June 2013 – RISC Management and Consulting

If you think your organization is too small to attract the attention of the U.S. Department of Health and Human Services, think twice.
The department recently settled a security dispute with a hospice in Idaho for $50,000. The potential violation of the Security Rule of the Health Insurance Portability and Accountability Act of 1996 involved a data breach of health information affecting 441 patients.

The Hospice of North Idaho agreed to pay $50,000 to settle potential violations after an unencrypted laptop computer containing the electronic protected health information of the patients had been stolen in June 2010.
Field workers for the hospice use laptops containing patient information as a regular component of their workflow. In an investigation by the Department of Human Services’ Office for Civil Rights, it was revealed the hospice had not conducted a risk analysis to safeguard the electronic patient information and didn’t have policies or procedures to address mobile device security. The lack of a risk analysis has become a regular theme in the publicly available settlement agreements published by the OCR.
The HIPAA Security Rule and HITECH Act Data Breach requirements mandate the existence policies and the reporting of inappropriate or unauthorized access to PHI or ePHI called breaches. The Health Information Technology for Economic and Clinical Health Breach Notification Rule requires covered entities to report an impermissible use or disclosure of protected health information of 500 individuals or more to the government and the media within 60 days after the discovery of the breach, or when the breach should have been discovered. Smaller breaches affecting less than 500 individuals must be reported to the secretary of Health and Human Services on an annual basis.
“This action sends a strong message to the health care industry that, regardless of size, covered entities must take action and will be held accountable for safeguarding their patients’ health information,” Office for Civil Rights Director Leon Rodriguez said in a press release from the Department of Health and Human Services. “Encryption is an easy method for making lost information unusable, unreadable and undecipherable.” RISC Management’s stance on encryption is that implementation has become easy enough, and cost has been reduced enough, that choosing not to implement encryption is difficult to justify. With the exception of “legacy systems” that were developed long before data encryption was readily available, there are few relational database platforms or operating systems that don’t support encryption today. And even for those systems, there are third party applications and technology that can implement encryption in such a manner that it both provides safe harbor, and, does not require the rewriting of legacy applications.
The Idaho hospice has taken steps to remedy its compliance since the 2010 theft.
The Department of Health and Human Services provides tips to physicians, health care providers and other healthcare professionals who use smartphones, laptops and tablets in their work here (visit http://www.HealthIT.gov/mobiledevices).
RISC Management and Consulting can help assess your encryption capabilities, identify supported encryption options, and assist you in implementing standards-based encryption that may provide safe harbor under the HITECH rules.

In a world of inflated and confusing job titles, a “privacy and security officer” is neither pretentious nor inconsequential – for health care providers, such an officer is crucial.

All health care providers have HIPAA-mandated responsibilities to ensure the adequate protection of individually identifiable health information and are required to officially designate both a Privacy and Security officer.

Among the provisions of the Health Insurance Portability and Accountability Act of 1996, commonly referred to as HIPAA, are specific requirements for handling patients’ health information in all its forms: Electronic, paper and oral.

These rules govern how pharmacies, physicians offices, clinics, life insurers, hospitals, dentists, and all their business partners – including billing agencies, information system providers and even employers — handle patient information designated as Protected Health Information (PHI).

It’s an onerous task ensuring patient privacy and so important that the law requires covered providers to designate both a privacy officer and a security officer on their staff.

Here are some of the responsibilities of a good HIPAA privacy and security officer:

Documents why and where security measures exist, how they were created and how they are monitored.
Keeps essential records regarding a health care provider’s or business associate’s policies in the event of a HIPAA audit or other audit of electronic health records, or a security survey from a business partner.
Compares current security measures to industry standards in safeguarding patient health information.
Develops an action plan for addressing risks and vulnerabilities. In many cases, basic security measures can be highly effective and affordable. Look for “low hanging fruit”, but ensure that a well-documented, consistently updated, and management-accountable project plan is in place to address all gaps and periodic requirements. HIPAA has a significant quantity of periodic requirements!
Develops written policies and procedures about how your organization protects patient’s, or member’s privacy and security, and keeps those records up to date.
Trains your staff on proper handling of all forms of PHI.
Communicates with patients and members and responds to requests and complaints. The Officers should regularly review the Notice of Privacy Practices (NPP), and update it as required, for example, the recent Omnibus Rule required every Covered Entity to update their NPP. The Officers must also be the primary points of contact for patient or member complaints, OCR communications, and questions from members of the organizations workforce.

Privacy and security officers can, and should, do much more, too, including working with your vendors and monitoring business associate compliance, monitoring rule changes and applying for incentive programs.

Please contact RISC Management if you need assistance filling an interim gap, getting a new Privacy or Security Officer up to speed, or assessing a business associate or your own practices. www.RISCsecurity.com 800.648.4358