HIPAA Compliance for Medical Practices
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The most dangerous data breach ever known

The most dangerous data breach ever known | HIPAA Compliance for Medical Practices | Scoop.it

From time to time I have the depressing task to write about yet another data loss event that caused the personal details of millions of people to fall into the hands of criminals. Usually this is credit card data, along with names and email addresses. Sometimes physical addresses are included, and occasionally even more sensitive data like Social Security numbers goes along for the ride. Usually this data was collected by a large retailer that had no qualms about storing the sensitive information, but clearly neglected to properly secure it.


Stolen data is primarily used for credit card fraud, though if there's enough information available, identity theft is a definite possibility. Millions of affected people have been forced to get new credit cards, check their statements for fraudulent charges, and rework any automated payment arrangements and whatnot. It's a big pain in the ass, and frankly, it has happened far too often, especially when once should be considered more than enough.




Heartland, Target, TJX, Anthem ... we've seen some massive data breaches over the years. But none can hold a candle to the breach the U.S. government announced last week. Not even close. On a scale of one to 10, with one being the loss of credit card numbers and names, this data loss event would conservatively be a 15.


Most people aren't aware of exactly what type of information the federal government collects on its employees, especially those with security clearances. We all have some idea that government employees have relatively strict reporting requirements for financial information, and we know that federal workers with higher clearances undergo thorough background checks and must submit to interviews of both themselves and their family and friends. This is done to flag potential problems and to prevent outside agents from having undue influence over people who may have access to sensitive information and materials.


Put simply, if you have a security clearance, the government would like to know if you have a drug problem or if you are in serious debt, because a foreign interest may try to use that situation as leverage to coerce you into revealing sensitive information. In the interest of national security, these safeguards make sense.


But the true nature and scope of the information required by the government and subsequently collected by the government on an employee is massive. Take a look at Standard Form 86. This is a 127-page form that usually takes a week or more to complete and requires the entry of the applicant's Social Security number on each page. The data included on this form is not just enough for identity theft, but enough to allow a person to literally become another person. Each Standard Form 86 fully documents the life of the subject. The only thing missing is the name of your first crush, though that might be in there somewhere too.


Some 18 million people had this level of personal data -- and more, including data collected by observers -- lost to foreign agents last week. If the government collected this data to know if an employee was vulnerable to undue outside influence, then it just succeeded in closing that loop itself, having now released it into the wild. All of those vulnerabilities are now known and available for exploit to whomever stole the data, or to whomever they wish to sell that data. This is very, very bad.


I should also mention that many of those whose personal information was swept up in this data loss event were never even government employees in the first place. They may have filled out the forms and submitted applications, but they were never hired or they declined the job. This includes prospective TSA agents right on up through CIA employees -- the higher the position, the higher the clearance, the more sensitive the data that was collected and lost. Information on these peoples' infidelities, sexual fetishes, mental illnesses, criminal activities, debts, and other highly personal information is now in the hands of cyber-attackers. This is damage that cannot be undone or mitigated. We can change credit card numbers and refund fraudulent charges, but we can't change any of the personal data and intimate details of these people's lives. That's a permanent loss.

One could argue that however disastrous this data loss event is, the government had a requirement to store this data. It needed to collect and maintain this data, even if it failed to secure it. That said, this is the same government that is collecting a massive amount of data on all of us, whether we're prospective federal employees or not, via Internet and phone surveillance. If the federal government is lax enough to lose immeasurably sensitive information on its employees, how secure is the data that it has decided it needs to collect on everyone in the world?


Many people believe that the U.S. government shouldn't be collecting and storing this data in the first place, and that there's no need to maintain that data collection. This event underscores the fact that maintaining this data is not just privacy invasion on a massive scale, but it's actually dangerous. What happens when the next data loss event contains highly sensitive data on hundreds of millions of people? We can't put that cat back in the box no matter how we might try. You might think that the best way to guard against that possibility is to stop collecting that data in the first place.

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HIPAA Compliance for Medical Practices
HIPAA Compliance and HIPAA Risk management Articles, Tips and Updates for Medical Practices and Physicians
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The Benefits of Performing a HIPAA Risk Assessment

The Benefits of Performing a HIPAA Risk Assessment | HIPAA Compliance for Medical Practices | Scoop.it

The Health Insurance Portability and Accountability Act (HIPAA) Security Rule mandates that covered entities must conduct a risk assessment of their healthcare company.

 

 A wide range of organizations – from healthcare insurance providers to hospitals – fall into this covered entity group. While it may seem taxing and time-consuming to provide standardized training to your employees, there are many reasons doing so can behoove you. For one, it’s the law. Since 2009, Security Risk Assessments (SRAs) have been a required annual practice set forth by the HIPAA Security Rule.

 

Don’t wait to become a breach headline; nip breaches in bud by detecting security issues before they wreak havoc. You can’t be secure if you are not compliant; and a HIPAA Risk Assessment will safeguard your organization in more ways than one. Technology is a timesaver that has simplified the medical filing and billing processes, but it leaves the potential for leaks and hacking.

 

A risk analysis will identify and document potential threats and liabilities that can cause a breach of sensitive data. An IT security consulting company can check all portable media (laptops), desktops, and networks to ensure they’re ironclad. IT security measures, such as encryption and two-factor authentication2, will be addressed in order to make it challenging for unwanted eyes to get a glimpse of patient information.  

 

Employees are the greatest threat to HIPAA compliance, so it’s important to make sure they’re well informed on how to prevent breaches. Annual HIPAA Security Awareness Training Programs provide a thorough understanding of each person’s role in preventing breaches and protecting physical and electronic information.

 

HIPAA training is a regulatory requirement, many employee actions that go awry could easily be prevented. A consultant will offer tips and tricks for minimizing that risk; a few include never leaving work phones and laptops unattended, never sharing passwords or company credentials, choosing to shred files as opposed to trashing them, and overcoming the temptation to “snoop” on patient information without just cause.

 

While many of these suggestions seem like common sense, there are also many lesser known incidences that arise while working in the medical field. Did you know that you cannot access your own medical records using your login credentials? While it may seem innocent enough, everyone is required to submit a request to access medical materials. 

 

Don’t deter a Risk Assessment out of indolence. HIPAA Risk Assessments must be accurate and extremely thorough.  Questions about all the administrative, technical, and physical safeguards an organization has in place must be asked about.

 

If outsourcing your HIPAA Risk Assessment, choose a company that provides comprehensive training courses. No two companies are alike so cookie-cutter answers don’t exist for compliancy; a client-facing doctor’s office and corporate health insurance agency will require that different preventive measures be put into place.

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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.

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Understanding the HIPAA Security Rule: HIPAA Physical Safeguards

Understanding the HIPAA Security Rule: HIPAA Physical Safeguards | HIPAA Compliance for Medical Practices | Scoop.it

While HIPAA covers a broad scope of healthcare related items, its Security Rule specifically sets forth standards concerning the safety of electronic Protected Health Information or ePHI. Furthermore, the Security Rule can be broken down into three keys areas of implementation: Physical Safeguards, Technical Safeguards, and Administrative Safeguards. In Part I of this blog series we will discuss the basics regarding HIPAA Physical Safeguards, or Section 164.310 of the Security Rule, and how they relate to ePHI (electronic Protected Health Information).

 

The Department of Health and Human Services defines HIPAA Physical Safeguards as “physical measures, policies, and procedures to protect a covered entity’s electronic information systems and related buildings from natural and environmental hazards, and unauthorized intrusion”. In short, a covered entity must have physical protocols in place to protect is ePHI from disaster and/or theft.

HIPAA Physical Safeguards can be broken down into the following standards:

  • Facility Access ControlThis standard requires covered entities to implement policies and procedures to limit physical access to information systems and the facilities in which they are stored. Proper authorization to access these systems should also be ensured. The Facility Access Control Standard also requires the following implementations:
    • Contingency Operations
    • Facility Security Plan
    • Access Control and Validation Procedures
    • Maintenance Records

 

  • Workstation Use: A workstation is defined as an electronic computing device and any electronic media stored in its immediate environment. According to this standard, covered entities must implement policies and procedures surrounding the functions and physical attributes of any workstation that can access ePHI. The importance of these policies and procedures is to limit exposure to viruses, compromisation of information systems, and breaches of confidential information.

 

  • Workstation Security: This standard differs from Workstation Use in that it refers specifically to how workstations are to be physically protected from unauthorized users. Under this standard, converted entities must implement physical safeguards for all workstations that access ePHI to restrict unauthorized users. Essentially, a covered entity must take precautions - such as locked doors/equipment – to prevent non-employees from physically accessing a workstation.

 

  • Device and Media Controls: Device and Media controls refer to electronic media- meaning electronic storage media devices in computers (hard drives) and any removable/transportable digital memory medium such as tapes, disks, or digital memory cards. The purpose of this standard is to have policies and procedures in place to govern the receipt and removal of hardware and electronic media that contains ePHI, into and out of a facility, and the movement of these items within the facility. Covered entities must be able to account for all ePHI as it is moved between electronic devices. They must be able to account for this ePHI, even if it is disposed of. This standard is broken down into the following implementations:
    • Disposal
    • Media Re-Use
    • Accountability
    • Data Backup and Storage

In order to comply with these standards related to HIPAA Physical Safeguards, here are some examples of basic practices that any covered entity can apply to its medical practice:

  • Keep access to any device that stores or processes ePHI restricted to authorized personnel only. Avoid having these devices in areas that can easily be accessed by patients or visitors.
  • Ensure that ePHI is disposed of properly. Hard drives and any other devices that store patient information must be destroyed in the proper manner, and a certificate of disposal should be obtained and kept as a record.
  • Keep an inventory of all devices in the office that store or process ePHI. Additionally, note down which staff have accesses to these devices and what roles they play in processing ePHI.

 

These are examples of general steps that will help covered entities comply with HIPAA.   It is important that the annual mandatory HIPAA risk assessments be comprehensive and should review all physical safeguards at your location, pinpoint specific vulnerabilities and determine the corresponding action items and additional physical safeguards that may need to be implemented.

In summary, the Physical Safeguards standard of the HIPAA Security Rule sets forth a comprehensive framework regarding the physical protection of ePHI. As covered entities continue to modernize and move away from traditional paper-based records keeping, they will need to keep these standards in mind for the privacy of their patients.

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Understanding the HIPAA Security Rule: Administrative Safeguards

Understanding the HIPAA Security Rule: Administrative Safeguards | HIPAA Compliance for Medical Practices | Scoop.it

The Administrative Safeguards are the most comprehensive standards, as they cover over half of the HIPAA Security Rule. These standards encompass many of the oversight aspects of managing a covered entity. The other two posts in this blog series covered Technical Safeguards and Physical Safeguards.

 

The Department of Health and Human Services defines these safeguards as “administrative” actions, and policies and procedures, to manage the selection, development, implementation, and maintenance of security measures to protect ePHI and to manage the conduct of the covered entity’s workforce in relation to the protection of that information”.

 

Administrative Safeguards are broken down into the following standards:

  • Security Management Process: A covered entity must implement policies and procedures to prevent, detect, contain, and correct security violations. There are four required implementations for this standard:
    • Risk Analysis
    • Risk Management
    • Sanction Policy
    • Information System Activity Review
  • Assigned Security Responsibility: This standard requires the designation of a security official who is responsible for the development and implementation of policies and procedures.
  • Workforce Security: Under this standard, a covered entity must implement policies and procedures to ensure that all staff members have appropriate access to ePHI, and also to prevent those workforce members who do not have permission, from accessing it. There are three addressable implementations under this standard:
    • Authorization and/or Supervision
    • Workforce Clearance Procedure
    • Termination Procedures
  • Information Access Management: This standard relates to the implementation of policies and procedures regarding the authorization of access to ePHI. There are three addressable implementations under this standard:
    • Isolating Healthcare Clearinghouse Functions
    • Access Authorization
    • Access Establishment and Authorization
  • Security Awareness and Training: Under this standard, a covered entity must have a security awareness and training program for all members of its workforce, including physicians and management. There are four implementations for this standard:
    • Security Reminders
    • Protection of Malicious Software
    • Log-in Monitoring
    • Password Management
  • Security Incident Procedures: Covered entities must have policies and procedures in place to address security incidents. There is one implementation:
    • Response and Reporting
  • Contingency Plan: The purpose of this standard is for covered entities to establish policies and procedures for responding to emergencies or other occurrences (fire, vandalism, natural disasters, etc.) that may damage systems containing ePHI. There are five implementations for this standard:
    • Data Backup Plan
    • Disaster Recovery Plan
    • Emergency Mode Operation Plan
    • Testing and Revision Procedures
    • Applications and Data Criticality Analysis
  • Evaluation: This standard requires covered entities to perform periodic technical and nontechnical evaluations in response to environmental and operational changes affecting the security of ePHI.
  • Business Associate Contracts and Other Arrangements: The final standard relates to the relationship between a covered entity and the vendors it uses. It states that the covered entity may permit a business associate to create, receive, maintain, or transmit ePHI on the covered entity’s behalf, only if the covered entity obtains the correct assurances. There is one implementation under this standard:
    • Written Contract or Other Arrangement

HIPAA Administrative standards provide a broad and wide-encompassing scope of administrative functions that a covered entity must implement regarding the security of ePHI. Here are some basic practices that a covered entity can put into place:

 

  • Perform a regular risk analysis of systems used by the office to determine any new vulnerabilities or weaknesses.
  • Appoint a HIPAA Security Officer who oversees the implementation of these standards and maintains all policies and procedures related to security measures.
  • Ensure that all staff members adhere to a policy of creating strong passwords to access workstations/software programs that access ePHI. These passwords should not be common words or phrases and should not be shared among employees.
  • Create regular backups of any servers or systems that process ePHI. This can be done via a cloud-based system or an encrypted backup tape/hard drive.
  • Immediately remove access to any programs that process ePHI (EMR, billing/scheduling software, etc.) for any employee that becomes no longer associated with the covered entity (termination or job change). This will help prevent improper access to patient data.
  • Obtain and maintain Business Associate Agreements (BAAs) with any third-party vendors that store or process PHI. These agreements must ensure that the vendor will appropriately safeguard patient information.

 

As with Physical and Technical Standards, Administrative Standards need to be reviewed for each covered entity through an annual HIPAA Security Risk Assessment. These assessments are not only mandatory, but they are essential to determine any risks that can lead to a breach of data.

 

In closing, the HIPAA Security Rule covers a wide range of standards and implementations that covered entities must employ to ensure HIPAA compliance. Failure to adhere to these policies can lead to OCR (Office of Civil Rights) sanctions in the forms of audits and even severe civil penalties.

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Is it time for your Annual HIPAA Risk Assessment?

Is it time for your Annual HIPAA Risk Assessment? | HIPAA Compliance for Medical Practices | Scoop.it

Top 5 actions you can take to prepare for your next HIPAA Compliance review or risk assessment:

  • Identify where all your Patient Health Information (PHI) is stored, received, maintained or transmitted.
  • Assess current security measures used to safeguard PHI.
  • Make a list of all vendors that may have access to your PHI.
  • Have all your written HIPAA Policies and Procedures in place.
  • Be ready to document the assessment and take action where necessary.

Identify where your PHI is stored:

On your Computer?

  • Electronic Health Records (EHR)
  • Shared network drives
  • Word documents
  • Faxes
  • Recycle bin
  • Emails

In your office?

  • Paper Charts or files
  • File rooms and closets
  • CDs and USB drives
  • Old computers/servers that are no longer in use
  • Shredders or shred bins
  • Tablets and other mobile devices
  • Diagnostic equipment such as ultrasound machines and scanners.

Within your network storage?

  • A database
  • Other folders on the hard drive
  • Unencrypted images on other folders
  • Remote servers
  • Documents on network shares

On the cloud?

  • Electronic Health Record systems
  • Online cloud backup service
  • e-Fax services
  • Online file storage and transmission services such as Box, Dropbox, Google Drive.
  • Email services

How to Safeguard your PHI?

  1. Administrative Safeguards are used to develop a formal security management process including having written HIPAA Policies and Procedures readily available for medical office staff. Require that all staff, including physicians undergo security training to stay current on the laws and guidelines. Develop policies and procedures for the transfer, removal, and reuse of PHI.  
  2. Physical Safeguards are used to secure location and workspaces for staff members limiting access to unauthorized people and potential intruders. Provide Physical Cameras and Alarm systems as needed. Lock all IT equipment and limit access to authorized personnel only.
  3. Technical Safeguards are used to secure and control access to ePHI.  This is done in many ways such as establishing passwords, PIN numbers, implementing automatic logoff control. Ensure that antivirus is updated on all PCs. The PCs/Laptops on which PHI data and Images are stored should be fully encrypted. Do not share passwords.

What are compensating controls?

Compensating controls or alternative controls are put in place to satisfy the requirement for a security measure that is impractical to implement at the present time.

Examples of compensating controls:

When a medical office has paper charts that are filed on open shelves in a storage room or behind the reception desk, it is recommended to lock the charts at the end of the day.  Many times it is not practical to put locks on all open shelves that are used to file charts.  A compensating security measure can be used to install cameras surrounding the premises to monitor and record all activities. It is important that you also have a process in place to monitor the video recordings periodically.

Or

If an Ultrasound Technician uses CDs, Tapes, and Disks to store images or uses a USB hard drive to transfer the images to PCs and the EHR, then these devices have to be encrypted.  Many times, the Technician is not sure if the Thumb drives are encrypted. A compensating control here would be to lock the CDs and flash drives in a cabinet when not in use.

The Health Insurance Portability and Accountability Act (HIPAA) is primarily concerned with the Privacy and Security of Patients' Protected Health Information.  All entities that come into contact with Protected Health Information on a regular basis are covered under the Act.  Has it been more than one year since your last HIPAA Risk Assessment?  Or have you never had a HIPAA Risk Assessment done before? Either way, be sure to schedule your 2018 HIPAA Risk Assessment and 2018 HIPAA Training right away - don't wait until its too late.

Technical Dr. Inc.'s insight:
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inquiry@technicaldr.com or 877-910-0004
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HIPAA regulatory actions on failure to comply with breach rules

HIPAA regulatory actions on failure to comply with breach rules | HIPAA Compliance for Medical Practices | Scoop.it

Caps on HIPAA penalties restrict OCR's ability to enforce proportionately

OCR Director Roger Severino said at the 2018 HIPAA NIST/ OCR conference, that it may be necessary for them to revisit the caps in HIPAA enforcement actions.  When asked about the inconsistency among different federal agencies on the amounts of penalties levied for data breaches, Director Severino said that having consistency or standard among agencies may not be easy to accomplish.  On the HIPAA side, there are caps on the penalties that can be levied.  He admitted that it may be necessary to take another look at these caps to ensure fairness and proportionality for judgments.  If a company is so large that a multi-million dollar fine may not be a big impact for them, then the caps may actually be hindering OCR’s ability to impose an appropriate enforcement action on such a company.

HIPAA enforcement highlights

The OCR Director highlighted their recent HIPAA enforcement highlights and provided some details behind those cases.  Some of the cases he discussed were how one covered entity left unprotected medical records on an open truck, one entity mentioned a patient’s name on a press release, insufficient monitoring of logs to detect incidents and how film crews were allowed into a medical center without prior authorization.

$45, 360, 383 is the total amount collected by OCR in HIPAA enforcement actions from January 1, 2017, to October 15, 2018.  They have exceeded $100 million in collection amounts from 2008 onwards.

Regulatory actions against entities that fail to report breaches

When asked about the future of the desk audit program, Director Severino indicated that while they are pleased with the number of entities coming forward to report their breaches, OCR may now focus some energy on entities who have not reported their breaches in accordance with the breach notification rule. They may look into taking regulatory action against entities who do not report breaches as required.  

A note to all healthcare entities – If you suffer from a reportable breach, make sure you adhere to breach notification rules and procedures in a timely manner as dictated by law.

 

Healthcare Information is a precious resource 

Director Severino closed his address by saying that healthcare information is like a bar of gold.  There are bad people who want access to it. 

  • Store it in a safe place.
  • Put a perimeter of defenses.
  • Train your personnel.
  • Monitor your logs.
  • Do your risk analysis. 
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Six Common HIPAA Violations and how you can prevent them

Six Common HIPAA Violations and how you can prevent them | HIPAA Compliance for Medical Practices | Scoop.it

HIPAA compliance is an ongoing process.  Do you have security and privacy policies and procedures for your organization?  Do you review your policies and procedures periodically? Is your HIPAA training planned for new employees and to update everyone as necessary?  Do you know where the gaps are in your data security and do you have a plan to address these gaps?  Do your vendors and their staff follow a culture of privacy?

 

Our Managing director, Rema Deo has created a list of the top 6 HIPAA Violations 24By7Security staff have found, based on over 500 security risk assessments conducted by our security analysts for healthcare organizations ranging from one doctor practices to multi-location hospitals.  This list of HIPAA violations comes complete with appropriate risk mitigation recommendations that can help you in your organization. 

  

1. Lack of Business Associate Agreements (BAAs) with your vendors

Often healthcare organizations, especially the smaller to medium sized medical practices, fail to enter into Business Associate Agreements with their vendors or business associates. These vendors could range from a small IT vendor to large Electronic Health Record System (EHR).  Sometimes, smaller practices use free insecure email and even use insecure email to share or communicate PHI. This puts them at unnecessary risk.  Healthcare providers should also note that business associate agreements should be dated after the Omnibus Final Rule came into effect, i.e. after January 2013.   

How can you mitigate this risk when it comes to Business Associate Agreements?

  1. Prevent this risk by getting HIPAA-compliant Business Associate Agreements signed with all your vendors or business associates who have access to PHI.
  2. Be sure to always use secure means of transmission of PHI, and enter into a Business Associate Agreement with the vendors who are providing this secure transmission.  For example, secure email providers, external cloud storage solutions, EHR systems, and such providers usually have HIPAA-compliant service options where they provide business associate agreements.

 

2. Loss or theft of portable devices

Many covered entities take insufficient steps to safeguard PHI especially on thumb drives and other portable devices. The Office of Civil Rights (OCR) is clear that loss of PHI is not considered a breach if it is properly encrypted.

Mitigate your risk in case devices are lost or stolen

  1. Covered entities must ensure that their portable devices, thumb drives, laptops, computers and servers are all encrypted.
  2. Drives, storage devices and other portable devices storing PHI must be kept locked when not in use.
  3. Develop, implement and maintain an appropriate data backup policy.  Ensure that backups are encrypted as well.

 

3. Failure to complete an enterprise-wide Risk Analysis

OCR has also often found that failure to complete an enterprise-wide risk analysis is a HIPAA violation, and they have levied significant penalties and fines on entities who could not show evidence of having completed an enterprise-wide risk analysis.  The case of the large fine imposed on Anthem recently is an example of this.  We mentioned this breach and the monumental price tag that came with it in our October Newsletter.

Mitigate your risk of fines in the event of an audit

  1. All areas of the enterprise should be covered with periodic, thorough enterprise-wide security risk analysis.
  2. The risk assessment or analysis should be repeated periodically and after any major changes. We recommend doing this annually as a best practice.
  3. Review your findings from the Risk Analysis and prepare an action plan with remediation plans and target dates.

 

4. Insufficient physical safeguards or keeping PHI unlocked or easily accessible

Paper files are often kept unlocked. This practice carries a risk of penalties if your data is breached.

Mitigate your risk of unauthorized PHI access

  1. We recommend keeping paper files with PHI locked 
  2. IT closets/ network/ security/ server equipment should also be kept locked to prevent unauthorized access.

 

5. Lack of HIPAA security and privacy policies and procedures. 

Often covered entities do not maintain and implement satisfactory HIPAA security and privacy policies and procedures.  Or even if they have policies and procedures, not all of them review and update their policies and procedures periodically. 

Mitigate your risk

  1. Take the time to prepare and maintain policies and procedures.
  2. Review these policies and procedures annually or after a major change.
  3. Ensure that employees are trained on your policies and procedures, and follow them.

 

6. Delays in reporting breaches as per the breach notification rule.

Breaches affecting more than 500 patients are required to be reported to the Department of Health and Human Services (HHS) within 60 days of being discovered.  It’s bad enough to delay reporting to HHS, but covered entities may often not be aware of state-level breach notification requirements.  Some states like Florida can be very strict with breach notification delays. Florida, under the Florida Information Protection Act, has 30-day breach notification requirements and other specific rules depending on the number of records breached. The fines are also drastic, an example being $1000 per day for every day late for the first 30 days and more stringent penalties after that. All 50 states have enacted laws regarding breach notification.

Mitigate your risk of penalties for failing to report breaches in a timely manner

  1. If you suffer a breach, be sure to take legal advice in terms of all the requirements in your industry and location.
  2. Ensure that you are aware and comply with your state or location specific breach reporting requirements in addition to federal HIPAA breach notification rules.
  3. Cyber Insurance can help mitigate some of the expenses of a breach, but take a close look at what is covered and what you need to be doing in order to maintain coverage.

Don't risk making one of these costly mistakes!  Schedule your HIPAA risk assessment, HIPAA training for you and your staff, and prepare and/ or review your Policies and Procedures. 

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The Benefits of HIPAA Compliance Services for Physicians

The Benefits of HIPAA Compliance Services for Physicians | HIPAA Compliance for Medical Practices | Scoop.it

As a doctor, you have your hands full just taking care of your many patients, running a practice, and providing quality healthcare service. The last thing you need to worry about is whether your practice is being managed properly when it comes to Health Insurance Portability and Accountability Act (HIPAA) compliance.

 

HIPAA regulations can be complex – at least to an inexperienced or understaffed office management team – and there’s no margin of error for unintended breaches that can lead to costly penalties. That’s why it’s important that your practice utilizes professional HIPAA compliance services that offer these key benefits:

Protection against rampant data breaches

HIPAA data breaches happen at an alarming rate. Employee carelessness is a major contributing factor.  According to the HIPAA JournalData breaches caused by employee carelessness have increased year on year. More unencrypted devices are being lost, data still is being inadvertently disclosed, and simple email errors are still being made. Performing regular training on data privacy and security can help to reduce the number of data breaches suffered.”

 

To reduce – if not eliminate – your risk, you may need on-site compliance experts who are not only able to answer your questions at every step during the process, but who can educate and empower your workforce. These experts can provide real-time advice for best practices for securely handling protected health information, protecting patient privacy, and understandinghow to avoid potential breaches.

A customized HIPAA risk management plan

No two practices are alike. Which is why your HIPAA risk management plan must be unique for your practice. Look for a compliance service provider with decades of experience in internal investigations, regulatory compliance, inspection, facility security, risk mitigation, and health information technology can give your practice an invaluable preventative edge.

Supporting evidence that your practice is exercising due diligence

The greater your medical practice can demonstrate its efforts to exercise reasonable diligence to mitigate risk, the greater your chances of avoiding civil monetary penalties. In the event of a breach of electronic medical records, or if your practice is subjected to a HIPAA compliance investigation, your compliance services provider can provide assistance in sufficiently answering any questions the HHS Office for Civil Rights (OCR) may ask about your compliance program.

 

Colington Consulting takes the uncertainty out of what is reasonable and appropriate for HIPAA compliance for your practice. We provide HIPAA risk assessments and on-site facility security surveys by our team of experts. Unlike other service providers that use web-based formats and expect you to answer questions you can hardly understand, we always conduct the assessment, value your input, and use a common-sense approach to compliance.

 

We are experts in the field of HIPAA rules and procedures. Colington Consulting can help you avoid problems and steep fines by bringing your practice into complete HIPAA compliance. It is what we do best, allowing you to do what you do best … provide health care to your patients.

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How Do I Become HIPAA Compliant?

How Do I Become HIPAA Compliant? | HIPAA Compliance for Medical Practices | Scoop.it

For healthcare providers, HIPAA compliance is a must. HIPAA guidelines protect patients’ health information, ensuring that it is stored securely, and used correctly.

 

Sensitive data that can reveal a patient’s identity must be kept confidential to adhere to HIPAA rules. These rules work on multiple levels and require a specific organizational method to implement comprehensive privacy and security policies to achieve compliance.

 

Most organizations find this to be a daunting task. We have put together a HIPAA compliance checklist to make the process easier.

 

The first is to understand how HIPAA applies to your organization. The second is to learn how to implement an active process, technology, and training to prevent a HIPAA-related data breach or accidental disclosure. Finally, the third is to put physical and technical safeguards in place to protect patient data.

By the time you’re done with our list, you will know what you need to consider to have a better conversation with your compliance advisors.

What is HIPAA?

Before talking about compliance, let’s recap the basics of HIPAA.

Signed into law by President Bill Clinton in 1996, the Health Insurance Portability and Accountability Act provides rules and regulations for medical data protection.

HIPAA does several important things. It reduces health care abuse and fraud and sets security standards for electronic billing of healthcare. It also does the same for the storage of patients’ healthcare information. The Act mandates the protection and handling of medical data, ensuring that healthcare data is kept private.

The part of HIPAA we are concerned with relates to healthcare cybersecurity. To be compliant, you must protect patients’ confidential records.

HIPAA rules have evolved. When the law was first enacted, it did not mention specific technology. As the HIPAA compliant cloud has become commonplace, it has inspired additional solutions. For example, our Data Security Cloud (DSC) is being developed to create a base infrastructure for a HIPAA compliant solution. Providing a secure infrastructure platform to ride on top of, DSC makes creating a HIPAA-compliant environment easier.

Secure infrastructure handles things at the lowest technical level that creates data, providing the key features to keep data safe. These features include separation/segmentation, encryption at rest, a secure facility at the SOC2 level of compliance, and strict admin controls among other required security capabilities.

 
 

Why Is HIPAA Compliance Important?

HIPAA compliance guidelines are incredibly essential. Failure to comply can put patients’ health information at risk. Breaches can have a disastrous impact on a company’s reputation, and you could be subject to disciplinary action and strict violation fines and penalties by CMS/OCR.

Last year’s Wannacry ransomware attack affected more than 200,000 computers worldwide, including many healthcare organizations. Most notably, it affected Britain’s National Health Service, causing serious disruptions in the delivery of health services across the country.

To gain access to the systems, hackers exploited vulnerabilities in outdated versions of Windows that are still commonly used in many healthcare organizations. With medical software providers offering inadequate support for new OS’s and with medical devices such as MRIs lacking security controls, the attack was easy to carry out.

The attack demonstrated the strength of today’s hackers, highlighting the extent to which outdated technologies can pose a problem in modern organizations. This is precisely why HIPAA also regulates some aspects of technology systems used to store, manage, and transfer healthcare information.

The institutions that fail to implement adequate systems can suffer significant damage. If a breach takes place, the law requires affected organizations to submit various disclosure documents, which can include sending every subject a mailed letter. They may also be required to offer patients a year of identity protection services.  This can add up to significant dollars, even before confirming the extent of the breach.

 

What is the HIPAA Privacy Rule?

The HIPAA Privacy Rule creates national standards. Their goal is to protect medical records and other personally identifiable health information (PHI).

It applies to three types of companies: providers, supply chain (contractors, vendors, etc.) and now service providers (such as data centers and cloud services providers). All health plans and healthcare clearinghouses must be HIPAA compliant.

The rules also apply to healthcare providers who conduct electronic health-related transactions.

The Privacy Rule requires that providers put safeguards in place to protect their patients’ privacy. The safeguards must shield their PHI. The HIPAA Privacy Rule also sets limits on the disclosure of ePHI.

It’s because of the Privacy Rule that patients have legal rights over their health information.

These include three fundamental rights.

    • First, the right to authorize disclosure of their health information and records.
    • Second, the right to request and examine a copy of their health records at any time.
    • Third, patients have the right to request corrections to their records as needed.

The HIPAA Privacy Act requires providers to protect patients’ information. It also provides patients with rights regarding their health information.

 

What Is The HIPAA Security Rule

The HIPAA Security Rule is a subset of the HIPAA Privacy Rule. It applies to electronic protected health information (ePHI), which should be protected if it is created, maintained, received, or used by a covered entity.

The safeguards of the HIPAA Security Rule are broken down into three main sections. These include technical, physical, and administrative safeguards.

Entities affected by HIPAA must adhere to all safeguards to be compliant.

Technical Safeguards

The technical safeguards included in the HIPAA Security Rule break down into four categories.

    • First is access control. These controls are designed to limit access to ePHI. Only authorized persons may access confidential information.
    • Second is audit control. Covered entities must use hardware, software, and procedures to record ePHI. Audit controls also ensure that they are monitoring access and activity in all systems that use ePHI.
    • Third are integrity controls. Entities must have procedures in place to make sure that ePHI is not destroyed or altered improperly. These must include electronic measures to confirm compliance.
    • Finally, there must be transmission security. Covered entities must protect ePHI whenever they transmit or receive it over an electronic network.

The technical safeguards require HIPAA-compliant entities to put policies and procedures in place to make sure that ePHI is secure. They apply whether the ePHI is being stored, used, or transmitted.

Physical Safeguards

Covered entities must also implement physical safeguards to protect ePHI. The physical safeguards cover the facilities where data is stored, and the devices used to access them.

Facility access must be limited to authorized personnel. Many companies already have security measures in place. If you don’t, you’ll be required to add them. Anybody who is not considered an authorized will be prohibited from entry.

Workstation and device security are also essential. Only authorized personnel should have access to and use of electronic media and workstations.

Security of electronic media must also include policies for the disposal of these items. The removal, transfer, destruction, or re-use of such devices must be processed in a way that protects ePHI.

Administrative Safeguards

The third type of required safeguard is administrative. These include five different specifics.

    • First, there must be a security management process. The covered entity must identify all potential security risks to ePHI. It must analyze them. Then, it must implement security measures to reduce the risks to an appropriate level.
    • Second, there must be security personnel in place. Covered entities must have a designated security official. The official’s job is to develop and implement HIPAA-related security policies and procedures.
    • Third, covered entities must have an information access management system. The Privacy Rule limits the uses and disclosures of ePHI. Covered entities must put procedures in place that restrict access to ePHI to when it is appropriate based on the user’s role.
    • Fourth, covered entities must provide workforce training and management. They must authorize and supervise any employees who work with ePHI. These employees must get training in the entity’s security policies. Likewise, the entity must sanction employees who violate these policies.
    • Fifth, there must be an evaluation system in place. Covered entities must periodically assess their security policies and procedures.

Who Must Be HIPAA complaint?

There are four classes of business that must adhere to HIPAA rules. If your company fits one of them, you must take steps to comply.

The first class is health plans. These include HMOs, employer health plans, and health maintenance companies. This class contains schools who handle PHI for students and teachers. It also covers both Medicare and Medicaid.

The second class is healthcare clearinghouses. These include healthcare billing services and community, health management information systems. Also included are any entities that collect information from healthcare entities and process it into an industry-standard format.

The third class is healthcare providers. That means any individual or organization that treats patients. Examples include doctors, surgeons, dentists, podiatrists, and optometrists. It also includes lab technicians, hospitals, group practices, pharmacies, and clinics.

The final class is for business associates of the other three levels. It covers any company that handles ePHI such as contractors, and infrastructure services providers. Most companies’ HR departments also fall into this category because they handle ePHI of their employees. Additional examples include data processing firms and data transmission providers. This class also includes companies that store or shred documents. Medical equipment companies, transcription services, accountants, and auditors must also comply.

If your entity fits one of these descriptions, then you must take steps to comply with HIPAA rules.

What is the HIPAA Breach Notification Rule?

Even when security measures are in place, it’s possible that a breach may occur. If it does, the HIPAA Breach Notification Rule specifies how covered entities should deal with it.

The first thing you need to know is how to define a breach. A breach is a use or disclosure of PHI forbidden by the Privacy Rule.

The covered entity must assess the risk using these criteria:

    1. The nature of the PHI involved, including identifying information and the likelihood of re-identification;
    2. The identity of the unauthorized person who received or used the PHI;
    3. Whether the PHI was viewed or acquired; and
    4. The extent to which the risk to the PHI has been mitigated.

Sometimes, PHI may be acquired or disclosed without a breach.

The HIPAA rules specify three examples.

  • The first is when PHI is unintentionally acquired by an employee or person who acted in good faith and within the scope of their authority.
  • The second is inadvertent disclosure of PHI by one authorized person to another. The information must not be further disclosed or used in a way not covered by the Privacy Rule.
  • The third occurs if the covered entity determines that the unauthorized person who received the disclosure would not be able to retain the PHI.

 

If there is a breach as defined above, the entity must disclose it. The disclosures advise individuals and HHS that the breach has occurred.

 

Personal disclosures must be mailed or emailed to those affected by the breach. A media disclosure must be made in some circumstances. If more than 500 people in one area are affected, the media must be notified.

 

Finally, there must also be a disclosure to the HHS Secretary.

The HIPAA Breach Notification Rule protects PHI by holding covered entities accountable. It also ensures that patients are notified if their personal health information has been compromised.

 

What Are The HIPAA Requirements for Compliance

The common question is, how to become HIPAA compliant?

The key to HIPAA compliance certification is to take a systematic approach. If your entity is covered by HIPAA rules, you must be compliant. You must also perform regular audits and updates as needed.

 

With that in mind, we’ve compiled a comprehensive checklist for use in creating your HIPAA compliance policy.

HIPAA Compliance Checklist

These questions cover the components to make you are HIPAA-compliant. You can use the checklist to mark each task as you accomplish it. The list is intended to be used for self-evaluation.

Have you conducted the necessary audits and assessments according to National Institutes of Standards and Technology (NIST) Guidelines?

 

The audits in question involve security risk assessments, privacy assessments, and administrative assessments.

Have you identified all the deficiencies and issues discovered during the three audits?

 

There are several things to consider before doing the self-audit checklist. You need to ensure that all security, privacy, and administrative deficiencies and issues are appropriately addressed.

 

Have you created thorough remediation plans to address the deficiencies you have identified?

After covering the deficiencies and issues mentioned above, you need to provide remediation for each group.

Do you have policies and procedures in place that are relevant to the HIPAA Privacy Rule, the HIPAA Security Rule, and the HIPAA Breach Notification Rule?

 

You must be aware of these three critical aspects of a HIPAA compliance program and ensure each is adequately addressed.

    • Have you distributed the policies and procedures specified to all staff members?
      • Have all staff members read and attested to the HIPAA policies and procedures you have put in place?
      • Have you documented their attestation, so you can prove that you have distributed the rules?
      • Do you have documentation for annual reviews of your HIPAA policies and procedures?
    • Have all your staff members gone through basic HIPAA compliance training?
      • Have all staff members completed HIPAA training for employees?
      • Do you have documentation of their training?
      • Have you designated a staff member as the HIPAA Compliance, Privacy, or Security Officer as required by law?
    • Have you identified all business associates as defined under HIPAA rules?
      • Have you identified all associates who may receive, transmit, maintain, process, or have access to ePHI?
      • Do you have a Business Associate Agreement (Business Associate Contract) in place with each identify you have identified as a Business Associate?
      • Have you audited your Business Associates to make sure they are compliant with HIPAA rules?
      • Do you have written reports to prove your due diligence regarding your Business Associates?
    • Do you have a management system in place to handle security incidents or breaches?
      • Do you have systems in place to allow you to track and manage investigations of any incidents that impact the security of PHI?
      • Can you demonstrate that you have investigated each incident?
      • Can you provide reporting of all breaches and incidents, whether they are minor or meaningful?
      • Is there a system in place so staff members may anonymously report an incident if the need arises?

As you work your way through this checklist, remember to be thorough. You must be able to provide proper documentation of your audits, procedures, policies, training, and breaches.

As a final addition to our checklist, here is a review of the general instructions regarding a HIPAA compliance audit.

    • If a document refers to an entity, it means both the covered entity and all business associates unless otherwise specified
    • Management refers to the appropriate officials designated by the covered entity to implement policies, procedures, and standards under HIPAA rules.
    • The covered entity must provide all specified documents to the auditor. A compendium of all entity policies is not acceptable. It is not the auditor’s job to search for the requested information.
    • Any documents provided must be the versions in use as of the audit notification and document request unless otherwise specified.
    • Covered entities or business associates must submit all documents via OCR’s secure online web portal in PDF, MS Word, or MS Excel.
    • If the appropriate documentation of implementation is not available, the covered entity must provide examples from “equivalent previous time periods” to complete the sample. If no such documentation is available, a written statement must be provided.
    • Workforce members include:
      • Entity employees
      • On-site contractors
      • Students
      • Volunteers
    • Information systems include:
      • Hardware
      • Software
      • Information
      • Data
      • Applications
      • Communications
      • People

Proper adherence to audit rules is necessary. A lack of compliance will impact your ability to do business.

In Closing, HIPAA Questions and Answers

HIPAA rules are designed to ensure that any entity that collects, maintains, or uses confidential patient information handles it appropriately. It may be time-consuming to work your way through this free HIPAA self-audit checklist. However, it is essential that you cover every single aspect of it. Your compliance is mandated by law and is also the right thing to do to ensure that patients can trust you with their personal health information.

One thing to understand is that it is an incredible challenge to try to do this by yourself. You need professional help such as a HIPAA technology consultant. Gone are the days you can have a server in your closet at the office, along with your office supplies. The cleaning personnel seeing a print out of a patient’s file constitutes a ‘disclosable’ event.

Screen servers, privacy screens, and professionally-managed technology solutions are a must. Just because you use a SAS-based MR (Medical Records) solution, does not mean you are no longer responsible for the privacy of that data. If they have lax security, it is still the providers’ responsibility to protect that data. Therefore the burden of due diligence is still on the provider.

Phoenix NAP’s HIPAA compliant hosting solutions have safeguards in place, as audited in its SOC2 certifications. We provide 100% uptime guarantees and compliance-ready platform that you can use to build secure healthcare infrastructure.

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10 Best Practices for HIPAA Compliance 

10 Best Practices for HIPAA Compliance  | HIPAA Compliance for Medical Practices | Scoop.it

A failure to understand HIPAA requirements can be a very costly mistake, as CardioNet learned just a couple months ago. In April, the wireless health services provider agreed to a settlement of $2.5 million for a potential noncompliance with the HIPAA Privacy and Security Rules. (1) The violation occurred when a company laptop containing the ePHI of 1,391 individuals was stolen from an employee’s vehicle parked outside their home. The Office for Civil Rights (OCR)’s investigation revealed that CardioNet had insufficient risk analysis and risk management processes in place at the time of the theft. In addition, the company’s policies and procedures implementing the standards of the HIPAA Security Rule were in draft form and had not been implemented. CardioNet was also unable to produce any final policies or procedures regarding the implementation of safeguards for ePHI, including those for mobile devices. 

 

“Mobile devices in the health care sector remain particularly vulnerable to theft and loss,” said Roger Severino, OCR Director. “Failure to implement mobile device security by Covered Entities and Business Associates puts individuals’ sensitive health information at risk. This disregard for security can result in a serious breach, which affects each individual whose information is left unprotected. 

 

Most HIPAA violations can be prevented by implementing HIPAA regulations into practice policies and procedures and ensuring all individuals with access to patient information receive the proper training. Below are ten best practices for keeping your practice HIPAA compliant.

 

10 Best Practices for HIPAA Compliance

  • Implement safeguards such as password protected authorization and encryption to access patient-specific information on all computers, laptops, and devices.
  • Practices should keep all patient paperwork, charts, and records locked away and safe out of the public's view. Never leave patient information out or unattended.
  • Computer programs containing patient information should be closed and logged out of when not in use. Never share passwords between employees.
  • Ensure all computers have updated anti-virus software installed. This will help keep a practice guarded against malicious software.
  • Limit emailing PHI if the information can be sent another way. When faxing PHI, always use a cover sheet.
  • Always properly dispose of information containing PHI by shredding paper files.
  • Make sure employees are aware that using social media to share patient information is considered a violation of HIPAA law.
  • If patient information is being accessed at home, ensure all home computers and laptops are password protected.
  • Back up all disks that contain PHI. Store patients’ information in a HIPAA compliant cloud server.
  • Compliance training is one of the simplest ways to avoid a violation. Practices should provide ongoing, up-to-date training on the handling of PHI for all employees.
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Recent Ransomware Attacks Could be HIPAA Violations

Recent Ransomware Attacks Could be HIPAA Violations | HIPAA Compliance for Medical Practices | Scoop.it
By now, you may have heard about the massive ransomware attack that has struck over 150 countries, including The United States, over the past week.
 
If health care data taken hostage in a ransomware attack is unencrypted, it could constitute a HIPAA violation. Any electronic protected health information (ePHI) that is affected by a breach without proper encryption methods in place is very likely to be compromised in the event of a ransomware attack.
 
These recent attacks come out of a growing trend in malware incidents over the past year. OCR has released guidance about how to handle a ransomware incident in your health care practice. The federal government has stressed the importance of safeguarding your organization and protecting your confidential patient data.
 
 
If you’re interested in protecting your organization from a ransomware incident–and want education about how to prevent ransomware attacks from spawning HIPAA breaches and fines–attend the upcoming webinar.
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HIPAA liability protections: business associate agreements are must for effective risk management

HIPAA liability protections: business associate agreements are must for effective risk management | HIPAA Compliance for Medical Practices | Scoop.it

The first step for a physician, known under the language of HIPAA as a “covered entity,” is to determine the need for a BAA with a vendor. A vendor is considered a “business associate” under HIPAA if the vendor creates, receives, maintains, or transmits patient health information (PHI) on the provider’s behalf.

 

Common services performed by a business associate (BA) include claims processing, data analysis, quality assurance, billing and collection, practice management, legal, accounting, and consulting.

 

Entities that only serve as conduits, such as the post office or Internet service providers, are not considered BAs even though they handle patient information.

 

What BAs must include

If a business associate is providing services to a covered entity, the parties must enter into a written BAA that:

 

  • establishes the permitted uses/disclosures of PHI,
  • stipulates that the BA must use appropriate safeguards to prevent unauthorized PHI uses and disclosures,
  • spells out that the BA reports to the covered entity any unauthorized uses and disclosures,
  • extends the terms of the BAA to its subcontracts, and
  • establishes that upon termination of the BAA, the vendor must either return or destroy all PHI.

 

The consequences of not having a written BAA can be severe. The Office of Civil Rights (OCR) could request a copy of a covered entity’s BAA if there is a complaint registered over a covered entity or if a breach occurs.

 

Violations under HIPAA can be penalized at anywhere between $100 to $50,000 per violation, up to a calendar year maximum penalty of $1,500,000 for a single violation. The OCR could take the position that every day that the BA and covered entity did not have a business associate agreement is a violation, and multiply the fine by the number of days no BAA penalty was in place, so the penalties can be steep.

 

Liability of agents

Under HIPAA, a covered entity is liable for the acts of its agents, which can include a BA.

 

Whether an agency relationship exists is determined case by case, with the essential factor being whether the provider has the right or authority to control the BA’s conduct. The authority of a provider to give instructions or directions is the control that can result in an agency relationship.

 

The language in the BAA will be considered in determining whether an agency relationship is present. If a covered entity is controlling the performance of its BA, the covered entity should closely monitor the BA’s performance since the covered entity will be held accountable for its performance.

 

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HIPAA compliance tips for small medical practices

HIPAA compliance tips for small medical practices | HIPAA Compliance for Medical Practices | Scoop.it

You’ve seen the headlines splashed on TV and across the internet: data breaches hit national businesses such as Target, Chipotle, and many large healthcare systems.

 

But data breaches don’t just affect large corporate entities, they affect small healthcare organizations as well. Take the case of Holland Eye Laser Surgery in March 2018. Their five-provider group practice saw a data breach which made available the patient records of 42,000 patients. Hackers were able to access Social Security numbers, birth records, and other sensitive protected health information (PHI).

 

In fact, some of the medical records of these patients were sold off by data hackers. Officials from the practice stated that they’re now working to strengthening their security system. But once patient trust is lost, sometimes it just cannot be restored.

 

Brief primer on HIPAA and data breaches

 

• The Privacy Rule protects individually identifiable health information held or transmitted by a covered entity or its business associate, in any form, whether electronic, paper, or verbal

 

• Each entity must analyze the risks to e-PHI in its environment and create solutions appropriate for its own situation.

 

• The HIPAA Breach Notification Rule requires providers to notify affected individuals, HHS, and in some cases, the media of a breach of unsecured PHI. Most notifications must be provided without delay and no later than 60 days following the discovery of a breach.

 

5 tips to help you and your medical staff to avoid data breaches

 

1. CMS requires organizations to “[i]mplement policies and procedures to prevent, detect, contain, and correct security violations.” (45 C.F.R. § 164.308(a)(1).) Conduct a detailed risk analysis to evaluate the current staff and product deficiencies and create corrective measures.

 

2. Designate a staff member to train employees on your practice’s HIPAA policies and procedures and spend time going over typical breaches.

 

3. Hire an outside expert to help your organization with compliance support. Your outside organization should set up monthly meetings with the business owners to evaluate your company compliance program and work with your organization to identify cost-effective resources to keep your company compliant.

 

4. Customize your internet toolbars with anti-phishing protection. These applications can run website checks and compare them to lists of known phishing sites and alert users.

 

5. Be suspicious of any email message that asks you to enter or verify personal information through a website or by replying to the message itself. Practice groups and or staff members should never reply to or click the links in such a messages.

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Why should you care about HIPAA?

Why should you care about HIPAA? | HIPAA Compliance for Medical Practices | Scoop.it

Why should you care about HIPAA?

Can you afford a $50,000 fine for a HIPAA violation? The healthcare industry is extremely vulnerable to cyber-attacks and data theft. According to the HIPAA enforcement rule, penalties can reach up to $1,500,000 per year per violation depending upon the type of HIPAA violation.

Look at some of the biggest HIPAA penalties enforced by the Office for Civil Rights:

In October 2018, Anthem Insurance pays OCR $16 Million in Record HIPAA Settlement after a series of cyberattacks led to the largest U.S. health data breach in history and exposed the electronically protected health information of almost 79 million people. OCR’s investigation revealed that Anthem failed to conduct an enterprise-wide risk analysis, had insufficient procedures to regularly review information system activity, failed to identify and respond to suspected or known security incidents, and failed to implement adequate minimum access controls to prevent the cyber-attackers from accessing sensitive ePHI, beginning as early as February 18, 2014.

 

A judge ruled in June 2018 that MD Anderson Cancer Center has to pay $4,348,000 in civil money penalties to OCR following an investigation of the theft of 3 unencrypted devices that resulted in a breach of ePHI (electronic Protected Health Information) of over 33,500 individuals.

 

Fresenius Medical Care North America (FMCNA) is paying 3.5 million dollars with a corrective action plan after 5 separate data breaches in 2012 because they failed to implement policies and procedures and to implement proper protection of PHI (Protected Health Information).

 

CardioNet has been fined 2.5 million with a corrective action plan after a laptop was stolen from an employee's vehicle. Further investigation revealed insufficient risk analysis and risk management at the company. Their policies and procedures were in draft status and had not been implemented.

 

One surprise inspection can expose a HIPAA violation and change your business forever.  New legislation now allows patients in Connecticut to sue healthcare providers for privacy violations or PHI disclosure as well.  You may say that your job as a healthcare provider is only to treat your patients, that you don't need to worry about Cybersecurity or technology. 

 

Bear in mind though - it is a fact that Cybersecurity issues can impact and have impacted patient care on several occasions! Protect the integrity of your business and your patients' private health information to avoid a HIPAA violation that could cost you money, respect, and patients!

 

You may understand that HIPAA violations can lead to fines, but you may also be wondering: What is a corrective action plan? Often, when the Office of Civil Rights (OCR) imposes a fine for a HIPAA violation, they also enforce a Corrective Action Plan with a strict timeline to correct underlying compliance problems and a goal to prevent breaches from recurring.

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HIPAA Training is not HIPAA Compliance

HIPAA Training is not HIPAA Compliance | HIPAA Compliance for Medical Practices | Scoop.it

We hear from so many doctors’ and dentists’ offices that they are “HIPAA-compliant” because they have completed the required annual HIPAA training for their staff.   FALSE! HIPAA Training is not HIPAA Compliance. HIPAA Training is only one of the components of HIPAA Compliance – thinking otherwise could lead to a false sense of security.

 

HIPAA law consists of various requirements in the areas of security and privacy, use and disclosure of PHI (protected health information) and in breach notification rules.

Minimum steps needed for HIPAA Compliance:

At the very minimum, a doctor’s or dentist’s office must do the following for HIPAA Compliance:

  1. Exercise privacy in the office everywhere.   Be careful about accidental disclosure of patient information.
  2. Display the Notice of Privacy Practices prominently in your office lobby and on your website.
  3. Exercise caution in the use and disclosure of PHI (Protected Health Information).     Patients have the right to review and obtain their PHI.   The onus falls on the medical practice to secure and protect PHI from unauthorized disclosure of any kind.
  4. Conduct the mandatory annual risk assessment, or hire an expert to conduct it for you.   The assessor must take into consideration all the security and privacy-related criteria while conducting the assessment, including all your administrative, physical and technical safeguards.   A detailed list of recommendations and action items should follow as a result of the risk assessment.
  5. Prepare and follow security and privacy policies and procedures.   Your risk assessment should highlight the minimum required policies and procedures that you would need to prepare or obtain.   Physicians and staff members should be familiar with and should follow these policies and procedures on a daily basis.
  6. Provide annual HIPAA Training to your staff and physicians.

Breach notification:

Breaches have unfortunately become only too common these days in an environment where medical records are extremely valuable in the black market.   HIPAA law also specifies strict breach notification requirements in the event of a breach.   The Office of Civil Rights (OCR) of the Department of Health and Human Services (HHS) requires the practice to inform all individuals whose data might have been lost or stolen.  

 

A breach of more than 500 records is considered a reportable breach, that is, the practice must notify HHS.   This could result in an audit of the practice by federal agencies, and the first thing they are going to ask you for is a copy of your last annual risk assessment.

Small practices may be targets of breaches too:

Many small practices think that they are too small to be targeted.   False again!   If you look at the HHS "Wall of Shame" which lists reported breaches of more than 500 patient records, you will see several small practices listed there who have undergone breaches.   The reality is that smaller practices are likely to be even more affected by a breach considering the high expenses and workload that follow.    The Ponemon Institute has calculated the average healthcare data breach cost to be $380 per record - for 500 records, that comes to approximately $190,000, which can be highly damaging for a small healthcare practice.

 

We often hear from dentists that they do not believe they need to comply.   Also False!  In fact, just recently, on January 2018, Steven Yang, DDS of California and Zachary Adkins, DDS of New Mexico had breaches of 3000+ patient records each due to the theft of a laptop and other portable electronic devices respectively.   

 

Robert Smith, DMD of Tennessee reported 1500 records breached after a hack.  Several other providers such as physicians, hospitals, pharmacies, health plans, and business associates have experienced breaches in the recent past.   It can and will happen to anyone regardless of size - please do not think that it won't happen to you!

Culture of Security and Privacy:

HIPAA Training is not HIPAA Compliance.   Practices should take these requirements seriously as they are here to protect patients and medical professionals.   Protect yourself and your patients by incorporating a culture of security and privacy compliance in your medical practice.

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Do you know the HIPAA Technical Safeguards-Security Rule?

Do you know the HIPAA Technical Safeguards-Security Rule? | HIPAA Compliance for Medical Practices | Scoop.it

The HIPAA Security Rule is broken down into three specific implementations – Physical Safeguards, Technical Safeguards, and Administrative Safeguards. In this post, we will discuss the specific standards surrounding HIPAA Technical Safeguards, or section 164.312 of the HIPAA Security Rule.

 

The HIPAA Security Rule defines Technical Safeguards as “the technology and the policy and procedures for its use that protect electronically protected health information (ePHI) and control access to it”. Essentially, these safeguards provide a detailed overview of access and protection of ePHI.

 

Technical Safeguards can be broken down into the following standards:

  • Access Control: This standard requires a covered entity to implement technical policies and procedures for electronic information systems that maintain ePHI to allow access only to those persons or software programs that have been granted access rights. The Access Control Standard is broken down into four specific implementations:
    • Unique User Identification
    • Emergency Access Procedure
    • Automatic Logoff
    • Encryption and Decryption

These implementations ensure that only the correct person is logging on to an electronic device and accessing information on that device in an appropriate manner.

 

  • Audit Controls: Under this standard, covered entities must implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ePHI. By implementing this standard, a covered entity can examine its information systems and determine if any security violations are taking place.
  • Integrity: The Integrity standard requires the covered entity to implement policies and procedures to protect ePHI from improper alteration or destruction. This standard has one specific implementation:
    • A mechanism to Authenticate Electronic Protected Health Information

Under this implementation, the covered entity must have mechanisms in place to ensure that ePHI has not been altered or destroyed in an unauthorized manner.

 

  • Person or Entity Authentication: Under this standard, covered entities must implement procedures to verify that a person or entity seeking access to ePHI is the one claimed.
  • Transmission Security: The final standard requires covered entities to implement technical security measures to guard against unauthorized access to ePHI that is being transmitted over an electronic communications network. This standard has two specific implementations:
    • Integrity Controls
    • Encryption

Much of the language surrounding the HIPAA Technical Safeguards can be a little overwhelming, but here are some example practices that covered entities can implement as they strive to get HIPAA compliant:

 

  • Ensure that all staff have unique user IDs/log-in credentials for all workstations and any programs that store or process ePHI. This will allow the HIPAA Security officer or IT administrator to determine exactly which staff member has accessed specific data.
  • Create defined roles for staff members within medical software/programs (EMR, scheduling, billing, etc.) based on their job status with the practice. For example, some staff members can be given read-only access, while others can change and edit data.
  • Avoid transmitting ePHI over unsecured electronic means such as email. If the covered entity maintains a website, a good practice would be to make sure it does not transmit or store any ePHI unless the website is protected with encryption.
  • Update/patch all technological devices that process ePHI regularly. The software can become quickly outdated, it is crucial to implement these updates to stay current with security needs.

 

These general steps are building blocks towards HIPAA compliance. Annual mandatory HIPAA risk assessments will help covered entities determine any additional vulnerabilities that need to be addressed regarding HIPAA Technical Safeguards.

 

The HIPAA Technical Safeguards are an integral part of the HIPAA Security Rule. Keeping in line with the standards mentioned above will allow a covered entity to ensure that it is doing all it can to secure the technology it uses to treat patients.

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Do Dentists need to comply with HIPAA?

Do Dentists need to comply with HIPAA? | HIPAA Compliance for Medical Practices | Scoop.it

In April 2018, a dental office in New Jersey, Michael Gruber, DMD, PA reported that their computers were hacked and 4624 patient records were stolen.  Now, this incident appears on the “Wall of Shame” at the Department of Health and Human Services website. Yes, it can happen to anybody.

 

Many dentists seem to think that either they do not need to comply with HIPAA (Health Insurance Portability and Accountability Act) or that they are already compliant as they have taken HIPAA training provided by their EHR or by a consultant. While HIPAA training is indeed one of the annual requirements to be compliant with HIPAA law, it certainly is not the only requirement.

 

In the event of a breach like the one reported by Michael Gruber, DMD, PA, as it involved the loss or theft of more than 500 patient records, it became a reportable breach. Dentists, like any other covered entity, are required to comply with HIPAA breach notification rules that involve notifying OCR (Office of Civil Rights), the patients and in some cases, media.  This can become an expensive proposition as legal fees, penalties, media costs, postage costs, forensic investigation costs, and other related expenses are incurred during this breach notification and investigation phase.

 

Once a covered entity becomes a victim of a breach, OCR puts the case under investigation and more likely than not, conducts an audit of the practice.   One of the first documents requested in this case is a copy of the office’s HIPAA risk assessment or analysis which should be done annually.   

 

They would typically also ask to see your HIPAA policies and procedures.  Depending on the outcome of the investigation, OCR, as the enforcement arm of the Department of Health and Human Services, might also decide to impose monetary fines for HIPAA violations.  In severe cases of criminal negligence or impropriety, federal agencies such as the FBI or Department of Homeland Security or the Department of Justice get involved and there have been examples where a healthcare provider or an employee has been jailed.

Basic requirements for HIPAA compliance for a dental office:

  • Risk Assessment or Analysis:

    Conduct a risk analysis or risk assessment every year.

  • HIPAA Training:

    Train all your employees (including dentists, hygienists, assistants and all administrative/ office staff) every year on HIPAA privacy, security and breach notification rules.

  • Policies and Procedures:

    Create and maintain HIPAA policies and procedures and ensure that employees are familiar with them and follow them regularly.

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What you should know about HIPAA PRIVACY RULE

What you should know about HIPAA PRIVACY RULE | HIPAA Compliance for Medical Practices | Scoop.it

Does the HIPAA Privacy rule affect you?  

You should be familiar with the Health Insurance Portability and Accountability Act also known as HIPAA, but do you know how the privacy rule affects you? The U.S Department of Health and Human Services (HHS) has worked diligently since establishing HIPAA law to regulate privacy standards in the healthcare industry. When you think of the word privacy many things may come to mind, such as closing the door during a patient’s consultation or ensuring confidentiality while discussing patient treatments with fellow staff members. As a covered entity it is your responsibility to protect the privacy of your patients. 

 

6 ways in which you can implement a Culture of Privacy:

During your day to day operations, you need to be aware of how to implement the culture of privacy in your practice and comply with the law. Across all roles, every employee in your practice needs to be exercising compliance with HIPAA. Here are six ways in which you can implement a culture of privacy.

  • Provide HIPAA training to all your employees and maintain documentation that your entire staff has completed HIPAA training.
  • Ensure that your entire staff knows what patient information can be shared and not shared outside and inside of the workplace.
  • Get your patients to sign consent forms regarding sharing any form of PHI for any purpose including your own marketing purposes.
  • Stay updated on changes in the law on new disclosure restrictions and Update your patient authorization forms updated regularly on any such new disclosure restrictions.
  • Educate your patients and give them a clear outline of how they can request or obtain a copy of their medical records.
  • Ensure that you are giving your staff only the minimum necessary access to PHI to perform quality healthcare.

 

It is your responsibility to maintain professional top-quality healthcare for all parties involved while maintaining compliance with the law. Exercising the privacy culture is the way your practice stays current and minimizes the potential of a data breach. As a covered entity you need to be aware of the potential consequences that come with non- compliance. Consequences range from significant monetary fines to criminal penalties like jail time and a damaged reputation.  In addition, there are strict breach notification requirements outlined in the law.

 

In the event of a breach, you may be investigated by the appropriate federal agency like Office of Civil Rights (OCR) or the Department of Homeland Security or the Department of Justice, or other federal agencies who may be involved.  Depending on the results of the investigation, you may face penalties. Here are some penalties for data breaches that may apply. 

 

  • 100 dollars per record per day under HIPAA law with the maximum annual penalty being 1.5 million dollars per violation.
  • Loss of patient trust and repeat business due to damage to your reputation.

 

Millions of dollars in fines could potentially cause you to lose your livelihood and business. A bad reputation would stop repeat business and new customers from coming. These top penalties and consequences are avoidable and quality healthcare is attainable if you are complying with the law and practicing the culture of privacy every day. Remember to instill a culture of privacy in your office and follow the Five Steps to HIPAA Compliance every year.

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Proposed HIPAA Law Changes

Proposed HIPAA Law Changes | HIPAA Compliance for Medical Practices | Scoop.it

Upcoming proposed changes to HIPAA law from the Office for Civil Rights (OCR)

Roger Severino, Director of the Office for Civil Rights (OCR), in his keynote address at the 11th Annual OCR/ NIST conference “Safeguarding Health Information: Building Assurance through HIPAA Security”, informed of some proposed policy changes in HIPAA law that OCR is in the process of working through.  Be on the lookout for upcoming policy enhancements. 

 

These proposed changes to legislation are provoked by input from covered entities, business associates and experts on what issues they currently face due to HIPAA regulations.   

Here are some of the proposed changes that Director Roger Severino talked about.

Good faith disclosures by health care providers

Often people say “I didn’t know” when it comes to either their own health records or those of their loved ones.  Sometimes, especially regarding public health emergencies like the opioid crisis, parents don’t know what is happening with the health of their children until it is too late. In those cases, good faith disclosures may be the right way to go.   Should OCR pursue action against a provider who disclosed patient health information when the patient’s or someone else’s life was at risk?  There should also be a provision for providers to inform the patient’s emergency contacts listed on the consent form when there is a true emergency. 

Improving care coordination and reducing regulatory burden

Notice of Privacy Practices

  • Providers make the Notice of Privacy Practices available to patients and often ask patients to sign the notice as part of the patient package of documents.  Patients sometimes do not know what this is for, what the notice provides them.  It raises several questions like “is this a contract”, “what exactly am I signing here”, “am I giving up my privacy”, etc.  OCR is looking into the notice of privacy practices to see how the process can be improved.

Required Provider to Provider Information Sharing

  • When patients go from doctor to doctor, the patient’s information should follow seamlessly to provide the best possible coordinated care to the patient. Providers are allowed to share information about patients with each other as part of the treatment process.
  • However, today there is no guarantee of receiving the information requested from one provider to another.   OCR is looking at the possibility of changing the law to make this provider-to-provider information sharing mandatory upon information request.

Accounting of Disclosures

  • Another area of review is the Accounting of Disclosures.   Should the TPO (Treatment Payment Operations) provision be revoked or modified?
  • Today, TPO allows for the sharing of protected health information among entities for the purpose of treatment, payment of operations related to a patient.  

OCR is keen on reducing the burden in the healthcare process. Director Severino stated that we definitely do not want a situation where a doctor is treating a computer screen instead of the patient in front of the doctor.

Civil Monetary Penalties or Monetary Settlements to harmed individuals

  • OCR is also looking at the patient compensation process.  Congress wants OCR to compensate patients for breach of privacy. 
  • This can be very complicated as the gravity of breaches could differ greatly from one breach to another.  For instance, the risks vary depending on if patient name and address are stolen, or if a name, address and social security number are stolen, or worse, if sensitive health or disease information is stolen. What level of privacy breach should be compensated?

HIPAA/ FERPA

There is joint guidance available between HIPAA and FERPA for educational institutions.  FERPA is all-encompassing for educational institutions.  However, after a string of recent school shootings, some rules may have to change in terms of communication to psychologists to handle the trauma related to these incidents.

 

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HIPAA compliance tips for small medical practices

HIPAA compliance tips for small medical practices | HIPAA Compliance for Medical Practices | Scoop.it

But data breaches don’t just affect large corporate entities, they affect small healthcare organizations as well. Take the case of Holland Eye Laser Surgery in March 2018. Their five-provider group practice saw a data breach which made available the patient records of 42,000 patients. Hackers were able to access Social Security numbers, birth records, and other sensitive protected health information (PHI).

 

In fact, some of the medical records of these patients were sold off by data hackers. Officials from the practice stated that they’re now working to strengthening their security system. But once patient trust is lost, sometimes it just cannot be restored.

 

Brief primer on HIPAA and data breaches

• The Privacy Rule protects individually identifiable health information held or transmitted by a covered entity or its business associate, in any form, whether electronic, paper, or verbal

• Each entity must analyze the risks to e-PHI in its environment and create solutions appropriate for its own situation.

• The HIPAA Breach Notification Rule requires providers to notify affected individuals, HHS, and in some cases, the media of a breach of unsecured PHI. Most notifications must be provided without delay and no later than 60 days following the discovery of a breach.

 

5 tips to help you and your medical staff to avoid data breaches

1. CMS requires organizations to “[i]mplement policies and procedures to prevent, detect, contain, and correct security violations.” (45 C.F.R. § 164.308(a)(1).) Conduct a detailed risk analysis to evaluate the current staff and product deficiencies and create corrective measures.

2. Designate a staff member to train employees on your practice’s HIPAA policies and procedures and spend time going over typical breaches.

3. Hire an outside expert to help your organization with compliance support. Your outside organization should set up monthly meetings with the business owners to evaluate your company compliance program and work with your organization to identify cost-effective resources to keep your company compliant.

4. Customize your internet toolbars with anti-phishing protection. These applications can run website checks and compare them to lists of known phishing sites and alert users.

5. Be suspicious of any email message that asks you to enter or verify personal information through a website or by replying to the message itself.  Practice groups and or staff members should never reply to or click the links in such a messages.

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Five Steps to HIPAA Compliance for a Doctor's Office

Five Steps to HIPAA Compliance for a Doctor's Office | HIPAA Compliance for Medical Practices | Scoop.it

Why do you, as a doctor, dentist or any other medical provider, need to comply with HIPAA? HIPAA, the Health Insurance Portability and Accountability Act, was enacted by the US government to not only protect patient confidentiality and privacy but also to ensure that doctors and other medical practices protect their data to prevent unauthorized persons and criminals from getting access to patients' confidential, private and financial information.

 

Patient health records called PHI (Protected Health Information) are a valuable commodity for criminals and sell for high prices in the black market.   Medical professionals must therefore strictly abide by HIPAA rules in order to avoid monetary fines, damage to their reputation, loss of their license(s), and even imprisonment. Over the last few years, we have been hearing of multiple instances of doctors, nurses and healthcare workers being jailed or fined hefty sums for HIPAA violations. The Office of Civil Rights (OCR) has concentrated on education and outreach and has also focused on enforcement of HIPAA law especially when a healthcare organization suffers a breach or is in violation of HIPAA law.

 

Professionals in the medical field have the moral and ethical responsibility to abide by laws that govern them and to provide the utmost care, which includes protecting the health information of each and every patient. This requires the ability to make logical decisions minute by minute, plus a great deal of patience, professionalism, and high standards related to HIPAA compliance to ensure protection of ALL health information… which includes the following steps:

 

1. Exercise Privacy in Your Office Everywhere

  • Give patients the privacy they deserve in your office whether it’s in the lobby or their patient room.
  • Minimize references to patients; it is best to call patients by first or last name only when directing them to their patient room.
  • Allow for a quiet, private space when talking with patients individually so only those intended for the information are the ones who hear it.
  • Never leave patient documents/files unattended or unsecured.
  • Always knock before entering patient rooms.
  • While accessing electronic PHI (ePHI), make sure that no unauthorized person can see the data on your screen or device.
  • Continuously enforce this culture of privacy with your staff.

2. Post Notice of Privacy Practices

  • Print notice of privacy practices and place it in a common and clearly visible area in your office, so that patients are openly provided with the privacy laws and information that strives to keep their care confidential.
  • If you have a website for your practice, then be sure to post a copy of the Notice of Privacy Practices prominently on your website.
  • Keep copies of the Notice of Privacy Practices available in case any of your patients asks for a copy.

3. Maintain and Follow Written Policies and Procedures

  • Develop a written policies and procedures manual for everyone in your practice to follow, to ensure patient privacy and security. The manual should also contain forms, notices, disclosures and step-by-step procedures for patient privacy notification and overall HIPAA compliance.
  • Your policies and procedures should be accessible to all staff.  Get attestations from your staff that they have read and will abide by your written policies and procedures.
  • Review your policies and procedures annually to ensure that they are still current, and review them with your staff every year after this review.
  • Review, and if needed update, your policies and procedures whenever there is a major change in your practice, for instance, a change in your EHR or key software used like anti-virus, data backup service or anything similar.

4. Train Your Team on HIPAA Do’s and Don’ts

  • Ensure that your employees go through HIPAA training every year.
  • Your employees should sign and acknowledge their awareness of these HIPAA policies and procedures.
  • Document training dates and employee names as proof that all your employees have been trained.
  • All healthcare providers - doctors, nurses, and all staff - should undergo annual HIPAA training.
  • Ensure that your Business Associates also undergo annual HIPAA training.

5. Conduct the Mandatory Annual HIPAA Security Risk Assessment

  • This mandatory HIPAA security risk assessment should be completed in order to analyze risks within the practice. Typically, a security risk assessment will check your office for compliance with the HIPAA Security Rule and the HIPAA Privacy Rule.   Your security risk assessment would involve reviewing in detail your technical safeguards, physical safeguards and administrative safeguards which are all key elements of the HIPAA Security Rule.
  • You can either do this annual assessment internally or hire a HIPAA expert to perform the assessment.
  • If any evaluated areas require remediation or follow-up, plans of action will have to be developed with timelines to address them.
  • Be sure to address your follow-up action items within a reasonable period of time.  About 3-4 months is often considered a reasonable time for most doctors' offices.  For instance, if you are using a straight-cut shredder, your report might ask you to procure a cross-cut shredder or shredding service to make your document disposal process more secure.
  • Know where your patients' Protected Health Information is - where it is stored on your EHR, where your data backups are kept, on which employees you or your employees store any PHI, where printed versions of PHI may be kept.
  • If you don't already have Business Associate Agreements with your vendors, you should arrange to get them immediately.  These are important legal documents where you can specify the roles and responsibilities of your vendors or business associates when it comes to handle your patients' protected health information that you are ultimately responsible for.
  • While disposing of anything that has PHI on it - in any format - use secure disposal techniques. Your security consultant can guide you on how to securely dispose of PHI on different media. 
  • Some of the action items may be very technical, for instance, it may recommend that you implement secure email or encrypt your storage devices, or that you may need to get a vulnerability assessment done. Your IT vendor or security vendor should be able to guide you in these situations.

 

Ultimately, medical facilities that do not stray from complying with current rules and laws that govern their care and practice will continue to have the best reputation and the best rapport with their patients. Enforcing the highest level of HIPAA compliance within your facility means that you understand the importance of protecting health information and providing continuity of care across the medical spectrum to provide the best care outcomes for each and every patient in every way possible.

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HIPAA Audits of Covered Entities and Business Associates

HIPAA Audits of Covered Entities and Business Associates | HIPAA Compliance for Medical Practices | Scoop.it

In August, Advocate Health Care Network agreed to pay a $5.55 million settlement with the U.S. Department of Health and Human Services Office for Civil Rights (OCR), for multiple HIPAA violations. In addition, HHS also recently announced a $650,000 resolution settlement against the Catholic Health Care Services of the Archdiocese of Philadelphia.

 

These multi-million dollar penalties should be a warning for all covered entities or business associates.  Especially, with the next phase of audits now underway. During this phase, OCR is reviewing the policies and procedures utilized by covered entities and their business associates to ensure they meet the standards and specifications of the Privacy, Security, and Breach Notification Rules. These will mostly be desk audits. However, there will be some on-site audits conducted as well.

 

The audit process began in May 2016 when OCR audit sent emails to verify entity’s address and contact information. The next step was a pre-audit questionnaire that was used to gather information about the size, type, and operations of the facilities. Those who participate in the desk audits are required to provide a list of their business associates and their contact information. Emails will go out to the chosen business associates, who are expected to respond promptly. The audits are expected to focus heavily on breach responses. If a business associate does not respond within the timeframe, they will be scheduled in January 2017 for the comprehensive audits.

 

Some frequently asked questions regarding audits include:

Who Will Be Audited?

 

Every covered entity and business associate are eligible for an audit, including covered individual and organizational providers of health services; health plans, health care clearinghouses; and a range of business associates of these entities.

 

What is a Business Associate?

Business associates are considered any third-party contractor that performs work or activities on behalf of a healthcare organization or covered entity that involve the use or disclosure of protected health information.  A few examples may include:

  • Example of business associates: lawyer’s working on a case, a medical transcription or medical billing companies, document storage or disposal companies, answering services, software vendors, and consultants, patient safety and accreditation organizations, health information exchanges, etc.)
  • Examples NOT typically considered business associates: an employee, maintenance or repair personnel, a financial or banking institution that only performs payment activities or a janitorial service. 

 

What are Business Associate Agreements?

HIPAA and HITECH require practices to sign a business associate agreement (BA) with business associates that ensures they will protect all patient's PHI. The contract protects personal health information (PHI) by HIPAA guidelines. Business associates can be held accountable for any data breach and penalized for noncompliance.

 

Why are Business Associates Agreements important?

Business associate contracts are not only necessary for staying in compliance; they are crucial for the adequate protection of patient PHI.  The following are HIPAA requirements for business associate agreements:

  1. Establish the permitted and required uses and disclosures of protected health information by the business associate.
  2. Provide that the business associate will not use or further disclose the information other than as permitted or required by the contract or as required by law.
  3. Require the business associate to implement appropriate safeguards to prevent unauthorized use or disclosure of the information, including implementing requirements of the HIPAA Security Rule about electronic protected health information.
  4. Require the business associate to report to the covered entity any use or disclosure of the information not provided for by its contract, including incidents that constitute breaches of unsecured protected health information.
  5. Require the business associate to disclose protected health information as specified in its contract to satisfy a covered entity’s obligation with respect to individuals' requests for copies of their protected health information, as well as make available protected health information for amendments (and incorporate any amendments, if required) and accountings.
  6. To the extent the business associate is to carry out a covered entity’s obligation under the Privacy Rule, require the business associate to comply with the requirements applicable to the obligation.
  7. Require the business associate to make available to HHS its internal practices, books, and records relating to the use and disclosure of protected health information received from, or created or received by the business associate on behalf of, the covered entity for purposes of HHS determining the covered entity’s compliance with the HIPAA Privacy Rule.
  8. At termination of the contract, if feasible, require the business associate to return or destroy all protected health information received from, or created or received by the business associate on behalf of, the covered entity.
  9. Require the business associate to ensure that any subcontractors it may engage on its behalf that will have access to protected health information agree to the same restrictions and conditions that apply to the business associate with respect to such information.
  10. Authorize termination of the contract by the covered entity if the business associate violates a material term of the contract.  Contracts between business associates and business associates that are subcontractors are subject to these same requirements. (1)

 

How Will Auditees Be Selected?

OCR is identifying groups of covered entities and business associates that represent a broad range of health care providers, health plans, health care clearinghouses and business associates.  According to HHS, the sampling criteria for selection will include the size of the entity, affiliation with other healthcare organizations, the type of entity and its relationship to individuals, whether an organization is public or private, geographic factors, and present enforcement activity with OCR. OCR will not audit entities with an open complaint investigation or that are currently undergoing a compliance review.

 

What If an Entity Doesn’t Respond to OCR’s Requests for Information?

If an entity does not respond to requests for information from OCR, they will utilize publicly available information about the entity to create its audit pool.  An entity that does not respond to OCR may still be selected for an audit or subject to a compliance review.

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Is it Time for Your Organization to Hit the HIPAA Breach Panic Button? 

Is it Time for Your Organization to Hit the HIPAA Breach Panic Button?  | HIPAA Compliance for Medical Practices | Scoop.it

Indeed, it is. According to the latest statics from the HHS Office of Civil Rights (OCR), 43% of all reported breaches are now caused by hacking or other related information network discrepancies—not to mention those breaches that are the result of impermissible disclosures made by members of the work force.

 

Let’s face it, breaches will happen, especially those related to information systems. When it comes to breaches, most network security experts say it is “when” and not “if.” Regardless of whether the breach is related to the network or some other means such as lost or stolen devices containing ePHI, what is important is having a process in place to deal with it. This includes the ability to conduct an internal investigation to determine the basics such as how the breach was caused, the type of breach, and how many individuals were affected.

 

The HIPAA Breach Notification Rule states that a breach is, generally, an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information. The exception is when the covered entity or business associate, as applicable, demonstrates that there is a low probability that the protected health information has been compromised based on a risk assessment of at least the following factors:

  1. The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification;
  2. The unauthorized person who used the protected health information or to whom the disclosure was made;
  3. Whether the protected health information was actually acquired or viewed; and
  4. The extent to which the risk to the protected health information has been mitigated.

 

So, what is the best way to conduct the breach risk assessment to determine this probability? Start with some type of Breach Notification Risk Assessment Tool which is a decision tree-based process. This will help determine if the breach is reportable. Even if the determination is made that the breach is not reportable, documentation that this assessment was conducted must be maintained.

 

Having a comprehensive breach notification policy is critical. This will save a lot of headaches and layout a process to follow during the period of uncertainty associated with a breach. The policy should state the obvious such as who needs to be notified internally within the organization, who is responsible for conducting the assessment, and what specific notifications need to be made. What is even more important is the actual procedure to implement the policy. Procedures should cover how to undertake the investigation of the breach to cover the who, what, how, and when of the occurrence. If it is a reportable breach, this type of information is required for submitting “Notice of a Breach” to the Secretary of HHS (which technically is delegated to OCR.) When submitting the Notice, one should be prepared to answer a number of questions. This is why it is important that the internal investigation uncover as much information as possible.

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What is required for HIPAA Compliance?

What is required for HIPAA Compliance? | HIPAA Compliance for Medical Practices | Scoop.it

Lots of our visitors ask us “what is required for HIPAA compliance?” Because this is such an important question, we try to direct our visitors to the most trusted sources for HIPAA education. The most important aspect to remember is that a checklist based “solution” is my no means affective. What we do endorse is the ability to use a checklist to understand what aspect of HIPAA you are doing, and to recognize ones you may have looked over or need to address in further detail. We recommend taking a look at Compliancy Group who has two resources for your organization, whether you’re a Covered Entity or a Business Associate. First, we recommend reading and downloading their HIPAA compliance checklist. Or you can register for their HIPAA compliance checklist webinar!

 

Some of the key findings in the checklist highlight Business Associate Agreements, and also help point out the need for more than just a security risk assessment. As many are familiar with there is a need for HIPAA training, but we do appreciate how it points out the need for documentation of training and other attestations.

 

HIPAA Compliance Checklist: What You Need to Know

The divide between what is required for compliance under HIPAA regulation and the misconceptions that healthcare professionals have about being compliant is more extensive than ever. When she was appointed in late 2015, Jocelyn Samuels, director of the Office of Civil Rights (OCR) announced her plan to start on a new wave of audits. Extensively reported upon, these Phase 2 audits are reaffirming that the over $10 million in fines levied against non-compliant Covered Entities (CE’s) and Business Associates (BA’s) seen in 2015 alone is set to become the norm, and perhaps even grow over the coming months.

 

Compliancy Group is here to make sure that you’re not the one being hit with these fines. We’ve compiled this HIPAA checklist to help guide you through some of the most often overlooked components of total HIPAA compliance, and to help ready you for this sweeping new series of audits that OCR has lined up.

 

The HIPAA Compliance Checklist: The Privacy Rule

The HIPAA Privacy & Security Rule is a series of national regulations concerned with safeguarding patients’ PHI and medical records from unauthorized access. It gives patients the primary rights over their own health information. The rule applies to health plans, healthcare clearinghouses, and health care providers that make certain electronic healthcare transactions. These groups are required to have appropriate limitations and conditions on the use and disclosure of PHI.

  • Implement written policies, procedures, and standards of conduct: Ensure that you have written training standards as well as written penalties that employees are informed of in the case of a violation.
  • Have BA agreements in place: When conducting business with a BA, you need to ensure that you have comprehensive, up-to-date agreements in place to protect your firm from liability in the event that a BA breaches HIPAA regulation.
  • Data safeguards: Maintain administrative, technical, and physical safeguards to monitor use or disclosure of PHI.
  • Complaints procedures: Implement procedures where patients can file a complaint to the CE about its HIPAA compliance, and patients must be informed that complaints may also be submitted to HHS.
  • Retaliation and waiver: Retaliation can’t be taken out against a patient who exercises their rights under the Privacy Rule. Patients cannot be made to waive their Privacy Rule rights as a means of obtaining treatment, payment, or enrollment.
  • Documentation and record retention: Records of all privacy policies, privacy practice notices, complaints, remediation plans, and other documentation must be stored and accessible for six years after their initial creation.
  • Privacy personnel: Ensure that an appointed privacy officer is in place to develop and implement the rest of these privacy policies.

 

The HIPAA Compliance Checklist: The Security Rule

The HIPAA Security Rule outlines specific regulations that are meant to prevent breaches in the creation, sharing, storage, and disposal of ePHI. Since its adoption, the rule has been used to manage patients’ confidentiality alongside changing technology. And now, with the growing trends of cloud computing and online and remote document sharing, the protection of ePHI is becoming more important than ever.

 

These safeguards each require different standards that need to be implemented in order to be deemed fully compliant. The legal jargon that surrounds each safeguard and standard can be confusing, so we’ve broken them down into a simple, but comprehensive list below.

 

The HIPAA Security Rule Checklist: Administrative Safeguards

Administrative safeguards should be in place to establish policies and procedures that employees can reference and follow to ensure that they’re maintaining compliance. Each of these standards should be documented as a written policy, accessible to all employees so that they understand the necessary steps they should be taking to maintain patients’ confidentiality.

Standard 1. Security Management Process

 

  • Risk Analysis should be done to assess confidentiality of ePHI
  • Risk Management measures should be implemented to assess potential breaches in ePHI
  • Sanction Policies should be extended to employees who fail to comply with policies and procedures
  • Information System Activity Reviews should be in place so that system activity is regularly monitored

Standard 2. Assigned Security Responsibility

  • Security Responsibility should be assigned to an employee who can regularly monitor, develop, and maintain privacy policies and procedures

Standard 3. Workforce Security

  • Employees who are meant to deal with ePHI should undergo Authorization and Supervision
  • Workforce Clearance Procedures should govern who is and isn’t allowed access to ePHI
  • Termination Procedures should be in place so that employees who have left a practice can no longer have access to ePHI that they’ve previously had access to

Standard 4. Information Access Management

  • Clearinghouses that are part of larger organizations need to have properly Isolated Access to ePHI
  • Employees should be given Access Authorization depending on whether or not their role requires that they handle ePHI
  • Access to ePHI should be governed by strict rules for when and how it is granted, Established, or Modified

Standard 5. Security Awareness and Training

  • Security Reminders should be regularly communicated
  • Protection from Malicious Software should be a priority to prevent ePHI from being compromised
  • Log-in Monitoring should be in place to detect any unauthorized access to ePHI
  • Password Management should be implemented for creating, changing, and protecting employees’ passwords

Standard 6. Security Incident Procedures

  • Breaches and their ramifications need to have documented Response and Reporting procedures

Standard 7. Contingency Plan

  • Data Backup Plan is required to ensure that there are ways to retrieve ePHI that has been lost because of a malfunction or a breach
  • Disaster Recovery Plans should be in place to ensure that any lost ePHI can be fully restored
  • Emergency Mode Operation Plans should be established so that employees can properly access and handle ePHI, while maintaining privacy, in the event of an emergency
  • Contingency procedures should be Tested and Revised on an ongoing basis to address faults or flaws
  • Contingency procedures should be go through Applications and Data Criticality Analysis to ensure that contingency plans are as streamlined as possible

Standard 8. Evaluation

  • The technical and non-technical elements of ePHI security should be regularly Evaluated, particularly when moving offices or changing operations

Standard 9. Business Associate Contracts and Other Arrangements

  • Written Contracts or Other Arrangements need to document that BAs will comply with all ePHI security measures.

 

The HIPAA Security Rule Checklist: Physical Safeguards

Physical safeguards should guide the creation of policies and procedures that focus on protecting electronic systems and ePHI from potential threats, environmental hazards, and unauthorized intrusion. And as is the case with administrative safeguards, each of these standards should be documented as a written policy, accessible to all employees so that they understand the necessary steps they should be taking to maintain patients’ confidentiality.

Standard 1. Facility Access Controls

  • Procedures should be in place to establish Contingency Operations plans that allow access to the physical office and stored data in the event of an emergency
  • Facility Security Plan needs to be well established to protect equipment that stores ePHI from unauthorized access and theft
  • Access Controls and Validation Procedures should govern when, how, and to whom access to equipment is granted
  • Maintenance Records should document modifications to the physical facility such as renovations or changing doors or locks

Standard 2. Workstation Use

  • Workstation Use policies need to specify the use, performance, and physical attributes of equipment and workstations where ePHI is accessed

Standard 3. Workstation Security

  • Workstation Security should entail physical safeguards that govern who can access workstations and equipment where ePHI is accessible

Standard 4. Device and Media Controls

  • Disposal of hardware or equipment where ePHI has been stored needs to be strictly managed
  • Policies should be in place to determine how and when ePHI should be removed from equipment or electronic media before Re-use
  • Hardware and equipment that has access to ePHI should be Accountable and, if necessary, tracked
  • Data Backup and Storage procedures should entail the creation of exact copies of ePHI

 

The HIPAA Security Rule Checklist: Technical Safeguards

Technical safeguards are the last piece of the Security Rule. They’re meant to provide written, accessible, policies and procedures that monitor user access to systems that store ePHI.

Standard 1. Access Control

  • Employees should be granted Unique User Identification in the form of a username or ID number that can be used to identify and track system usage
  • Procedures should be in place that determine Emergency Access protocols and authorization
  • Systems that store ePHI should be built with an Automatic Logoff function after inactivity
  • Encryption and Decryption methods should be built into systems that store ePHI

Standard 2. Audit Controls

  • Audit Controls must regularly monitor, record, and store system usage and ePHI access

Standard 3. Integrity

  • In order to ensure that ePHI hasn’t been accessed, altered, or destroyed without authorization, a Mechanism to Authenticate ePHI should be built into the system

Standard 4. Person or Entity Authentication

  • Person or Entity Authentication needs to be in place to ensure that only authorized employees or users have access to certain data and ePHI

Standard 5. Transmission Security

  • Any ePHI that is transmitted electronically needs to be protected by Integrity Controls to ensure that it hasn’t been modified in the process
  • Any stored ePHI should be Encrypted
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New HIPAA requirements target unsecured protected health information

New HIPAA requirements target unsecured protected health information | HIPAA Compliance for Medical Practices | Scoop.it

The American Recovery and Reinvestment Act of 2009, signed by President Barack Obama in February, modified the Health Insurance Portability and Accountability Act (HIPAA). In particular, the Health Information Technology for Economic and Clinical Health Act (HITECH) sets forth new requirements relating to business associates and notification of patients regarding breaches of unsecured protected health information. The new regulation covers breaches that occur after September 23, 2009.

 

Before HITECH, a covered entity, that is, a physician's office, hospital, clinic, etc.—only was required to mitigate the effects of an unauthorized disclosure, which may or may not have included notifying the patient Now, except for certain limited exceptions, a covered entity is required to notify a patient of an unauthorized disclosure of unsecured protected health information if a significant risk of "financial, reputational, or other" harm exists.

 

It is important to note that notification is only required for unsecured protected health information, not secured protected health information. The Department of Health and Human Services (HHS) issued guidance on what constitutes "secured" protected health information in April, stating that information is deemed secured if rendered "unusable, unreadable, or indecipherable" to unauthorized individuals.

 

To determine whether a "significant risk of harm" exists, the covered entity should consider what information was disclosed, to whom the information was disclosed, and what steps have been taken to eliminate or reduce the risk to the individual.

 

Any notification to the patient must include a brief description of what happened and the type of protected health information disclosed, any steps the patient should take to protect himself or herself, what the covered entity is doing to investigate and mitigate the breach, and information concerning who to contact for additional information. Any required notification must occur without unreasonable delay but no more than 60 days after the breach is discovered or should have been discovered with the exercise of reasonable diligence.

 

Notification must be in writing by mail (or by phone in urgent cases) or electronic means if the patient has consented to electronic notification. Also, specific rules exist regarding what to do if patients cannot be located. If a breach involves more than 500 patients—for instance, the loss of a laptop containing unsecured protected health information, then local media outlets must be notified. In addition, the HHS secretary must be notified—immediately for breaches involving more than 500 patients and annually for others.

 

With the new regulations, the knowledge of a covered entity's agents, including business associates, is imputed to the covered entity. Therefore, the clock for notifying patients could begin to run before the covered entity actually is aware of the disclosure. New agreements may be required, and education of business associates is important, to ensure that they are aware of these requirements and that they indemnify your practice if they fail to comply with the new rules and notify you promptly of any breach of protected health information.

 

The burden to disclose the breach or establish that no risk of harm to the patient exists is on the covered entity, even if the breach was the fault of one of its agents. A decision not to notify a patient because the covered entity does not believe that a significant risk of harm exists should be carefully investigated and documented.

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