HIPAA Compliance for Medical Practices
77.1K views | +11 today
Follow
HIPAA Compliance for Medical Practices
HIPAA Compliance and HIPAA Risk management Articles, Tips and Updates for Medical Practices and Physicians
Your new post is loading...
Your new post is loading...
Scoop.it!

The HIPAA Password Requirements

The HIPAA Password Requirements | HIPAA Compliance for Medical Practices | Scoop.it

The HIPAA password requirements stipulate procedures must be put in place for creating, changing and safeguarding passwords unless an alternative, equally-effective security measure is implemented. We suggest the best way to comply with the HIPAA password requirements is with two factor authentication.

 

The HIPAA password requirements can be found in the Administrative Safeguards of the HIPAA Security Rule. Under the section relating to Security Awareness and Training, §164.308(a)(5) stipulates Covered Entities must implement “procedures for creating, changing and safeguarding passwords”.

Experts Disagree on Best HIPAA Compliance Password Policy

Although all security experts agree the need for a strong password (the longest possible, including numbers, special characters, and a mixture of upper and lower case letters), many disagree on the best HIPAA compliance password policy, the frequency at which passwords should be changed (if at all) and the best way of safeguarding them.

 

Whereas some experts claim the best HIPAA compliance password policy involves changing passwords every sixty or ninety days, other experts say the effort is a waste of time. A competent hacker should be able to crack any user-generated password within ten minutes using a combination of technical, sociological, or subversive methods (i.e. social engineering).

 

There is more agreement between experts when it comes to safeguarding passwords. In respect of a best practice for a HIPAA compliance password policy, a large majority recommend the use of password management tools. Although these tools can also be hacked, the software saves passwords in encrypted format, making them unusable by hackers.

The HIPAA Password Requirements are Addressable Requirements

One important point to mention when discussing the HIPAA password requirements is that they are “addressable” requirements. This does not mean they can be put off to another date. It means Covered Entities can “implement one or more alternative security measures to accomplish the same purpose.”

In the context of the Administrative Safeguards, the purpose of the HIPAA password requirements is to “limit unnecessary or inappropriate access to and disclosure of Protected Health Information”. Therefore, if an alternative security measure can be implemented that accomplishes the same purpose as creating, changing and safeguarding passwords, the Covered Entity is in compliance with HIPAA.

 

Two-factor authentication fulfills this requirement perfectly. Whether by SMS notification or push notification, a person using a username and password to log into a database containing PHI also has to insert a PIN code to confirm their identity. As a unique PIN code is issued with each log in attempt, a compromised password alone will not give a hacker access to the secure database.

Two Factor Authentication is Already Used by Many Medical Facilities

Interestingly, two factor authentication is already used by many medical facilities, but not to safeguard the confidentiality, integrity and security of PHI. Instead it is used by medical facilities accepting credit card payments to comply with the Payment Card Industry Data Security Standard (PCI DSS) and by others to comply with the DEA´s Electronic Prescription for Controlled Substances Rules.

 

Healthcare IT professionals will be quick to stress that two factor authentication can slow workflows, but recent advances in the software allow for LDAP integration and Single Sign-On between healthcare technologies. As two factor authentication software only transmits PIN codes (and not PHI) the software does not need to be HIPAA compliant, and it is a far easier solution for compliance with the HIPAA Password requirements than frequent changes of passwords and password management tools.

 

Effectively, Covered Entities never need change a password again.

The only thing Covered Entities have to remember before implementing two factor authentication to protect PHI is that, because the HIPAA Password requirements are addressable safeguards, the reasons for implementing the alternative solution have to be documented. This will satisfy the HIPAA requirements for conducting a risk analysis and also satisfy auditors if the Covered Entity is chosen to be investigated as part of HHS´ HIPAA Audit Program.

Why an Alternative to the HIPAA Password Requirements should be Considered

It was mentioned above that most user-generated passwords can be cracked within ten minutes. That may seem an outrageous claim to some IT professionals, but this tool on the ramdom-ize password generating website will give you an idea of how long it could take a determined hacker to crack any password by brute force alone. Social engineering and phishing will likely accelerate the speed at which the hacker succeeds.

 

Randomized passwords containing numbers, symbols and a mixture of upper and lower case letters obviously take a longer to crack – but they are still crackable. They are also much harder for users to remember; and although secure password management tools exist to store passwords securely, if a user wants to access a password-protected account from another device, password management tools are ineffective. The only way for the user to access the account is to have the password written down or saved on another device – such as an unsecured smartphone.

 

Accessing password-protected accounts from secondary devices increases the risk of a data breach due to keylogging malware. This type of malware runs undetected on computers and mobile devices, secretly recording every keystroke in a file for later retrieval by a hacker. As this is a foreseeable risk to the security of Protected Health Information, Covered Entities must either introduce policies to limit users to the devices from which they can access password-protected accounts, or find an alternative to the HIPAA password requirements.  

Technical Dr. Inc.'s insight:
Contact Details :

inquiry@technicaldr.com or 877-910-0004
www.technicaldr.com

more...
No comment yet.
Scoop.it!

How HIPAA Helps Strengthen Patient Trust

How HIPAA Helps Strengthen Patient Trust | HIPAA Compliance for Medical Practices | Scoop.it

Trust is a vital factor that affects the success of any relationship, whether it be personal or professional. Without this foundational element, interpersonal and business relationships would be filled with suspicion and uncertainty leading to conflict and ultimately the disintegration of any bond that existed.

 

In today’s digitally-driven world, this core human value is now more critical than ever. Many of the transactions we perform daily force us to deal with entities we have never met in real life. Dealing with any organization that processes and stores our personal data requires us to trust that they will honor their commitments and keep our sensitive information secure.

 

When it comes to healthcare, patient trust is a core element of any practice. Any incident that jeopardizes patient trust can destroy the relationship and threaten the future of the organization.  As people are effectively placing their health and welfare under the direct care of a practitioner, trust is effectively the only human emotion at play in this relationship.

 

We not only trust them with our lives but with keeping our medical information private and secure. Should this data be compromised in any way, it would not only place the patient in a precarious position but would also destroy the trust relationship that existed with the practitioner.

HIPAA Strengthens Patient Trust

The Health Insurance Portability and Accountability Act (HIPAA) helps strengthen patient trust in various ways. It provides mechanisms that enhance the transparency, privacy, and security of electronic healthcare information. Not only does the Act help prevent sensitive patient data from compromise, but it also gives patients access and protects their private medical information.

 

Under HIPAA, medical organizations and practitioners that process and store patient healthcare information must implement measures that ensure compliance with the obligations stipulated under the statute.

 

Some of these measures include conducting regular security risk assessments and deploying technologies that protect access to patient information such as Multi-Factor Authentication (MFA) and encryption.

 

Complying with the provisions specified under HIPAA should not only be seen as a legal or regulatory obligation but as accreditation that the organization takes patient confidentiality and security seriously. It helps build that vital trust factor as patients know that the entity has implemented the necessary safeguards needed to protect the privacy of their sensitive medical information. Achieving HIPAA compliance should therefore not be seen as a regulatory obligation but as an essential business practice that builds patient trust.

The Healthcare Industry is Not Immune to Cybersecurity Risks

As the world has become more digital and many of the vital services that run our lives have moved online, cybersecurity is a fundamental principle that every organization needs to put into practice. No enterprise is immune from a cyberattack, and this fact is particularly true for organizations that operate in the healthcare industry.

 

According to the 2018 Verizon Protected Health Information Data Breach Report, 58% of incidents involved insiders. This statistic highlighted the fact that healthcare is the leading industry in which internal actors are the biggest threat to an organization. It’s interesting to note that the majority of these incidents involved human error.

 

Although malicious actions such as misuse of information, physical intrusion, and hacking also contributed to breaches involving the healthcare industry, human error was a leading cause of data compromise. These statistics show the vital role HIPAA can play in helping organizations reduce the risk of data breaches involving protected health information.

How to Comply with HIPAA Rules

HIPAA compliance is not a one time exercise but an ongoing assessment that involves a synchronized endeavor involving people, processes, and technology. As human error is the leading cause of data breaches in the healthcare industry, it is vitally important to implement the safeguards that HIPAA has created to reduce the risk of intentional or accidental compromise of patient healthcare information.

 

Under HIPAA, there are specific obligations that are required and others that are addressable. Required safeguards are mandatory for any organization that stores, processes, or transmits electronically protected healthcare information. Addressable provisions are not mandatory, but organizations need to either implement these or provide evidence that shows that these are not relevant to their specific circumstances.

 

The HIPAA Privacy Rule deals with protected health information (PHI) in general.  The HIPAA Security Rule provides compliance regulations for electronic PHI (ePHI). Under this section of the Act, there are various administrative, physical, and technical safeguards that offer the appropriate measures healthcare organizations need to implement to ensure patient privacy and the security of their ePHI.

 

Administrative safeguards include actions such as undertaking risk analysis and performing an information system activity review. It also recommends that organizations conduct regular cybersecurity awareness training and create an incident response plan.

 

Physical safeguards include measures such as deploying facility access controls and implementing the necessary steps to securely and safely dispose of media that contain ePHI.

Finally, the technical safeguards specified under HIPAA’s security rule include legislative obligations that healthcare organizations need to implement such as ensuring unique user identification, creating an emergency access procedure, and installing technologies that provide data integrity and transmission security.

Technical Dr. Inc.'s insight:
Contact Details :

inquiry@technicaldr.com or 877-910-0004
www.technicaldr.com

more...
No comment yet.
Scoop.it!

Case Management and HIPAA information

Case Management and HIPAA information | HIPAA Compliance for Medical Practices | Scoop.it

An employee of the Iowa’s Mahaska County government alleged that another employee committed a HIPAA violation when she locked a member of the public inside a building where files containing PHI were stored unsecured, the Oskaloosa News reported.

 

Kim Newendorp, general assistant director for Mahaska County, told the Board of Supervisors this month that a fellow county employee had locked a member of the public in the Annex Building and left that person alone in the facility.

 

“This person was waiting for me, but in doing so, she left all of the case management confidential and HIPAA information unlocked and accessible to that person. This is a HIPAA violation,” Newendorp told the board.

 

Newendorp said she notified her boss, one of the board members, about the incident but received no response. She then spoke with the county’s chief privacy officer, Jim Blomgren, who passed information about the incident on to the company that handles human resources for the county. No action was taken.

 

Newendorp said that she filed an official grievance with the Board of Supervisors, who passed it onto Blomgren, who then passed it on to the HR people, again with no result.

 

“I’m disappointed this situation has not been handled,” she told the board. “Especially due to the importance of HIPAA. The state DHS official has come forward to say that this situation is an issue, and yet nothing has been done.”

 

“I understand this topic may not be as important to you as roads, 911, and the airport, but I can tell you that the people’s right to have their personal information locked and secured is important to the hundreds of past clients of Mahaska County Case Management, and their families and myself.”

 

Willie Van Weelden, chairman of the Mahaska County Board of Supervisors, said he took action at the time, but declined to say what he specifically did to address Newendorp’s concerns.

Oskaloosa News asked Blomgren to comment on Newendorp’s testimony. “Since the comments of the employee at the meeting of the Board of Supervisors involves personnel issues and alleged HIPAA infractions I do not believe I am at liberty to discuss them,” he responded.

 

“I think in most counties, the board of supervisors, you would never do an investigation into HIPAA. You would never do a human resources investigation. No county I know of would have their board do that,” Paul Greufe of PJ Greufe & Associates told Oskaloosa News.

 

Greufe said that most counties hire professional services such as his to do the HR work and would direct those people to start an investigation. “And so that was the process that was followed to the letter.”

SIMILAR INCIDENT IN BOSTON RESULTS IN OCR REPORT

The incident alleged by Newendorp is similar to one that occurred at the Boston Healthcare for the Homeless Program (BHCHP) earlier this year. In that case, someone was not let into the facililty unattended but broke in.

 

There was unsecured PHI in the facility, but no evidence that the PHI was viewed by the intruder. Still, BHCHP did notify people affected about the incident and reported it to OCR. 

 

The unsecured PHI included handwritten staff notes, printed patient lists, referral forms, and insurance/benefits applications. BHCHP told OCR that 861 individuals were affected by the breach.

BHCHP said it conducted an internal investigation that included a search of the clinic to which the intruder would have had access and interviews with clinic and shelter staff.

 

The program also ensured that the clinic door was secure and implemented additional safety measures, including an additional lock on internal doors within the clinic and secure storage of keys to internal doors, file cabinets, and storage cabinets.

 

BHCHP also updated its policies governing how staff use and store patient information.

Technical Dr. Inc.'s insight:
Contact Details :

inquiry@technicaldr.com or 877-910-0004
www.technicaldr.com

more...
No comment yet.
Scoop.it!

What Will HIPAA Enforcer Do in 2015?

What Will HIPAA Enforcer Do in 2015? | HIPAA Compliance for Medical Practices | Scoop.it

Time to rub the dust off my crystal ball to predict what we might see from the Office for Civil Rights' in 2015 when it comes to regulatory activities and enforcement of the HIPAA privacy, security and breach notification rules.

But first, note that 2014 represented a year of significant changes in leadership and approach for OCR, the unit of the Department of Health and Human Services that's responsible for HIPAA enforcement. Jocelyn Samuels joined OCR as its director in July. She was tapped to lead the agency by HHS Secretary Sylvia Mathews Burwell when Leon Rodriquez was confirmed as director of the U.S. Citizenship and Immigration Services.

 I expect the agency will launch more high-profile enforcement actions in 2015. 


Additionally, OCR's health information privacy division is being led by an acting deputy director following the retirement of Susan McAndrew.

The OCR division responsible for overseeing the work of its regional offices, including enforcement efforts, is also being led by an acting deputy director. In addition to the leadership changes in Washington, three of the 10 managers leading OCR's regional offices were newly appointed this year. That's a lot of leadership change in a short period.

Enforcement Actions

The recent OCR settlement in which an Alaska mental health organization paid a $150,000 fine and agreed to a corrective action plan over shortcomings in their security rule compliance program is the first since director Samuels took over the agency.

This resolution agreement could signal that OCR is regaining its footing after the transition to a new leadership team and will be moving ahead more aggressively to reach settlement agreements in cases where the agency finds serious violations of the privacy and security rules. According to OCR's website, there are more than 6,000 HIPAA privacy and security rule complaints and compliance reviews being investigated. I expect the agency will announce more high-profile enforcement actions in 2015.

Through the 2009 HITECH Act, Congress mandated HHS to make a number of significant changes to the privacy regulations, expanding the jurisdiction oversight to business associates, and encouraging the development of new tools for enhanced regulatory enforcement.

The tools include self-funding HIPAA enforcement authority from fines and penalties collected by OCR and an audit program to measure industry compliance. However, significant provisions of the HITECH Act have not been adopted or are in some stage of development. What are the prospects for the remaining provisions of HITECH to be enacted in 2015?

Accounting of Disclosures

The HITECH Act mandated an expansion of the HIPAA Privacy Rule's current standard for covered entities to provide individuals an accounting of unauthorized disclosures, which exempts disclosures made for purposes of treatment, payment or healthcare operations, or TPO. Congress called on HHS to revamp the standard by requiring accounting for disclosures to include TPO disclosures by covered entities and businesses using electronic health records.

In its 2011 proposed rulemaking, HHS sought to give individuals an accounting of uses in addition to expanding the disclosures to be reported. Under intense pressure to scale back the scope of the proposed rule, HHS had its panel of outside experts, the Privacy and Security Tiger Team, made recommendations in December 2013. The team has since disbanded with HHS taking no action on their recommendations. Nor does publication of a final rule appear to be in the offing anytime soon.

Monetary Settlements

Under HITECH, Congress called for HHS to develop a methodology to distribute a percentage of monetary settlements collected by OCR to individuals affected by breaches.

The first step was for the Government Accountability Office to make recommendations to HHS on a methodology to share a percentage of the proceeds from fines and penalties with consumers harmed by the unlawful uses or disclosures resolved through OCR's investigation. Although the GAO apparently has delivered its recommendations, the HHS regulatory agenda does not include a proposal under development or being reviewed.

With continuing pressures on federal spending restricting the growth of agency budgets and resources to support OCR's expansive mission, it seems unlikely that the office will aggressively pursue an initiative that would result in the sharing with consumers the proceeds from its monetary settlements from HIPAA enforcement actions.

HIPAA Audits

The HITECH Act also called on OCR to perform periodic audits of covered entities and business associates' compliance with the HIPAA rules. With funding provided through HITECH, OCR developed and implemented a pilot audit program through which 115 audits of covered entities were conducted.

Beginning in early 2015, OCR plans to audit 200 covered entities, including healthcare providers and group health plans, to measure their compliance with the HIPAA privacy, security and breach notification rules requirements. These audits of covered entities will be followed by up to 400 audits of business associates to measure their compliance with the security rule and how they intend to approach their obligations under the privacy and breach notification rules.

In comments at the the September 2014 HIPAA security conference hosted by OCR and the National Institute of Standards and Technology, OCR's Iliana Peters said it was the agency's intention to use the audit findings as a tool in the enforcement arsenal. Covered entities found to have significant gaps in their HIPAA compliance will be ripe for follow-up compliance reviews and could face penalties.

With millions of dollars of monetary penalties collected from covered entities since adoption of the HITECH Act changes, this is the one OCR initiative that seems on track. Don't wait for your notice from OCR to prepare for your HIPAA compliance audit. Take action now by going through the steps to ready your organization if it were to be randomly selected for one of those audits.


more...
No comment yet.
Scoop.it!

BOSTON: Children's Hospital settles over data breach | Technology | The Bellingham Herald

BOSTON: Children's Hospital settles over data breach | Technology | The Bellingham Herald | HIPAA Compliance for Medical Practices | Scoop.it

Boston Children's Hospital has agreed to pay $40,000 and bolster its patient data security following a data breach that compromised the personal information of more than 2,100 patients, the state attorney general's office announced Friday.

The judgment, entered in Suffolk Superior Court, alleges the hospital failed to protect the health information of the patients, about 1,700 of whom were children.

The data — including names, birthdates, diagnoses and surgery dates — was on a hospital-issued unencrypted laptop stolen from a doctor on official business in Argentina in May 2012. The information had been sent in an email from a colleague.

Under the terms of the consent judgment, the hospital will pay a $30,000 civil penalty and a payment of $10,000 to a fund administered by the attorney general's office for educational programs concerning protected health information.

"Today's settlement will put in place and enforce important technological and physical security measures at Boston Children's Hospital to help prevent a breach like this from happening again," Attorney General Martha Coakley said.

The hospital said it has already toughened security protocols.

"After this incident, we worked closely with the federal and state governments, as well as security industry experts, to ensure that Boston Children's security policies and technologies are state-of-the-art," the hospital said in a statement. "Every device that is issued by Boston Children's is encrypted before it is used, and every employee must attest on an annual basis that his or her personal devices are also encrypted."


more...
No comment yet.
Scoop.it!

Health Care Industry To See Phishing, Malware Attacks Intensify in 2015 -

Health Care Industry To See Phishing, Malware Attacks Intensify in 2015 - | HIPAA Compliance for Medical Practices | Scoop.it

That’s the analysis of industry executives who contend the information security threats facing health care institutions will only intensify in 2015. They say attackers believe hospitals and health systems hold a wealth of data, from credit card information to demographic details to insurance beneficiary data. The notion that health care trails other industries in IT security may encourage attempts to seize those data.

But while attacks are on the rise, health care budgets aren’t quite as buoyant.

Phyllis Teater, CIO and associate vice president of health services at the Ohio State University’s Wexner Medical Center, said, “The threats continue to mount … at a time when all of health care is looking to reduce the cost of delivering care.”

Earlier this month, Art Coviello — executive chair of RSA, the security division of EMC — predicted that “well-organized cyber criminals” will ramp up their efforts to steal personal information from health care providers. Coviello, in what has become his annual security outlook letter, described health care information as “very lucrative to monetize” and “largely held by organizations without the means to defend against sophisticated attacks.”

Some health care providers, however, plan to strengthen their defenses. Health care organizations’ expected security priorities for 2015 include:

  • Encryption and mobile device security;
  • Two-factor authentication;
  • Security risk analysis;
  • Advanced email gateway software;
  • Incident response management;
  • Expansion of IT security staff; and
  • Data loss prevention (DLP) tools.
Uptick in Attacks

Lynn Sessions, a partner with the law firm BakerHostetler, cited an uptick in cyber-attacks targeting health care. Sessions, who specializes in health care data security and breach response, said much of her firm’s activity once focused on unencrypted devices that were lost or stolen, unencrypted backup tapes and email delivered to the wrong recipient. Those incidents were typical of the years immediately following the passage of the HITECH Act, which in 2009 established a breach notification duty for HIPAA-covered entities. But since the beginning of 2014, the rise of hacking and malware attacks has become “very noticeable,” Sessions said.

That trend seems likely to carry over into 2015.

Scott Koller, a lawyer at BakerHostetler who focuses on data security, data breach response and compliance issues, said he believes two types of attacks will see increased prevalence next year:

  • Phishing; and
  • Ransomware.

Phishing attempts to convince users to give out information such as usernames and passwords or credit card numbers. In settings such as health care, phishing may also provide a stepping stone for more advanced attacks, Koller noted. For example, a user could open an attachment in a phishing email that installs malware on the user’s device. From that foothold, an attacker could then infiltrate the enterprise network.

“Phishing emails often provide the entry point,” Koller said.

Attackers, he added, have become adept at disguising their phishing emails.

“They are much more sophisticated in terms of crafting them and targeting them to users and making them more difficult to detect,” Koller explained.

Phishing emails can also serve as a vehicle for ransomware attacks, which encrypt the data on a computer’s hard drive. Cyber criminals demand payment from users before they will provide the means to unlock the data.

CryptoLocker and CryptoWall are examples of ransomware. In August, the Dell SecureWorks Counter Threat Unit research team reported that nearly 625,000 systems were infected with CryptoWall between mid-March and late August 2014. The researchers called CryptoWall “the largest and most destructive ransomware threat on the Internet” and one they expect will continue expanding.

To further complicate matters, ransom may be demanded in the form of bitcoin, a digital currency. The use of bitcoin makes the perpetrators a lot harder for law enforcement to track down, Koller said. He said he anticipates that ransomware will see greater prevalence and use in the future.

Tightening Security

Against the backdrop of increasing attacks, health care organizations are taking steps to boost their IT security.

Ohio State’s Wexner Medical Center, for example, plans to make staffing a focal point of next year’s IT security investment. It expects to fill three openings over the next few months.

“Much of our investment is in recruiting top talent and growing the team by adding” full-time employees, Teater said.

Technology adoption is also in the works.

“We are deploying a new mobile security tool that has better capabilities,” she said. “We are also starting down the road to deploy data loss prevention” in conjunction with the Ohio State University.

In addition, Ohio State’s medical center is looking at how to enable two-factor authentication for use cases such as remote/mobile access and e-prescribing, Teater noted.

Koller said two-factor authentication will rank among the top IT security measures health care organizations take on in 2015. Two-factor authentication typically involves a traditional credential, such as user name/password and adds a second component such as a security token or biometric identifier.

Two-factor authentication does a good job of counteracting phishing emails, Koller said. If an attacker obtains an employee’s username/password via phishing, it will still lack the additional authentication factor, he noted.

Koller also cited encryption as another security measure health care providers should look to deploy next year. He said that larger institutions already recognize encryption as an issue but that smaller practices still struggle to find ways to implement encryption for laptops and mobile devices.

“Encryption very much needs to be on everybody’s radar,” he said.

To date, it hasn’t been. Forrester Research in September reported that “only about half” of health care organizations secure endpoint data through technology such as full-disk encryption or file-level encryption.

Health care providers next year may also invest in incident response management, as well as prevention.

Mahmood Sher-Jan, vice president and general manager of the RADAR Product Unit at ID Experts, said most people accept that security incidents are a certainty, which places the emphasis on risk reduction and response. ID Experts provides software and services for managing incident response.

Chief information security officers and health care IT security personnel “recognize now that their success is going to be measured on how they manage incident response and minimize the impact on reputation and churn,” Sher-Jan said.



more...
No comment yet.
Scoop.it!

Protecting PHI: Managing HIPAA Risk with Outside Consultants 

Protecting PHI: Managing HIPAA Risk with Outside Consultants  | HIPAA Compliance for Medical Practices | Scoop.it

The rising complexity of healthcare, particularly as it relates to providers’ growing technical needs, is increasingly prompting healthcare organizations to seek the help of outside consultants. In engagements with healthcare entities, thought IT consultants try to minimize interaction with patient data, they often have access to protected health information (PHI). When working with HIPAA Covered Entities, consultants are treated as “business associates” and are required to comply with Privacy Rules designed to protect PHI.

 

Managing HIPAA compliance when engaging outside consultants requires that consultants enter into a Business Associate Agreement (BAA). The BAA must:

  • Describe the permitted and required uses of PHI by the business associate in the context of their role
  • Provide that the business associate will not use or further disclose the PHI, other than as permitted or required by the contract or by law
  • Require the business associate to use appropriate safeguards to prevent a use or disclosure of the PHI, other than as provided for by the contract

Here are several best practices to follow to ensure the protection of PHI in consulting arrangements.

 

FTE Mentality

During the contract period, the expectation is that consultants act as if they were an employee of the hospital or provider organization and therefore treat PHI in this manner. It is important to know that consultant business associates could be held liable or equally responsible for a PHI data breach in the same way a full-time employee could be.

 

Role-Based Access Rules

Limit access to PHI based on role to ensure that only the parties that need PHI have access to it. An IT strategist, for example, does not need to see live patient data. Associates leading implementation projects, on the other hand, may need access to live PHI. Typically, this occurs late in the implementation process, when the time comes to test a system with live, identifiable patient data.

 

Safeguard Access Points

If a hospital wants a consultant to have regular access to PHI, it would be preferable that the hospital provides the consultant with a computer or device with appropriate access authorizations and restrictions in place. Avoid the use of personal devices whenever possible. Make sure that only approved and authorized devices can be used inside the firewall and require multi-factor authentication during log-in. Avoid inappropriate access to PHI by way of shared or public data access points. Don’t allow private access to PHI where others could intervene.

 

Keep it Local

Don’t take PHI away from the source of use. Consultants should avoid storing PHI on personal devices, including smart phones, which are particularly susceptible to theft and loss. Devices used to store or access PHI must be registered. Best practices often include controls giving IT staff advance permission to remotely wipe or lock a stolen registered device. Avoid leaving registered devices in cars or unprotected areas.

 

Paper-based reports also pose threat of PHI leak. Documents you take home over the weekend, for example, could be accessed by family members, lost, or stolen. Electronic, paper, verbal and image-based PHI should all be confidently secured. Of course the regulations also relate to visual and verbal protections. When accessing PHI avoid allowing others to view your screen over your shoulder. When discussing PHI make sure only those who need to know and have appropriate authority can hear the conversation.

 

The healthcare industry is making great strides in establishing digital infrastructure, much of which is cloud-based, putting new onus on providers and their business partners to ensure the security of that information. No one wants to make headlines for the latest data breach, least of all the IT consultants hired by providers to help guide their data management efforts. Rigorous attention to HIPAA Privacy Rule guidelines is not only required – it’s imperative to maintaining trust in the healthcare ecosystem.

Technical Dr. Inc.'s insight:
Contact Details :

inquiry@technicaldr.com or 877-910-0004
www.technicaldr.com

more...
No comment yet.
Scoop.it!

HIPAA Privacy Rule Can Be Tool for Health Information Exchange

HIPAA Privacy Rule Can Be Tool for Health Information Exchange | HIPAA Compliance for Medical Practices | Scoop.it

Rather than being a barrier to information sharing and interoperability, the HIPAA Privacy Rule can be seen as a tool to facilitate health information exchange and flow across the health ecosystem, argued OCR and ONC in an Aug. 30 blog post. 

 

The HIPAA Privacy Rule provides individuals with a right to access information in their medical and other health records maintained by a HIPAA covered entity, such as an individual’s healthcare provider or health plan, noted ONC Chief Privacy Officer Kathryn Marchesini and OCR Acting Deputy Director for Health Information Privacy Timothy Noonan.

 

The authors wrote that the 21st Century Cures Act, enacted in 2016, among other things called for greater individual access to information and interoperability of healthcare records. The act directed HHS to address information blocking and promote the trusted exchange of health information.

 

 

“Information blocking occurs when a person or entity – typically a health care provider, IT developer, or EHR vendor – knowingly and unreasonably interferes with the exchange and use of electronic health information,” ONC explained.

 

ONC and OCR recently began a campaign encouraging individuals to access and use copies of their healthcare records.

The two HHS offices are offering training for healthcare providers about the HIPAA right of access and have developed guidance to help consumers take more control of decisions regarding their health.

 

These guidelines include access guidance for professionals, HIPAA right of access training for healthcare providers, and the Get It. Check It. Use It. website for individuals.

The authors also noted that the HIPAA Privacy Rule supports the sharing of health information among healthcare providers, health plans, and those operating on their behalf, for treatment, payment, and healthcare operations. It also provides ways for transmitting health information to relatives involved in an individual’s care as well as for research, public health, and other important activities.

 

“To further promote the portability of health information, we encourage the development, refinement, and use of health information technology (health IT) to provide healthcare providers, health plans, and individuals and their personal representatives the ability to more rapidly access, exchange, and use health information electronically,” they commeted.

 

The Centers for Medicare & Medicaid Services (CMS) and the National Institutes for Health (NIH), along with the White House Office of American Innovation, are working to support the exchange of health information and encourage the sharing of health information electronically.

 

For example, CMS is calling on healthcare providers and health plans to share health information directly with patients, upon their request.

 

Also, NIH has established a research program to help improve healthcare for all individuals that will require the portability of health information.

 

The White House’s MyHealthEData initiative, which originated from President Donald Trump’s 2017 executive order to promote healthcare choice and competition, aims to break down the barriers preventing patients from having access to their health records.

 

The executive order directed government agencies to “improve access to and the quality of information that Americans need to make informed healthcare decisions.” The order is part of a broader effort to increase market competition in the healthcare market.

 

ONC developed a guide intended to educate individuals and caregivers about the value of online medical records as well as how to access and use their information. ONC also produced videos and fact sheets to inform individuals about their right to access their health information under HIPAA.

 

“It’s important that patients and their caregivers have access to their own health information so they can make decisions about their care and treatments,” said National Coordinator for Health Information Technology Don Rucker. “This guide will help answer some of the questions that patients may have when asking for their health information.”

 

The agency said that an individual’s ability to access and use health information electronically is a cornerstone of its efforts to increase patient engagement, improve health outcomes, and advance person-centered health.

 

ONC noted that the guide supports both the 21st Century Cures Act goal of improving patient access to their electronic health information and the MyHealthEData initiative.

Technical Dr. Inc.'s insight:
Contact Details :

inquiry@technicaldr.com or 877-910-0004
www.technicaldr.com

more...
No comment yet.
Scoop.it!

Fearing The Dreaded HIPAA Audit?

Fearing The Dreaded HIPAA Audit? | HIPAA Compliance for Medical Practices | Scoop.it

The HHS Office for Civil Rights plans to begin a random audit program this year to assess compliance with the HIPAA privacy, security and breach notification rules. David Holtzman, a former senior advisor at OCR and now vp of compliance services at security firm CynergisTek, offers the following outline of what providers selected for an audit can expect and how to prepare.

 

Red Flags

In a 2012 pilot audit program, security rule problems were seen twice as often as anticipated, so expect security issues addressed under a permanent audit program to be bumped up. OCR found through the pilot audits that many organizations had not conducted a security risk analysis or never updated an initial analysis-which signals that an organization is not taking HIPAA seriously. Other areas with significant deficiencies included access management, security incident procedures, contingency planning, audit controls, and movement and destruction of protected health information.

 

Getting Notified

OCR plans to send notification letters to 1,200 healthcare organizations to confirm their address, HIPAA officers, sizes and functions. This is not an audit notice, but the information will be used to build a list of those that will be audited. Organizations selected for audit by OCR will not receive email notification-they will receive a formal audit notification letter-so beware of scammers.

 

Desk Audits

About 200 covered entities and 300-400 business associates will receive notification of a "desk audit," which will include a request for submission of specific content and other documentation that demonstrates the scope and timeliness of an organization's efforts to comply with HIPAA rules. Focus areas for covered entities likely will include risk analysis and risk management, content and timeliness of breach notifications and notice of privacy practices updated to reflect changes in the HIPAA Omnibus rule implemented in 2013. The likely focus for breach audits will be risk analysis and risk management, and appropriate breach reporting to covered entities.

 

Follow Instructions

Under a desk audit, only documentation delivered on time will be reviewed. Send only the information required. Auditors likely will be looking for updated privacy practice notices, the ability of patients to get a copy of their health record and to access them electronically if desired, and how organizations treat requests to restrict access to sensitive treatment paid out-of-pocket. Desk audits, Holtzman says, are not an opportunity for a conversation or give-and-take. Auditors will not contact an organization again for clarifications or additional information; they will work only with what they get. Failure to respond to a desk audit notification likely will lead to a more formal compliance review. (Audit findings will not become a matter of public record.)

 

On-Site Audits

OCR this year and likely into 2016 will conduct on-site audits of an unspecified number of covered entities and business associates. This is more comprehensive than a desk audit, with a greater focus on privacy. Expect OCR in these on-site audits to look at security rule compliance in such areas as device and media controls, secure transmissions, encryption of data (including documented justification if you're not using encryption), facility access controls, administrative and physical safeguards, and workforce training. And expect an emphasis on training, as many organizations haven't trained since first required in 2003. "That really rubs [auditors] the wrong way," Holtzman says.

 

Plan Now

If your risk-analysis and risk-management plans are more than 2 years old, update now, Holtzman suggests. Select 10 focus areas covering both the privacy and security rules, and if vulnerabilities have not been addressed, address them. "The best process to prepare for an audit is to be prepared the day the letter arrives," Holtzman says. "Be honest with yourself. Don't paint a happy picture because you think you know what management wants to hear."


more...
No comment yet.
Scoop.it!

HIPAA breach leads to firstever neglect settlement for a healthcare provider

HIPAA breach leads to firstever neglect settlement for a healthcare provider | HIPAA Compliance for Medical Practices | Scoop.it

A recent, first-of-its-kind HIPAA settlement demonstrates that long-term care and other providers need to be vigilant about updating software and other basic security tasks, officials say.

Anchorage Community Mental Health Services in Alaska has agreed to a $150,000 settlement related to a data breach that the five-facility organization self-reported to the Department of Health and Human Services Office for Civil Rights, according to a recent bulletin from that agency. It is the first settlement related to “neglect” of systems, because the breach was traced to the provider's failure to “address basic risks,” such as running outdated software and failing to install patches.

“Successful HIPAA compliance requires a common sense approach to assessing and addressing the risks to ePHI [electronic personal health information] on a regular basis,” stated OCR Director Jocelyn Samuels. “This includes reviewing systems for unpatched vulnerabilities and unsupported software that can leave patient information susceptible to malware and other risks.”

The breach was caused by malware and affected the information of more than 2,700 people, according to the OCR. The healthcare provider was cooperative with the investigation and has agreed to a corrective action plan, according to authorities.



more...
No comment yet.
Scoop.it!

Latest HIPAA settlement emphasizes need to regularly address software vulnerabilities | Lexology

Latest HIPAA settlement emphasizes need to regularly address software vulnerabilities | Lexology | HIPAA Compliance for Medical Practices | Scoop.it

On December 2, the Department of Health and Human Services, Office for Civil Rights (OCR) announced a $150,000 settlement with Anchorage Community Mental Health Services, Inc. (ACMHS) for alleged violations of the HIPAA Security Rule. The announcement followed an OCR investigation into a breach of unsecured electronic protected health information (ePHI) affecting 2,743 individuals. OCR highlighted three Security Rule violations in its resolution agreement: (1) failure to conduct an accurate and thorough risk analysis; (2) failure to implement security policies and procedures; and (3) failure to have reasonable firewalls in place, as well as supported and patched IT resources. In a press release regarding the settlement, OCR Director Jocelyn Samuels noted that “successful HIPAA compliance . . . . includes reviewing systems for unpatched vulnerabilities and unsupported software that can leave patient information susceptible to malware and other risks.”

OCR began its investigation after ACMHS reported a malware-related breach of unsecured ePHI on March 12, 2012. OCR stated that the breach was the direct result of ACMHS’ failure to “identify and address basic risks” to the security and confidentiality of ePHI in its custody. ACMHS adopted sample Security Rule policies and procedures in 2005, but apparently did not implement them until OCR’s investigation began in 2012. OCR’s review of the ACMHS IT infrastructure revealed critical shortcomings including unpatched systems running outdated or unsupported software, and inadequate firewalls with insufficient threat identification monitoring of inbound and outbound traffic.

The ACMHS settlement emphasizes three key takeaways for HIPAA covered entities and business associates:

  • Tailor Security Rule compliance programs. Although the HIPAA Security Rule provides flexibility to entities in choosing the most appropriate compliance strategies, each organization must (1) conduct an accurate and thorough assessment of the particular risks facing ePHI held by the entity and (2) tailor its policies and procedures to adequately address those risks. This settlement demonstrates that a “one size fits all” approach based on template policies and procedures will not suffice for Security Rule compliance.
  • Conduct regular and thorough risk assessments. As OCR and NIST emphasized in a September conference on safeguarding health information, comprehensive risk analysis and risk management are two cornerstones of an effective IT security program. In its press release regarding the ACMHS settlement, OCR highlighted its Security Rule Risk Assessment Toolreleased in March 2014, which was developed to assist small- to medium-size providers with conducting risk assessments.
  • Regularly patch and update software. The OCR investigation determined that the breach suffered by ACMHS may have been preventable had its employees regularly patched known vulnerabilities and kept software up to date. OCR also identified the need for entities to maintain threat identification monitoring, which is significant given the dynamic and evolving cybersecurity threat landscape.

In addition to the monetary payment, the settlement agreement imposes a two-year corrective action plan. The ACMHS settlement follows a series of enforcement actions in which OCR has entered into resolution agreements and corrective action plans with HIPAA covered entities for alleged violations of the Privacy, Security, and Breach Notification Rules. In the past two years, OCR has entered into twelve HIPAA resolution agreements, with settlements totaling over $11.7 million. As OCR prepares to roll out the next phase of its audit program, which will be used as an enforcement tool and may lead to full-scale compliance reviews, HIPAA-regulated entities should examine their security practices to ensure they are appropriately managing risks to ePHI—which includes reviewing systems and applications for unpatched vulnerabilities or unsupported software.



more...
No comment yet.