’s LinkedIn profile has also been updated to include his new position as OCR chief. Severino has a background in civil rights litigation, having worked as a trial attorney for the Department of Justice for seven years in the Housing and Civil Enforcement division. During his time at the DOJ, Severino enforced the Fair Housing Act, Title II...

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Alleged Social Media Retaliation by Doctor Breached HIPAA Privacy Rule
Mar20

Alleged Social Media Retaliation by Doctor Breached HIPAA Privacy Rule

A physician at the Dr. O Medical and Wellness Center in San Antonio, Texas allegedly retaliated against a patient by posting a video of the individual clad only in underwear on Facebook and YouTube. The doctor’s actions, which appear to be a clear violation of the HIPAA Privacy Rule, have resulted in her being sanctioned by the Texas Medical Board following a complaint by the patient. The patient, Clara Aragon-Delk, underwent a series of cosmetic surgery procedures starting in 2015. Non-invasive laser treatments were performed by Dr. Tinuade Olusegun-Gbadehan, and while consent was provided by the patient to have photographs and videos taken, authorization was only given for ‘anonymous use for the purposes of medical audit, education, and promotion.’ The images and video contained full face shots of the patient. Rather than protecting the patient’s privacy by pixelating the patient’s face, a video was posted to Olusegun-Gbadehan’s Facebook page without any attempt to protect the patient’s privacy. From the video, it would appear that the patient was happy with the treatment,...

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Updated HIPAA Compliance Audit Toolkit Issued by AHIMA
Mar07

Updated HIPAA Compliance Audit Toolkit Issued by AHIMA

Phase 2 of the Department of Health and Human Services’ Office for Civil Rights HIPAA compliance audits are now well underway. Late last year, covered entities were selected for desk audits and the first round of audits have now been completed. Now OCR has moved on to auditing business associates of covered entities. At HIMSS17, OCR’s Deven McGraw explained that the full compliance audits, which were initially penciled in for Q1, 2017, are to be delayed. This gives covered entities more time to prepare. The phase 2 HIPAA compliance desk audits were more detailed than the first phase of audits conducted in 2011/2012. The desk audits covered a broad range of requirements of the HIPAA Privacy, Security, and Breach Notification Rules, although they only consisted of a documentation check to demonstrate compliance. The onsite audits will be much more thorough and will look much deeper into organizations’ compliance programs. Not only will covered entities be required to show auditors documentation demonstrating compliance with HIPAA Rules, OCR will be looking for evidence of HIPAA in...

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AHIMA Publishes New Resource Confirming Patients’ PHI Access Rights under HIPAA
Mar02

AHIMA Publishes New Resource Confirming Patients’ PHI Access Rights under HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) permits patients to obtain a copy of their medical records in electronic or paper form. Last year, the Department of Health and Human Services released a series of videos and documentation to explain patients’ right to access their health data. Yesterday, the American Health Information Management Association (AHIMA) also published guidance – in the form of a slideshow – further explaining patients’ access rights, what to expect when requests are made to healthcare providers, possible fees, and the timescale for obtaining copies of PHI. AHIMA explains that copies will not be provided immediately. Under HIPAA Rules, healthcare providers have up to 30 days to provide copies of medical records, although many will issue designated record sets well within that timeframe. However, in some cases, provided there is a justifiable reason for doing so, a healthcare provider may request a 30-day extension. In such cases, it may take up to 60 days for patients to obtain copies of their health data. AHIMA has explained to whom...

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Simplified HITRUST CSF Program Helps Small Healthcare Organizations with Compliance and Risk Management
Mar02

Simplified HITRUST CSF Program Helps Small Healthcare Organizations with Compliance and Risk Management

HITRUST has announced that it has updated the HITRUST CSF and has also launched a new CSF initiative specifically for small healthcare organizations to help them improve their resilience against cyberattacks. While the HITRUST CSF – the most widely adopted privacy and security framework – can be followed by healthcare organizations to improve their risk management and compliance efforts, for many smaller healthcare organizations following the framework is simply not viable. Smaller healthcare organizations simply don’t have the staff and expertise to follow the full HITRUST CSF framework. While the HITRUST CSF program is beneficial for smaller healthcare organizations, they do not face the same levels of risk as larger organizations. Given that the risks are lower and the requirements to comply with HIPAA already take up a lot of resources, HITRUST has developed a more simplified, streamlined framework which is much better suited to small healthcare organizations. The new framework – called CSF Basic Assurance and Simple Institution Cybersecurity or CSFBASICs for short – has a more...

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Small Healthcare Data Breach Notification Deadline: March 1, 2017
Feb23

Small Healthcare Data Breach Notification Deadline: March 1, 2017

The Health Insurance Portability and Accountability Act’s Breach Notification Rule requires all covered entities to report breaches of unsecured electronic protected health information to the Department of Health and Human Services’ Office for Civil Rights. While large data breaches – those impacting 500 or more individuals – must be reported to OCR within 60 days of the discovery of the breach, covered entities can delay the reporting of smaller data breaches. While patients must be notified of any breach of their ePHI within 60 days – regardless of the number of individuals affected by the breach – notifications of security incidents are not required by OCR until 60 days after the end of the calendar year in which the data breaches were discovered. The deadline for reporting 2016 healthcare data breaches impacting fewer than 500 individuals is March 1, 2017. As with larger data breaches, all smaller incidents must be submitted via the OCR breach reporting tool. While smaller data breaches can be reported together, each breach must be entered into the breach reporting tool...

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New HIPAA Guidance in 2017: Texting, Social Media, & Case Walkthrough
Feb22

New HIPAA Guidance in 2017: Texting, Social Media, & Case Walkthrough

At HIMSS17, OCR’s Deven McGraw shed some light on the HIPAA guidance OCR expects to release in 2017. OCR may be busy with assessing the findings of the HIPAA compliance desk audits of healthcare organizations and their business associates, but a swathe of new HIPAA guidance is set to be released this year. Last year, the Joint Commission lifted the ban on the use of text messages for orders, although within weeks of the announcement the ban was back in place. Late last year, the Joint Commission partially lifted the ban, saying the use of a secure text messaging platform was acceptable for doctors when communicating with each other, although the use of text messages – regardless of whether a secure, HIPAA-compliant platform was used – remained prohibited. OCR receives many questions from physicians and covered entities on the use of text messaging and HIPAA Rules. McGraw has confirmed that in response to the many questions, OCR will be issuing HIPAA guidance on text messaging later this year. In an interview with Information Security Media Group, McGraw explained “There are a...

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Onsite HIPAA Audits Could Be Delayed by a Year
Feb21

Onsite HIPAA Audits Could Be Delayed by a Year

In an interview at HIMSS17 with the Information Security Media Group, Deven McGraw, Deputy Director of Health Information Privacy at the Department of Health and Human Services’ Office for Civil Rights, explained that the Phase 2 HIPAA compliance audits are progressing, although the onsite audits of covered entities will be delayed. It is currently unclear how much of a delay there will be. The onsite audits were to immediately follow the 211 desk audits that were conducted last year, although the decision has been taken to push back the onsite audits until the reports of the desk audits have been written and analyzed. For the HIPAA compliance desk audits, covered entities and business associates of covered entities were sent notifications that they had been selected for audit. They were asked to supply a range of documentation on various aspects of their HIPAA compliance programs. The documentation has now been assessed and OCR is very close to issuing reports to the 166 covered entities that were audited. Those reports will be sent out in groups, with the first batch hopefully...

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Horizon BCBS of New Jersey Pays $1.1 Million for HIPAA Violation
Feb21

Horizon BCBS of New Jersey Pays $1.1 Million for HIPAA Violation

The New Jersey Division of Consumer Affairs recently announced that Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) has agreed to pay a $1.1 million fine for failing to protect the electronic protected health information of almost 690,000 plan members. The Health Insurance Portability and Accountability Act (HIPAA) requires covered entities to implement administrative, technical and physical safeguard to protect the ePHI of patients and health plan members. While data encryption is not mandatory technical safeguard, it is an addressable issue. Covered entities must therefore consider the use of encryption technologies to protect ePHI at rest and in motion. If data encryption is not chosen, alternative, security measures must be implemented that offer an equivalent level of protection. Covered entities are required to conduct a comprehensive risk analysis to identify potential risks to the confidentiality, integrity and availability of PHI. If laptop computers are used to store the ePHI of patients or plan members, a risk assessment should show that there is a risk of...

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Record HIPAA Settlement Announced: $5.5 Million Paid by Memorial Healthcare System
Feb17

Record HIPAA Settlement Announced: $5.5 Million Paid by Memorial Healthcare System

The Department of Health and Human Services’ Office for Civil Rights (OCR) has matched last year’s record HIPAA settlement with Advocate Health. Yesterday, OCR announced that a $5.5 million settlement had been reached with Florida-based Memorial Healthcare Systems to resolve potential Privacy Rule and Security Rule violations. Memorial Healthcare Systems has paid the penalty for non-compliance with HIPAA Rules, and in addition to the $5.5 million settlement, a robust corrective action plan must be adopted to address all areas of non-compliance. Memorial Healthcare Systems operates six hospitals in South Florida, with its flagship hospital one of the largest in the state. The healthcare system also operates a range of ancillary healthcare facilities, a nursing home, urgent care center, and is affiliated with many physician offices through an Organized Health Care Arrangement (OHCA). In 2012, Memorial Healthcare discovered a breach of ePHI had occurred. The breach was reported to OCR on April 12, 2012.  That breach related to two employees who were discovered to have inappropriately...

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Covered Entities Flirting with Fines for Late Data Breach Reports
Feb14

Covered Entities Flirting with Fines for Late Data Breach Reports

Last month, the Department of Health and Human Services’ Office for Civil Rights sent a message to covered entities regarding the late reporting of data breaches with the announcement of a settlement with Chicago-based healthcare network Presense Health. The settlement was the first reached with a covered entity purely to resolve HIPAA Breach Notification Rule violations. Presense Health had delayed the issuing of breach notification letters to patients. Presense Health agreed to settle with OCR for $475,000 to resolve the potential HIPAA violations. However, since the announcement was made, there have been a number of instances where covered entities have unnecessarily delayed the issuing of breach notification letters to patients and data breach reports to OCR. The January Breach Barometer – released by Protenus yesterday – indicates 40% of data breaches reported in January 2017 had notifications sent outside of the timescale required by the Health Insurance Portability and Accountability Act’s Breach Notification Rule. The loss, theft, or exposure of patients’...

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Will HHS Secretary Tom Price Ease HIPAA Regulations?
Feb13

Will HHS Secretary Tom Price Ease HIPAA Regulations?

Tom Price was appointed as secretary of the Department of Health and Human Services on February 10, 2017, replacing Sylvia Matthews Burwell. The change in leadership could see a major change in focus at the HHS, which may extend to the HIPAA enforcement activities of the Office for Civil Rights. The appointment of a new director for the Office for Civil Rights may not be first on Price’s to do list, although the new HHS secretary is expected to appoint a new OCR director soon. Price’s leadership and choice of OCR director could have a major impact on how OCR enforces HIPAA Rules and how rigorous those enforcement activities are. Since taking up the position of OCR Director in July 2014, Jocelyn Samuels oversaw a major increase in HIPAA enforcement activity. Last year, Jocelyn Samuels announced 12 settlements (and one CMP) with covered entities who were discovered to have violated HIPAA Rules during investigations into data breaches – a record year of enforcement for OCR. Jocelyn Samuels also oversaw the second phase of the much delayed second phase of HIPAA compliance audits. Last...

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High Costs are Preventing Many Patients from Accessing their Medical Records
Feb02

High Costs are Preventing Many Patients from Accessing their Medical Records

The HIPAA Privacy Rule permits patients to obtain a copy of their medical records from their healthcare providers on request. By obtaining copies of medical records, patients are able to take a more active role in their healthcare and treatment. Obtaining copies of medical records also makes it much easier for patients to share their medical records with other healthcare providers and make smarter choices about their healthcare. The Department of Health and Human Services’ Office for Civil Rights (OCR) recently explained patients’ right to obtain copies of their medical records and created a series of videos explaining how the HIPAA Privacy Rule applies to patients. OCR also issued guidance for HIPAA-covered entities on allowable charges for labor, printing, and postage last year. A flat fee of $6.50 has been recommended for providing electronic copies of medical records – should HIPAA-covered entities opt for a single charge for providing designated record sets to patients. While not all covered entities choose this model, the costs associated with obtaining copies of electronic...

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$3.2 Million HIPAA Civil Monetary Penalty for Children’s Medical Center of Dallas
Feb02

$3.2 Million HIPAA Civil Monetary Penalty for Children’s Medical Center of Dallas

The Department of Health and Human Services’ Office for Civil Rights (OCR) has announced that Children’s Medical Center of Dallas has paid a civil monetary penalty of $3.2 million to resolve multiple HIPAA violations spanning several years. It is relatively rare for OCR a HIPAA Civil Monetary Penalty to be paid by a HIPAA-covered entity to resolve HIPAA violations discovered during OCR data breach investigations. In the vast majority of cases when serious violations of the Health Insurance Portability and Accountability Act are discovered by OCR investigators, the covered entity in question enters into a voluntary settlement with OCR. Typically, this sees the covered entity pay a lower amount to OCR to resolve the HIPAA violations. OCR attempted to resolve the matter via informal means between November 6, 2015, to August 30,2016, before issuing a Notice of Proposed Determination on September 30, 2016. In the Notice of Proposed Determination, OCR explained that Children’s Medical Center of Dallas could file a request for a hearing, although no request was received. Consequently,...

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$2.2 Million Settlement for Impermissible Disclosure of ePHI
Jan19

$2.2 Million Settlement for Impermissible Disclosure of ePHI

The U.S. Department of Health and Human Services’ Office for Civil Rights has agreed a $2.2 million settlement with MAPFRE Life Assurance Company of Puerto Rico – A subsidiary of MAPFRE S.A., of Spain – to resolve potential noncompliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The settlement relates to the impermissible disclosure of the electronic protected health information of 2,209 patients in 2011. On September 29, 2011, a portable USB storage device (pen drive) was left overnight in the IT Department from where it was stolen. The device contained a range of patients’ ePHI, including full names, Social Security numbers and dates of birth. The device was not protected by a password and data on the device were not encrypted. MAPFRE Life reported the device theft to OCR, which launched an investigation to determine whether HIPAA Rules had been violated, as is customary with all breaches of ePHI that impact more than 500 individuals. Multiple Areas of Noncompliance with HIPAA Rules Discovered During the course of the investigation,...

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No HIPAA Violation Fine for Virginia State Senator
Jan19

No HIPAA Violation Fine for Virginia State Senator

While campaigning to become Republican state senator for Virginia in 2015, Henrico County physician Siobhan Dunnavant, M.D., used patients’ contact information – classed as protected health information under HIPAA Rules – to solicit donations from patients to help fund her campaign. Contact information – names and addresses – was shared with her campaign team and was used to communicate with patients. The same information was also disclosed to a direct mail company: A violation of the HIPAA Privacy Rule. At least two complaints were received by the Department of Health and Human Services’ Office for Civil Rights about the privacy violation last year. An OCR regional office contacted Dunnavant after being alerted to the privacy violation and informed her that her actions constituted an impermissible use and disclosure of PHI – violations of the HIPAA Privacy Rule.  Such violations can result in financial penalties being issued. Dunnavant, who was later elect to the state senate, could have been fined up to $250,000 for the HIPAA violation and could potentially have been...

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OCR Reminds CEs of HIPAA Audit Control Requirements
Jan17

OCR Reminds CEs of HIPAA Audit Control Requirements

In the past few weeks, a number of HIPAA-covered entities have announced that employees have been discovered to have inappropriately accessed the medical records/protected health information of patients. Two of the recent cases were discovered when covered entities performed routine audits of access logs. In both instances, the employees were discovered to have inappropriately accessed the electronic protected health information (ePHI) of patients over a period of more than 12 months. Once case involved the viewing of a celebrity’s medical records by multiple staff members. Late last week, OCR released its January Cyber Awareness Newsletter which explained the importance of implementing audit controls and periodically reviewing application, user, and system-level audit trails. NIST defines audit logs as records of events based on applications, system or users, while audit trails are audit logs of applications, system or users. Most information systems include options for logging user activity, including access and failed access attempts, the devices that have been used to log on,...

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OCR HIPAA Enforcement: Summary of 2016 HIPAA Settlements
Jan12

OCR HIPAA Enforcement: Summary of 2016 HIPAA Settlements

The Department of Health and Human Services’ Office for Civil Rights has stepped up its enforcement activities in recent years, and 2016 HIPAA settlements were at record levels. In total, payments of $22,855,300 were made to OCR in 2016 to resolve alleged HIPAA violations. Seven settlements were in excess of $1,500,000. In 2016, OCR settled alleged HIPAA violations with 12 healthcare organizations. Last year also saw an Administrative Law Judge rule that civil monetary penalties previously imposed on a covered entity – Lincare Inc. – by OCR were lawful, bringing the total to thirteen for 2016. Lincare was only the second healthcare organization required to pay a civil monetary penalty for violations of the Health Insurance Portability and Accountability Act. All other organizations opted to settle with OCR voluntarily. Financial penalties are not always appropriate. OCR prefers to settle potential HIPAA violations using non-punitive measures. Financial penalties are reserved for the most severe violations of HIPAA Rules, when widespread non-compliance is discovered, or in cases...

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Healthcare Industry Prepares for the HIPAA 2017 Audits
Jan10

Healthcare Industry Prepares for the HIPAA 2017 Audits

Given the number of HIPAA 2017 audits that OCR has planned, the probability of any healthcare organization being selected for a compliance audit is relatively small; however, that does not mean healthcare organizations can afford to be lax when it comes to HIPAA compliance. With onsite audits looming, healthcare organizations need to be prepared. Even if covered entities and business associates have not been selected for a desk audit, they may be selected for a full compliance audit later this year. Should a healthcare organization escape a 2017 HIPAA compliance audit, if a data breach is experienced, OCR will investigate. OCR follows up on all data breaches impacting more than 500 individuals. Covered entities that have experienced a data breach or security incident will be required to demonstrate that HIPAA Rules have not been violated and policies and procedures comply with the HIPAA Rules. The high number of healthcare data breaches reported in recent years shows healthcare organizations need to be prepared for a HIPAA investigation in the event that a security incident is...

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$475,000 Settlement for Delayed HIPAA Breach Notification
Jan10

$475,000 Settlement for Delayed HIPAA Breach Notification

The Department of Health and Human Services’ Office for Civil Rights (OCR) has announced the first HIPAA settlement of 2017. This is also the first settlement to date solely based on an unnecessary delay to breach notification after the exposure of patients’ protected health information. Presence Health, one of the largest healthcare networks serving residents of Illinois, has agreed to pay OCR $475,000 to settle potential HIPAA Breach Notification Rule violations. Following a breach of PHI, the HIPAA Breach Notification Rule requires covered entities to issue breach notification letters to all affected individuals advising them of the breach. Those letters need to be issued within 60 days of the discovery of the breach, although covered entities should not delay the issuing of breach notifications to patients or health plan members unnecessarily. Additionally, if the breach affects more than 500 individuals, a breach report must be submitted to Office for Civil Rights within 60 days and the Breach Notification Rule also requires covered entities to issue a breach notice to...

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Nurse Fired for HIPAA Violation
Dec20

Nurse Fired for HIPAA Violation

Can a nurse be fired for a HIPAA violation? Certainly. Violate HIPAA Rules and having your employment contract terminated may not be the worst thing that will happen. There may also be criminal charges for HIPAA violations. Jail time is likely if protected health information (PHI) is stolen and passed on to an identity thief, although HIPAA Privacy Rule violations alone can result in a jail term. If there is aggregated identity theft, there will be a mandatory two-year sentence tacked on to the sentence. When a nurse is fired for a HIPAA violation, finding alternative employment can be problematic. Few healthcare organizations would be willing to hire an employee that has previously been fired for violated HIPAA Rules. In January this year, a nurse aide was fired from Wayne Memorial Hospital for a HIPAA violation after the inappropriate accessing of 390 patients’ records was discovered. One notable incident in 2011 saw nurses and other healthcare staff snoop on patient records. In that case, there had been a party in a neighboring town where there were multiple drug overdoses....

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UMass to Pay OCR $650K to Resolve HIPAA Violations
Nov23

UMass to Pay OCR $650K to Resolve HIPAA Violations

The Department of Health and Human Services’ Office for Civil Rights (OCR) has agreed to a $650,000 settlement with University of Massachusetts Amherst (UMass). The settlement resolves HIPAA violations that contributed to the university experiencing a malware infection in 2013. In early 2013, malware was installed on a workstation in the Center for Language, Speech, and Hearing. The infection resulted in the impermissible disclosure of the electronic protected health information of 1,670 individuals. Those individuals had their names, addresses, social security numbers, birth dates, health insurance information, diagnoses, and procedure codes disclosed to the actors behind the malware attack. Following the discovery of the infection in 2013, UMass conducted a detailed analysis of the infected workstation. The malware was a generic remote access Trojan and infection occurred because the workstation was not protected by a firewall. UMass ascertained that access to ePHI had been gained. OCR investigates all data breaches that impact more than 500 individuals to determine whether...

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Recent Cases of Device Theft Highlight Importance of Data Encryption
Nov04

Recent Cases of Device Theft Highlight Importance of Data Encryption

Since January 1, 2015, HIPAA-covered entities have reported 102 cases of loss or theft of unencrypted devices to the Department of Health and Human Services’ Office for Civil Rights. Those breaches have exposed the ePHI of more than 1.5 million individuals and could have been prevented had data encryption been employed. The Health Insurance Portability and Accountability Act (HIPAA) does not require covered entities to use data encryption on portable devices used to store ePHI. Encryption is an ‘addressable’ issue, not a ‘required’ element. (45 CFR § 164.312(a)(2)(iv) and (e)(2)(ii)) This does not mean encryption can simply be ignored. HIPAA requires all covered entities to perform a comprehensive, organization-wide risk assessment (45 CFR § 164.308(a)(1)(ii)(A)). The purpose of the risk assessment is to identify potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by a HIPAA-covered entity. If, after performing a risk assessment, a covered entity determines that data encryption is not a reasonable...

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Do Your HIPAA Authorizations Violate the FTC Act?
Oct25

Do Your HIPAA Authorizations Violate the FTC Act?

The Department of Health and Human Services’ Office for Civil Rights (OCR) has been vigorously providing guidance for covered entities on HIPAA Rules. Now, the Federal Trade Commission (FTC) has issued a reminder to covered entities of the need to comply not only with HIPAA Rules, but also the FTC Act. Under HIPAA, covered entities are permitted to share PHI with other covered entities or their business associates for treatment purposes, billing, and certain healthcare operations as detailed in the HIPAA Permitted Uses and Disclosures. Most other uses are prohibited unless prior authorization is obtained by the patient (or plan member) in writing. However, while authorizations may be compliant with HIPAA Rules, they might not satisfy the requirements of the FTC Act. The FTC Act protects consumers by preventing organizations from “engaging in deceptive or unfair acts or practices in or affecting commerce.” It is possible for a HIPAA-covered entity to comply with HIPAA Rules regarding patient authorizations, yet still violate the FTC Act. There is some overlap between the two...

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EHNAC and HITRUST Streamline Accreditation Processes
Oct20

EHNAC and HITRUST Streamline Accreditation Processes

The Electronic Healthcare Network Accreditation Commission (EHNAC) and the Health Information Trust Alliance (HITRUST) have announced a new collaboration. The aim is to reduce – and hopefully eliminate – redundant assessments and their associated costs. It is hoped by streamlining the organizations’ accreditation and certification programs the benefits for industry stakeholders will be preserved, while much of the complexity of information protection and compliance will be eliminated. EHNAC is an accreditation program for organizations that exchange healthcare information electronically, such as health information exchanges, health information service providers, accountable care organizations, medical billing companies, and electronic health networks. The HITRUST common risk and compliance management framework (CSF) is the most widely adopted security framework in the healthcare industry and is used by more than 84% of hospitals and health plans. EHNAC and HITRUST mapped their respective programs and discovered a considerable overlap between EHNAC HIPAA-related privacy and security...

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St. Joseph Health to Pay OCR $2.14 Million to Settle HIPAA Case
Oct19

St. Joseph Health to Pay OCR $2.14 Million to Settle HIPAA Case

The Department of Health and Human Services’ Office for Civil Rights has announced it has agreed to settle potential violations of the HIPAA Privacy and Security Rules with St. Joseph Health (SJH). SJH is required to pay $2.140,500 to OCR and adopt a corrective action plan (CAP) to bring policies and procedures up to the standard demanded by HIPAA. SJH is a not-for-profit integrated Catholic health care delivery system sponsored by the St. Joseph Health Ministry. SJH provides a wide range of medical services throughout California, New Mexico and Texas though 14 acute care hospitals and numerous community clinics, skilled nursing facilities, and home health agencies. SJH was investigated following an ePHI breach reported to OCR on February 14, 2012. Files containing ePHI were created by SJH under the Meaningful Use Program; however, those files were left unprotected and accessible on the Internet for more than a year from February 1, 2011 to February 13, 2012. The PDF files had been indexed by Google – and potentially other search engines. During that time the ePHI of 31,800...

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OCR Laser-Focused on Data Breaches Says Samuels
Oct18

OCR Laser-Focused on Data Breaches Says Samuels

Jocelyn Samuels, Director of the Department of Health and Human Services’ Office for Civil Rights (OCR) explained OCR’s role in enforcing HIPAA Rules in a recent blog post and confirmed where enforcement activities will be focused over the coming 12 months. Samuels said OCR is “laser-focused on breaches occurring at health care entities, and any issues that lead to them” and that will not change. In the post, Samuels spoke of the increase in enforcement activities and pointed out OCR has entered into a record number of financial settlements with organizations that have been discovered to have violated HIPAA Rules. There are just over two months left of 2016, yet OCR has already entered into 11 financial settlement agreements with HIPAA-covered entities this year, compared to 5 settlements in 2013, six in 2014, and six in 2015. In the most part, investigations of covered entities were triggered after major data breaches were experienced rather than the investigation of complaints filed by individuals. Many complaints are submitted to OCR each year about potential HIPAA violations....

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Guidance on HIPAA and Cloud Computing Issued by HHS
Oct10

Guidance on HIPAA and Cloud Computing Issued by HHS

The Department of Health and Human Services has released updated guidance on HIPAA and cloud computing to help covered entities take advantage of the cloud without risking a HIPAA violation. The main focus of the guidance is the use of cloud service providers (CSPs). Cloud service providers that are legally separate entities from a HIPAA-covered entity are classed as business associates under HIPAA regulations if the CSP is required to create, receive, maintain, or transmit electronic protected health information (ePHI). A CSP is also classed as a business associate when a business associate of a covered entity subcontracts services to the CSP that involve creating, receiving, maintaining, or transmitting ePHI. It is important to note that even when a HIPAA covered entity, business associate, or subcontractor of a business associate provides ePHI to a CSP in encrypted form, the CSP is still classed as a business associate under HIPAA Rules, even if a key to decrypt the data is not provided. A CSP would not be classed as a business associate and would therefore not be required to...

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EHR Vendors Violate HIPAA Rules by Blocking Access to ePHI
Sep29

EHR Vendors Violate HIPAA Rules by Blocking Access to ePHI

Yesterday, Office for Civil Rights (OCR) issued guidance for EHR vendors and other business associates of HIPAA covered entities explaining the need to ensure electronic protected health information (ePHI) is always available to covered entities. The guidance, which takes the form of a FAQ, also clarifies how the HIPAA Rules apply to the blocking or termination of access to ePHI maintained by a business associate. OCR has confirmed that blocking access to ePHI is a violation of the HIPAA Rules. EHR vendors that prevent a HIPAA-covered entity from accessing patient health records, such as during payment disputes, are violating HIPAA Rules and could potentially be fined for doing so. EHR vendors have been known to hit the kill switch and prevent access to patient data in the event of a payment dispute or after the termination of an agreement. OCR points out that the failure to return ePHI and/or blocking access to ePHI is a clear violation of the HIPAA Privacy Rule. The Privacy Rule requires a covered entity to allow patients to obtain copies of their ePHI on request. If a business...

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$400,000 HIPAA Settlement for BAA Failures
Sep26

$400,000 HIPAA Settlement for BAA Failures

The Department of Health and Human Services’ Office for Civil Rights (OCR) has announced it has arrived at a settlement with Care New England Health System (CNE) to resolve alleged violations of the Health Insurance Portability and Accountability Act (HIPAA). CNE is required to pay a financial penalty of $400,000 and must adopt a comprehensive Corrective Action Plan (CAP) to address various areas of HIPAA non-compliance. Care New England Health System (CNE) provides centralized corporate support for a number of subsidiary affiliated HIPAA-covered entities throughout Massachusetts and Rhode Island. An OCR investigation was triggered following the receipt of a breach notification from one of CNE’s subsidiary affiliated covered entities – Woman & Infants Hospital of Rhode Island (WIH) – on November 5, 2012. WIH reported the loss of a number of unencrypted backup tapes that contained the PHI of around 14,000 patients. The exposed PHI included names, dates of birth, dates of medical examinations, names of referring physicians, and Social Security numbers. The breach...

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WakeMed Health and Hospitals Fined for Patient Privacy Violations
Sep19

WakeMed Health and Hospitals Fined for Patient Privacy Violations

Raleigh-N.C-based WakeMed Health and Hospitals has been ordered to pay a fine of $70,000 by a North Carolina Bankruptcy Court for violating the privacy of patients. The privacy violations occurred when submitting proofs of claim to the bankruptcy court. Documents were submitted electronically; however, they contained the protected health information of debtors, including names, Social Security numbers, bank account numbers, and dates of birth. Under Bankruptcy Rule 9037, any proofs of claim submitted in court filings must have sensitive information redacted prior to transmission. Social Security numbers, taxpayer identification numbers, and account numbers must have all but the last four digits of the numbers redacted. Birthdates must also have the year of birth redacted. Additionally, if the filings include details of minors, only their initials must be included, not full names. WakeMed Health and Hospitals failed to redact this information, and further, a number of the proofs of claims also contained protected health information. It was alleged this was a violation of the Health...

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The Importance of Auditing Business Associates Highlighted by OIG Investigation
Sep14

The Importance of Auditing Business Associates Highlighted by OIG Investigation

The Department of Veteran Affairs’ Office of Inspector General (OIG) has published a report on the investigation of a VA contractor that was alleged to be allowing employees to access, share, and store the protected health information of veterans on personally owned devices. Anchorage-based ProCare Home Medical Inc., a supplier of home oxygen services on behalf of the VA, was reported to OIG for breaching federal information security standards. The tipoff came via the VA OIG Hotline in December 2014. OIG was informed that the company’s employees were permitted to use personal computers and smartphones to access the company’s computer system. They were also alleged to have downloaded the PHI of veterans to their personal devices. OIG conducted an onsite review of ProCare facilities in May 2015. Staff were interviewed and contractor business processes were observed. VA staff were also interviewed to determine the level of oversight of contractors that was taking place. The allegations made against ProCare were substantiated by OIG, and while it was not possible to examine the devices...

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Updated Security Risk Assessment Tool Released by ONC
Sep07

Updated Security Risk Assessment Tool Released by ONC

OCR prefers to settle HIPAA compliance issues through voluntary compliance and non-punitive means, although financial penalties are now becoming more commonplace. If OCR investigators uncover HIPAA violations, financial penalties may be issued. Fines of up to $1.5 million can be issued for each violation category discovered. One of the most common reasons for a financial penalty is the failure to conduct a comprehensive, organization-wide risk assessment. The risk assessment is a foundational requirement of the HIPAA Security Rule – 45 C.F.R. §§ 164.308(a)(1)(ii)(A), and is one of four required implementation specifications in the Security Management Process. The purpose of the risk assessment is to identify all potential risks to the confidentiality, integrity, and availability of all ePHI that a covered entity creates, receives, maintains, or transmits. The risk assessment must cover all forms of ePHI, and all devices and systems that touch ePHI. As was seen with the pilot phase of the HIPAA compliance audits and subsequent PHI breach investigations, small to medium-sized covered...

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OCR Investigation into Bizmatics Data Breach is Closed
Aug29

OCR Investigation into Bizmatics Data Breach is Closed

The Department of Health and Human Services’ Office for Civil Rights has closed the investigation into the 2015 Bizmatics data breach. The breach, which was discovered in late 2015, affected many of the company’s clients. The malware was discovered to have been installed on a server in early 2015. The server was used to house the company’s PrognoCIS EMR database. At least 300,000 patients were impacted and potentially had their PHI exposed as a result of a malware infection. A thorough breach investigation was conducted but Bizmatics was unable to confirm whether data were actually viewed or copied by the malicious actor responsible for installing the malware. No public breach announcement was issued by Bizmatics, although all affected clients were notified if the PHI of their patients was potentially accessed. The Office for Civil Rights conducted an investigation into the breach, but it would appear that the case has now been closed with no action against the business associate deemed necessary. When OCR conducts data breach investigations, investigators assess the company to...

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OCR to Increase Investigations of Small PHI Breaches
Aug18

OCR to Increase Investigations of Small PHI Breaches

The Department of Health and Human Services’ Office for Civil Rights (OCR) has announced it will be stepping up investigations of small PHI breaches with immediate effect. Breaches impacting fewer than 500 individuals will now be subjected to closer scrutiny, with the responsibility for investigating those breaches falling to the OCR’s Regional Offices. OCR currently investigates all PHI breaches that impact more than 500 individuals, although investigations of small PHI breaches – those that affect fewer than 500 individuals – have only been performed as resources permit. The responsibility for investigating small breaches has fallen to the OCRs Regional Offices, but due to limited resources, investigations of small breaches have been limited up until now. However, a new initiative has now been launched that will see Regional Offices investigate small PHI breaches much more widely, although OCR will continue to prioritize investigations of large-scale breaches of protected health information. According to a recent news release, each of the OCRs Regional Offices has been instructed...

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CMS Cracks Down on Social Media Abuse of Nursing Home Residents
Aug15

CMS Cracks Down on Social Media Abuse of Nursing Home Residents

A significant number of cases of abuse of nursing home and assisted living center residents have come to light in recent months. The cases involved the taking of degrading and demeaning photographs and videos of residents by employees of nursing facilities, and sharing the images and videos on social media websites. Photographs of residents in various states of undress, covered in feces, or made to pose in degrading positions have been published on social media websites such as Snapchat, Instagram, and Facebook. The cases were recently highlighted in a ProPublica report, which uncovered 47 reports of such abuse since 2012. That report, along with other media coverage of abuse in nursing facilities, has spurred the Centers for Medicare and Medicaid Services (CMS) to take action. The CMS recently sent a memo to state health departments reminding them of facility and state agency responsibilities and the rights of residents to be free from all types of abuse, including mental abuse. The taking of demeaning videos and/or photographs and publishing the imagery on social media websites...

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Walgreens Improper PHI Dumping Case Closed by OCR After 9 Years
Aug15

Walgreens Improper PHI Dumping Case Closed by OCR After 9 Years

Ten years ago, WTHR 13 conducted an investigation into the improper disposal of sensitive information by pharmacies. The investigation was conducted following a robbery that took place at the home of an Indiana resident. A drug addict targeted the individual knowing that she had pain medication. That information was obtained from a pharmacy dumpster. The investigation involved reporters checking the dumpsters behind a number of pharmacies in Indiana. The reporters discovered bags of trash, many of which contained sensitive information such as prescription details, names, addresses, and phone numbers. Reporters also discovered that in some cases, credit card details were also printed on documents discarded with regular trash. The investigation was first conducted on Walgreens, although it was later expanded to a number of other pharmacy chains including CVS and Rite Aid. The investigation was expanded to 12 states. Initially reporters were told by Walgreen’s representatives that the improper dumping of sensitive information was not company policy and occurred in isolated incidents....

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Former Tampa Hospital Employee Convicted of PHI Theft and Tax Fraud
Aug09

Former Tampa Hospital Employee Convicted of PHI Theft and Tax Fraud

A former employee of Tampa General Hospital was recently convicted of wrongful disclosure of individually identifiable health information and wire fraud. Shanakia Benton was accused of stealing the protected health information of patients during the time she was employed at Tampa General Hospital. According to court documents, between June 2011 and December 2012, Benton improperly accessed the computer system of Tampa General Hospital and printed out and removed the individually identifiable information of 644 patients. The stolen data included names, Social Security numbers, dates of birth, addresses, and medical diagnoses. In addition to using the information to file fraudulent tax returns in the names of the victims, Benton planned to sell the stolen data to other individuals. In total, Benton filed 29 fraudulent tax returns totaling $226,000. Benton had previously signed a document stating she was aware of the rules regarding the accessing of patient information and was aware that she was required to protect the privacy of patients. Benton’s actions were discovered and she was...

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Med Students Violating HIPAA by Tracking Patients on EHRs
Aug02

Med Students Violating HIPAA by Tracking Patients on EHRs

Medical students are using hospital electronic health records to track former patients, even though by doing so they are potentially violating the Health Insurance Portability and Accountability Act (HIPAA). While it is known that the practice occurs, little research has been performed to determine the extent to which EHRs are accessed and the exact reasons why patients are tracked. In August 2013, Gregory E. Brisson, MD of Northwestern University Feinberg School of Medicine in Chicago, IL and Patrick D. Tyler, MD of Beth Israel Deaconess Medical Center in Boston, MA conducted a survey on 169 students from one academic healthcare center to investigate medical students’ use of EHRs to track patients. The findings of the study have recently been published in JAMA Internal Medicine. The study revealed that the vast majority of medical students were using EHRs to track former patients. 96.1% of medical students admitted that they had previously used EHRs to track former patients. 92.9% of students said there were educational benefits to be gained from following up on patients’ progress...

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Third of Hospitals Lack HIPAA-Compliant EHR Contingency Plans
Jul26

Third of Hospitals Lack HIPAA-Compliant EHR Contingency Plans

According to a recent report issued by the Department of Health and Human Services’ Office of Inspector General, a third of hospitals do not have HIPAA-compliant EHR contingency plans in place, although most are “largely addressing” HIPAA requirements for EHRs. In September 2014, OIG sent a survey to 400 hospitals that had applied for Medicare EHR incentive payments and asked questions to determine whether HIPAA-compliant EHR contingency plans had been developed and implemented. Respondents were also asked about the extent to which EHR systems had been disrupted in the past. In addition to the survey, six hospitals were also selected for in-depth investigations involving site visits, interviews with hospital staff, documentation checks, and reviews of EHR contingency plans. The purpose of the study was to assess the state of hospitals’ EHR contingency planning and to determine whether patient health information could still be accessed during natural disasters and other situations where EHR system downtime occurs. In light of the recent ransomware attacks on hospitals in recent...

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2.75 Million Dollar HIPAA Settlement Reached with UMMC
Jul22

2.75 Million Dollar HIPAA Settlement Reached with UMMC

Hot on the heels of the 2.7 million HIPAA breach settlement with Oregon Health & Science University comes news of another multi-million-dollar settlement with another university. The Department of Health and Human Services’ Office for Civil Rights announced yesterday that University of Mississippi Medical Center (UMMC) has agreed to settle alleged HIPAA violations and will pay a financial penalty of $2.75 million. UMMC has also agreed to adopt a corrective action plan (CAP) to bring privacy and security standards up to the level required by HIPAA. UMMC Investigated After Theft of Unencrypted Laptop Computer The settlement stems from a breach of patients’ protected health information (PHI) in 2013. A laptop computer issued to UMMC’s Medical Intensive Care Unit (MICU) was discovered to be missing. The laptop computer contained the PHI of 500 patients. The data were not encrypted, although the laptop computer was password protected. The laptop is believed to have been stolen by a visitor who had asked about borrowing one of MICU’s laptops. OCR conducted an investigation into the...

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How Does OCR Deal with HIPAA Complaints?
Jul21

How Does OCR Deal with HIPAA Complaints?

The Department of Health and Human Services’ Office for Civil Rights (OCR) encourages individuals to file complaints about HIPAA-covered entities, or their business associates, if they feel that their privacy has been violated. Individuals are also able to file complaints if they believe the privacy of other individuals have been violated. Complaints about potential HIPAA violations are investigated by OCR, and while many prove to be unsubstantiated, oftentimes a HIPAA covered entity or an employee of that organization, is discovered to have violated patient privacy or breached HIPAA Rules. OCR receives many complaints and the breach portal contains many hundreds of breach reports from covered entities that have experienced major breaches of PHI, yet only a tiny percentage result in civil monetary penalties being issued or financial settlements being agreed. What happens to all the other complaints that involve violations of HIPAA Rules? What action does OCR take against covered entities that violate the privacy of patients or failed to adhere to HIPAA Rules? In the vast majority...

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Oregon Health & Science University to Pay OCR $2.7 Million for 2013 Data Breaches
Jul14

Oregon Health & Science University to Pay OCR $2.7 Million for 2013 Data Breaches

Oregon Health & Science University (OHSU) has agreed to settle a case with the Department of Health and Human Services’ Office for Civil Rights stemming from two data breaches experienced in 2013. A penalty of $2.7 million will be paid by OHSU to settle alleged HIPAA violations without admission of liability. The privacy breaches occurred shortly after each other in 2013. Within the space of three months, the protected health information of over 7,000 patients was exposed. The first breach of patient data involved the theft of an unencrypted laptop computer from a vacation apartment in Hawaii that was rented by an OHSU physician. The laptop computer contained the PHI of 4,022 patients. The second incident involved the accidental disclosure of PHI via a cloud storage service. Physicians were using the Internet service to share a spreadsheet containing patient data. However, the cloud service provider was a HIPAA business associate of OHSU and no business associate agreement had been obtained prior to the service being used. Consequently, the data of 3,044 patients was placed at...

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OCR Phase 2 HIPAA Audits: Documentation Requests Issued
Jul13

OCR Phase 2 HIPAA Audits: Documentation Requests Issued

The Department of Health and Human Services’ Office for Civil Rights (OCR) has now selected covered entities from its pool of eligible organizations and has chosen 167 for a HIPAA compliance audit. Covered entities selected for a compliance audit have now been notified by email. Those organizations now have just 10 days to respond to the emails and submit the requested documentation to the OCR. The audits – which are desk based – have been split between healthcare providers, health plans, and healthcare clearinghouses. The audits are being conducted on a geographically representative sample that includes healthcare organizations of all sizes. Desk audits of HIPAA business associates will follow in the fall. The desk audits comprise of a documentation check to ensure compliance with the Health Insurance Portability and Accountability Act’s Privacy, Security, and Breach Notification Rules. Earlier this year the OCR published details of the new audit protocol. The protocol contains a long list of different aspects of HIPAA Rules that could potentially be assessed by OCR...

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OCR Ransomware Guidance: Ransomware Attacks Are Reportable Breaches
Jul12

OCR Ransomware Guidance: Ransomware Attacks Are Reportable Breaches

The Department of Health and Human Services’ Office for Civil Rights has issued new guidance on ransomware. A fact sheet on healthcare ransomware attacks has been published along with a 12-page document providing technical guidance for CIOs and CISOs on best practices to adopt to prevent ransomware infections, mitigation strategies to adopt when ransomware is installed on computers or healthcare networks, and detailed information on the correct ransomware response. The new guidance is essential reading for CISOs, CIOs, and all members of the senior leadership team. Ransomware and HIPAA The OCR has confirmed the proactive measures that covered entities should take to prevent ransomware infections: Perform a comprehensive, organization-wide risk analysis Establish a plan to remediate any identified risks to the confidentiality, integrity, or availability of ePHI Implement policies and procedures to safeguard ePHI against malicious software – including malware and ransomware Provide staff members with training on cybersecurity best practices Train authorized users to detect malicious...

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Philadelphia Business Associate Agrees to $650,000 OCR Settlement
Jun30

Philadelphia Business Associate Agrees to $650,000 OCR Settlement

On June 24, 2016, the Department of Health and Human Services’ Office for Civil Rights (OCR) published details of a resolution agreement that was reached with Catholic Health Care Services of the Archdiocese of Philadelphia (CHCS).  CHCS has agreed to settle alleged HIPAA violations with the OCR and has agreed to implement a Corrective Action Plan (CAP). CHCS will also pay a financial penalty of $650,000. CHCS is the sole corporate parent of six nursing facilities – St. Francis Country House, Immaculate Mary Home, St. John Neumann Home, St. Mary’s Manor, St. Martha’s Manor, and St. Monica’s Manor – and provides management services to the nursing facilities. In its capacity as a HIPAA business associate, CHCS is required to comply with HIPAA Rules. In February 2014, each of the six nursing facilities submitted a breach notice to the OCR regarding a breach of ePHI. On April 17, 2014, the OCR launched an investigation into the breach. A large number of OCR investigations into ePHI breaches have revealed failures to comply with HIPAA administrative safeguards – specifically 45...

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ONC Reminds App Developers to Check Regulatory Requirements
Jun22

ONC Reminds App Developers to Check Regulatory Requirements

The Office of the National Coordinator for Health Information Technology (ONC) has reminded developers of health apps not only to put more thought into data security, but also to build security controls into the core of their apps. Data security features should not simply be bolted as an afterthought. They are an essential part of the design of the apps and therefore must be incorporated during the initial design process. The ONC points out that health apps are no longer just being developed by computer science graduates. Health apps have been developed by clinicians who have identified a need for an app and a gap in the market. Even patients have been working on health apps to log and record a wide variety of health data or to issue appointment and medication reminders. No matter who conceives and develops a new health app, it is essential that the legal implications are considered and incorporated into the design. App developers must become familiar with the legislation covering health apps and the data they record. The Health Insurance Portability and Accountability Act (HIPAA)...

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Indiana Attorney General’s Office Investigates Dumping of Medical Records
Jun18

Indiana Attorney General’s Office Investigates Dumping of Medical Records

Earlier this week, an officer from the Indianapolis Metropolitan Police Department (IMPD) discovered a number of medical records in a public recycling dumpster in Broad Ripple Park, Indianapolis. A number of confidential documents were found in file folders in the dumpster which had been mixed up with newspapers and other paper and cardboard. IMPD recovered the files and folders from the recycling dumpster, although there is no way of telling whether any documents had been removed by members of the public. It is also unclear whether files had been dumped on a single occasion, or whether material had been disposed of over an extended period of time. The Indiana Attorney General’s Office is now involved and efforts have been made to contact recycling and waste disposal companies who potentially may have come into contact with dumped medical records. If any further files and folders are recovered the attorney general’s office will arrange for the files to be collected and secured. According to the police report, the files contain highly sensitive data including patient names,...

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Head of House Select Investigative Panel Calls for HIPAA Investigation into Abortion Clinic PHI Disclosures
Jun06

Head of House Select Investigative Panel Calls for HIPAA Investigation into Abortion Clinic PHI Disclosures

Last week, the head of the House Select Investigative Panel tasked with investigating the trade of baby body parts by abortion clinics wrote to the director of the Department of Health and Human Services’ Office for Civil Rights requesting an investigation into violations of the Health Insurance Portability and Accountability Act (HIPAA). It is alleged that Planned Parenthood – Planned Parenthood Mar Monte (PPMM) and Planned Parenthood Shasta Pacific (PPSP) – and Family Planning Specialists Medical Group (FPS) improperly disclosed the protected health information (PHI) and personally identifiable information (PII) of female patients to StemExpress. In her June 1 letter to Jocelyn Samuels, Rep. Marsha Blackburn explains that employees of StemExpress were provided with details of the abortions that were scheduled to take place on each day and were also given access to the medical files of patients who would be likely to provide fetal tissue donations. Blackburn claims that StemExpress employees were allowed inside of clinics and were given permission to interview patients in...

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ONC Releases Videos Explaining Patients’ HIPAA Rights
Jun03

ONC Releases Videos Explaining Patients’ HIPAA Rights

Earlier this year, the HHS’ Office for Civil Right (OCR) released guidance for healthcare organizations on patients’ HIPAA rights in an attempt to clear up confusion over access and ensure that covered entities were aware of their obligations under the HIPAA Privacy Rule. The guidance covered many of the questions commonly asked by healthcare organizations, including the models that can be adopted by healthcare organizations for charging for PHI copies. Now that covered entities are prepared, efforts have shifted to advising patients of their access rights under HIPAA. This week, the Office of the National Coordinator for Health Information Technology (ONC) -in conjunction with the OCR – released a series of educational videos to improve understanding of patients’ HIPAA rights. The ONC wants to improve patient engagement and get patients to take greater interest in their health. Encouraging patients to obtain copies of their ePHI can help in this regard. Having access to medical records allows patients to check for errors, provide their data to other healthcare providers or...

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OCR Rules Townsend Violated the HIPAA Privacy Rule
Jun02

OCR Rules Townsend Violated the HIPAA Privacy Rule

The Department of Health and Human Services’ Office for Civil Rights (OCR) has recently ruled that a former town administrator of Townsend, MA., violated the HIPAA Privacy Rule in June last year when he posting an “information packet” online containing the protected health information of individuals who had used the town’s ambulance service. The information was intended to be viewed by Selectmen in order that a vote could be taken about whether or not to write off the unpaid bills. Rather than sharing the document securely, former town administrator Andrew Sheehan posted the information on the town website. The packet was only accessible for 18 hours before it was removed, but during that time it had been downloaded and shared on social media. The privacy breach was also reported to the OCR. The information packet contained the names of patients who had not yet paid their ambulance bills along with some sensitive medical information including medical conditions and whether patients were alive, dead, or were now living in a hospice. Prior to the uploading of the files, all...

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Healthcare Providers Violate HIPAA Responding to Negative Yelp Reviews
Jun01

Healthcare Providers Violate HIPAA Responding to Negative Yelp Reviews

Some healthcare providers have violated patient privacy and HIPAA Rules when responding to negative comments on Yelp and similar review sites according to a recent ProPublica report. For the report, ProPublica was provided with access to around 1.7 million Yelp reviews of healthcare providers. The researchers used a tool to sift through the reviews and isolated approximately 3,500 one-star ratings of healthcare providers – the lowest possible rating on the review site – that mentioned “Privacy” or “HIPAA”. ProPublica researchers discovered “dozens” of instances where healthcare providers had breached HIPAA Rules when responding to comments. In some cases, the responses to the negative comments involved the disclosure of patients’ protected health Information. ProPublica cited one example of a Californian chiropractor that replied to a negative comment from a patient and included details of the procedures he had performed and information about her medical condition. Another example involved a dentist who responded to a comment about an alleged unnecessary tooth...

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OCR Clears Up Confusion About the Charging of Flat Fees for Copies of PHI
May24

OCR Clears Up Confusion About the Charging of Flat Fees for Copies of PHI

Earlier this year the Office for Civil Rights issued guidance for healthcare providers and health plans on the general right of patients to obtain copies of their protected health information on request. The HIPAA Privacy Rule allows patients to obtain one or more designated record sets which a covered entity holds and maintains. By obtaining copies of their PHI, patients can take control of their own healthcare and wellbeing. Providing copies of PHI to patients involves a cost to the covered entity, such as the time taken to obtain and copy records and prepare summaries, the cost of paper and printing if record sets are supplied in physical form, the cost of media devices for electronic copies of PHI, and the cost of mailing records to patients if they are not collected in person. Covered entities are permitted to charge patients for providing copies of their PHI, which was explained in the OCR guidance; however, based on the questions submitted by covered entities there appeared to be some confusion over allowable charges, in particular regarding the charging of flat rate fees to...

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Deven McGraw Offers Advice on the Upcoming HIPAA Compliance Audits
May20

Deven McGraw Offers Advice on the Upcoming HIPAA Compliance Audits

Deven McGraw – deputy director of health information privacy at the Office for Civil Rights (OCR) – has offered some advice to covered entities ahead of the HIPAA-compliance audits which are scheduled to take place later this year. The second round of HIPAA-compliance audits will be conducted on covered entities first, followed by business associates. OCR contacted covered entities earlier this year to verify contact information. That process is almost complete and a pool of healthcare providers, health plans, and healthcare clearinghouses will soon be finalized. OCR will select approximately 200 organizations from that pool for a desk audit. Covered entities selected for audit will be notified and given 10 days to submit the requested documentation to the OCR. This does not give covered entities much time so it is important that preparations are made early. In an interview with the Information Security Media Group, McGraw suggested that covered entities should start preparing now in case they are selected for a desk audit. Last month, OCR released the updated audit protocol which...

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Are You Prepared for A Business Associate Data Breach?
May09

Are You Prepared for A Business Associate Data Breach?

HIPAA-covered entities may be prepared to execute their breach response procedures for a security breach that exposes patients’ Protected Health Information (PHI), but what about business associate data breaches? Have policies and procedures been developed to ensure a rapid breach response can be executed if a business associate suffers a data breach? The Department of Health and Human Services’ Office for Civil Rights has recently warned HIPAA-covered entities that they must take steps to ensure they can deal with a business associate data breach should one occur. OCR: HIPAA-Covered Entities Find Business Associate Data Breach Management Difficult The recent OCR cyber-awareness bulletin confirmed the need for action to be taken by HIPAA-covered entities to prepare for data breaches experienced by their vendors. The bulletin indicates a large percentage of covered entities are concerned that business associate data breaches may not be reported to them. OCR also suggests that when a business associate data breach does occur, covered entities are often unsure whether their vendors’...

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Joint Commission Ends Ban on Clinician Text Messaging
Apr29

Joint Commission Ends Ban on Clinician Text Messaging

For the past five years the Joint Commission has banned the use of text messaging by licensed independent practitioners (and other practitioners) due to security risks. That ban has now been lifted with immediate effect, although there are conditions. Test messaging is permissible, although only if a secure text messaging platform is used. Furthermore, that secure text messaging platform must meet the following criteria: The text messaging platform must incorporate a secure sign-on process All text messages must be protected by end to end encryption The platform must incorporate read and delivery receipts Messages must include a date and time stamp The platform must incorporate a contact list of individuals authorized to receive and record orders, and The platform must allow customized message retention time frames to be set Standard text messaging is still prohibited as encryption is not used, there are no authentication controls to ensure that only the intended recipient can view the messages, and original messages cannot be retained in order to validate information entered into...

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New York Hospital Fined $2.2 Million for Unauthorized Filming of Patients
Apr22

New York Hospital Fined $2.2 Million for Unauthorized Filming of Patients

The Department of Health and Human Services’ Office for Civil Rights (OCR) has fined New York Presbyterian Hospital (NYP) $2.2 million for allowing patients to be filmed for a TV show without obtaining prior permission from the patients. In 2011, an ABC crew was permitted to film inside NYP facilities for the show “NY Med” featuring Dr. Mehmet Oz. A number of patients were filmed including a dying man and another patient who was seriously distressed. The footage was aired in 2012. Authorization to film had been given by NYP, although not all patients gave their consent to be filmed. One of the patients was Mark Chanko . He had been rushed to hospital after being hit by a sanitation truck. He was filmed receiving treatment from chief surgery resident Sebastian Schubl. Despite the best efforts of Schubl, Chanko died from the injuries sustained in the accident. Chanko had not given NYP permission to film him. To hide his identity ABC used blurring and voice alteration software. This did not prevent the crew from viewing Chanko’s PHI and it was not sufficient to hide his identity from...

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Raleigh Orthopaedic Clinic Settles for 750K for Lack of BAA
Apr20

Raleigh Orthopaedic Clinic Settles for 750K for Lack of BAA

The Department of Health and Human Services’ Office for Civil Rights (OCR) has announced a settlement has been reached with Raleigh Orthopaedic Clinic, P.A., of North Carolina over alleged violations of HIPAA Rules. Raleigh Orthopaedic has agreed to pay OCR $750,000 for failing to enter into a business associate agreement (BAA) with a vendor before handing over the protected health information (PHI) of 17,300 patients in 2013. OCR launched an investigation into a data breach reported by Raleigh Orthopaedic on April 30, 2013. Raleigh Orthopaedic had agreed to provide a potential business associate (BA) with X-Ray films in order to have images transferred to a digital format. The company was allowed to recycle the original films to recover the silver after the images had been transferred to an electronic format. However, the agreement was reached over the telephone and no BAA was obtained. Prior to providing the company with the X-Rays Raleigh Orthopaedic should have issued a BAA and obtained a signed copy. The BAA should have detailed the responsibilities the company had to ensure...

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Lawsuit Filed Against Facebook and Cancer Sites for Alleged HIPAA Violation
Apr15

Lawsuit Filed Against Facebook and Cancer Sites for Alleged HIPAA Violation

A lawsuit has been filed in Federal Court in San Jose, California by cancer patients who allege they have had their privacy violated after visiting the websites of cancer institutes. The plaintiffs claim that the websites of some cancer institutes contain secret code that captures data and passes the information to Facebook for marketing purposes. After visiting the websites, the plaintiffs claim they have been served advertisements relating to very specific types of cancer. It is alleged that in order for those advertisements to be served, Facebook must have been provided with site search data and the specific webpages that were visited. Lead plaintiff in the case, Winston Smith, claims to have visited cancer.org, a website of the American Cancer Society. Smith conducted searches on the site for information on lung cancer and claims those searches, and information about the webpages he visited, were provided to Facebook which used the information to serve him targeted adverts. Smith claims that Facebook’s privacy policy does not specifically mention that highly sensitive medical...

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Healthcare Organizations Prioritizing Compliance Over Data Breach Prevention
Apr15

Healthcare Organizations Prioritizing Compliance Over Data Breach Prevention

A recent survey conducted by 451 Research on behalf of security firm Vormetric indicates 96% of IT managers expect their organizations to be attacked by cybercriminals. The survey was conducted on 1,100 IT managers including over 100 working in healthcare organizations. One in five organizations have experienced a data breach in the past 12 months, while 63% of respondents said they have experienced a data breach in the past. Even though the threat of a data breach is considerable, a majority of healthcare IT managers say their organizations are prioritizing compliance over data breach prevention. 61% of healthcare IT managers said compliance was their main priority, compared to just 40% that said it was data breach prevention. Other priorities were preventing reputation and brand damage and implementing security best practices, rated as the main priorities by 49% and 46% of respondents respectively. More than Two Thirds of Respondents Said Achieving Compliance Was an Effective Way of Protecting Data   69% of healthcare IT managers said achieving compliance with EPCS, FDA CFR...

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Compliance Assistance Provided to Mobile Health App Developers by FTC
Apr07

Compliance Assistance Provided to Mobile Health App Developers by FTC

A new interactive tool has been released by the Federal Trade Commission (FTC) to help mobile health app developers determine whether their apps need to comply with federal regulations. The new web-based tool was developed with assistance from the U.S Department of Health and Human Services (HHS), the Office for Civil Rights (OCR), Office of National Coordinator for Health Information Technology (ONC), and the Food and Drug Administration (FDA). By answering a series of 10 questions, mobile app developers can determine whether their health care products are covered under the Health Insurance Portability and Accountability Act (HIPAA), Federal Food, Drug, and Cosmetic Act (FD&C Act), Federal Trade Commission Act (FTC Act) or need to comply with the FTC’s Health Breach Notification Rule. In many cases, app developers will be required to comply with more than one set of federal laws. According to Jessica Rich, FTC Bureau of Consumer Protection director, “Mobile app developers need clear information about the laws that apply to their health-related products.” The tool aims to...

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