Not every HIPAA security requirement is related to technology. Just two of the requirements to keep in mind when you work to make your company HIPAA compliant include Business Associate Agreements and Risk Assessment.

HIPAA Requirement for Business Associate Agreement

In addition to your IT department’s need to keep Protected Health Information (PHI) in electronic form secure, you need to consider issues not related to technology. For example, if a company you work with is considered a business associate under HIPAA, this means you must have a business associate agreement (BAA) in place with them before transmitting PHI to them. This BAA is a contract to uphold PHI security according to HIPAA guidelines. Failure to have the (BAA) in place at the proper time can result in fines and other penalties.

In a recent case, a surgical practice ended up having to settle with the Office of Civil Rights of the U.S. Department of Health and Human Services (OCR) for $750,000 after it improperly disclosed several thousand patients’ PHI to a service provider without first entering into a BAA with the service provider. This service provider had agreed to digitize x-rays containing PHI, in exchange for extracting and keeping the silver from the x-ray film. While this provider’s service might not appear at first glance to be related to health care, the fact that the x-rays contained PHI and the provider “created, received, maintained, or transmitted” the PHI without a BAA in place made all the difference in this case.

HIPAA Requirement for Risk Assessment

HIPAA requires all covered entities, their business associates, and subcontractors of business associates to conduct a risk assessment. As stated in HIPAA these entities must, “…implement policies and procedures to prevent, detect, contain, and correct security violations.” Further, a risk assessment is defined as a, “…thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information.”

In another case, a Minnesota–based health care company paid a $1.5 million settlement after one of its business associates was investigated. A laptop containing PHI for the health care company’s patients had been stolen from the car of one of the business associate’s employees. The health care company was penalized both because there was no BAA in place between it and its business associate, and because it had not conducted an adequate analysis to the security threats to the PHI.

HIPAA Audits, Phase 2 – Business Associates May Also Be Audited

As we mentioned in our recent post, “Is Your Business Affected by HIPAA Regulations,” the OCR launched Phase 2 of its HIPAA Audit Program on March 21, 2016. In this phase, any covered entity or business associate may be audited. Per the OCR, these audits can involve onsite assessments or desk audits.

Need to Learn More about HIPAA Compliance?

If you’d like to learn more about how HIPAA compliance may affect your business, Aperio-IT will be holding a free Lunch and Learn Event on Wednesday, June 8. Brian Olsen, HIPAA Security Advisor, will be joining us to help answer your concerns about HIPAA regulations. You can find out details and register here to attend.

You can also take a look at our previous HIPAA-related posts:

• “What Does HIPAA Mean?”
• “What Does Your IT Team Need to Know about HIPAA Compliance?”
• “HIPAA Trends That Could Affect Your Business”
• “Is Your Business Affected by HIPAA Regulations?”

In the first part of this series, we discussed the recent increase in ransomware attacks on hospitals, what ransomware is, and what features of hospitals and healthcare organizations make them especially tempting targets. In this final part, we’ll look at what organizations can do to protect themselves and their patients or clients from these attacks.

How to prevent attacks – or at least minimize damage

A recent study by SailPoint on security practices within organizations takes the stand that organizations should assume that data breaches are now a matter of “when” rather than “if.” That is, a wise organization should focus not only on preventing data breaches, but also on recovering successfully from them when they inevitably occur.

Since many ransomware attackers gain access from successful phishing attempts, organizations still need to focus on educating their employees to identify phishing. This means continuing to teach users how to identify suspicious emails and share them with their IT teams so those IT teams can keep track of possible attacks.

Phishing is a specific type of social engineering attack in which confidential information is acquired by fraudulent methods. These attacks often attempt to acquire user names, passwords, or other information useful to hackers. In the case of ransomware attacks, hackers are generally attempting to get information that will allow them access to an organization’s systems.

Potential phishing attempts can be identified by educated users. For instance, they often make use of link shorteners or embedded links in an effort to create links that appear legitimate. Then after these links are clicked, they take victims to websites specifically created for fraudulent purposes.

Phishing attempts also frequently use threats to create a sense of urgency and fear so victims will hurry and not think carefully about the potential effects of their actions. Emails that threaten to cancel accounts immediately, etc., should be considered highly suspicious.

Some of the other measures suggested by the Department of Homeland Security include:

• Employing a data backup and recovery plan for all critical information.
• Using application whitelisting to help prevent malicious software and unapproved programs from running.
• Keeping operating systems and software up-to-date with the most recent patches.
• Maintaining up-to-date anti-virus software.
• Restricting user permissions to install and run software applications.
• Instructing users not to follow unsolicited web links in emails.
• Avoiding enabling macros from email attachments.

In the case of MedStar’s ransomware attack, data backups were a key part of their solution. The organization reported that they were able shut down their systems, isolating the damage, and later restore their data from backups without having to resort to paying a ransom.

Future security requirements and guidelines

It is possible that HIPAA requirements will be changed in the future in response to ransomware attacks. According to Bloomberg BNA, Rep. Ted Lieu (D-Calif.) is considering legislation “that would require hospitals and other health-care organizations to notify their patients when they’ve been the victim of a ransomware attack.” This would involve updating HIPAA’s current requirements regarding breach notification.

The FBI also offered guidance regarding the risks of ransomware in its podcast from May 25, 2016, “Ransomware on the Rise.”

Additional Links:

United States Computer Emergency Readiness Team, Alert TA16-091A: Ransomware and Recent Variants

Bloomberg BNA, Ted Lieu mulls ransomware attack requirements

A common question regarding HIPAA is whether a covered entity can be fined for violations of the HIPAA rules even if there is no breach of Protected Health Information. Worryingly, the answer is yes. So a clear understanding of the HIPAA rules is necessary to protect your company.

While HIPAA (the Health Insurance Privacy and Accountability Act) has many rules, when people speak of the “HIPAA Rules” they are usually referring to three primary sets of regulations. These “rules” lay out how covered entities are to handle PHI (Protected Health Information). The three main HIPAA Rules are:

• The Privacy Rule
• The Security Rule
• The Breach Notification Rule

The Privacy Rule

The Privacy Rule applies to PHI in any form, including oral, written, and electronic. Under the Privacy Rule, covered entities are responsible for making certain their employees (and business associates) use and/or disclose PHI only for authorized purposes. This means employers must keep their workforce trained to recognize what data is considered PHI and how to handle it appropriately.

Under this rule, covered entities are also responsible for making certain that only as much PHI as is necessary for a given purpose is disclosed. That is, the rule means it is not appropriate to just share entire medical records; only the portion of a record that is necessary for a given task is appropriate to share.

Other areas covered by the Privacy Rule include requirements for Business Associate Agreements (BAAs) with covered entities’ customers, vendors, and partners; standards to de-identification of Protected Health Information (that is, what kinds of information need to be removed from PHI in order to make it appropriate to share); specifications of patients’ rights to their own PHI; and requirements for covered entities to designate a privacy officer, publishing of privacy practices, and more.

The Security Rule

Unlike the Privacy Rule, the Security Rule applies only to electronic PHI. It delineates requirements for administrative, physical, and technical safeguards of electronic PHI and requires publication of documentation that describes the policies and procedures covered entities employ regarding those safeguards.

The Security Rule also specifies how long a covered entity must retain documentation of their Security Rule compliance.

The Breach Notification Rule

The Breach Notification Rule defines a reportable HIPAA breach, states what covered entities must do in case of such a breach, who they must notify, and how soon they must notify them.

This rule also states under what circumstances unauthorized access to encrypted PHI may not be considered a reportable breach.

Ready to Learn More about HIPAA Compliance?

If you’d like to learn more about how HIPAA compliance, Aperio IT will be holding a free Lunch and Learn Event on Wednesday, June 8. Brian Olsen, HIPAA Security Advisor, will be joining us to help answer your concerns about HIPAA regulations. You can find out details and register here to attend.

You can also take a look at our recent HIPAA-related posts:

• “HIPAA Trends That Could Affect Your Business”
• “Is Your Business Affected by HIPAA Regulations?”