News Events – Page 11 – RISC Management and Consulting

Just last month, a Pennsylvania-based hospital suffered a breach of patient data caused by unauthorized access and transmission of PHI by an employee. The 551-bed Penn State Milton S. Hershey hospital discovered through an internal investigation that a lab technician accessed and transmitted protected health data outside of the hospital’s secure network. The key in this breach was that the employee was authorized to work with PHI but in this case did not access and transmit the PHI securely. He used his own USB device and sent patient data through his own personal email address to two physicians.

The important thing to note in this situation is what your organization can do to avoid a situation like this: train your workforce. Not only is workforce training required by HIPAA, it is a prudent means of improving efficiency and confidence in your workforce. Many organizations believe that their biggest threat lies outside their walls. While it is a smart business decision to implement security controls to prevent intrusions from external threats, your organization should also prioritize properly training your workforce. Below is a list of the most investigated issues as noted in the OCR Enforcement highlights.

From OCR Enforcement highlights:

From the compliance date to the present, the compliance issues investigated most are, compiled cumulatively, in order of frequency:

Impermissible uses and disclosures of protected health information;
Lack of safeguards of protected health information;
Lack of patient access to their protected health information;
Uses or disclosures of more than the minimum necessary protected health information; and
Lack of administrative safeguards of electronic protected health information.

Security Rule Enforcement Results as of the Date of This Summary

With regard to the subset of complaints specifically pertaining to the Security Rule, since the OCR began reporting its Security Rule enforcement results in October 2009, HHS has received approximately 880 complaints alleging a violation of the Security Rule. During this period, HHS closed 644 complaints after investigation and appropriate corrective action. As of May 31, 2014, OCR had 301 open complaints and compliance reviews.

Here is the direct link to the Breaches Affecting 500 or More Individuals: http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html

In the most recent disciplinary action by the Office for Civil Rights regarding a HIPAA Data Breach, the OCR has set a new record for cost per affected individual and total fine amount. A breach affecting 6,800 individuals resulted in $4.8 Million in fines, or almost $706 per affected individual, in addition to the intense, and costly, corrective action plan.

Two health care organizations have agreed to settle charges that they potentially violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules by failing to secure thousands of patients’ electronic protected health information (ePHI) held on their network. The monetary payments of $4,800,000 include the largest HIPAA settlement to date.

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) initiated its investigation of New York and Presbyterian Hospital (NYP) and Columbia University (CU) following their submission of a joint breach report, dated September 27, 2010, regarding the disclosure of the ePHI of 6,800 individuals, including patient status, vital signs, medications, and laboratory results.

NYP and CU are separate covered entities that participate in a joint arrangement in which CU faculty members serve as attending physicians at NYP. The entities generally refer to their affiliation as “New York Presbyterian Hospital/Columbia University Medical Center.” NYP and CU operate a shared data network and a shared network firewall that is administered by employees of both entities. The shared network links to NYP patient information systems containing ePHI.

The investigation revealed that the breach was caused when a physician employed by CU who developed applications for both NYP and CU attempted to deactivate a personally-owned computer server on the network containing NYP patient ePHI. Because of a lack of technical safeguards, deactivation of the server resulted in ePHI being accessible on internet search engines. The entities learned of the breach after receiving a complaint by an individual who found the ePHI of the individual’s deceased partner, a former patient of NYP, on the internet.

In addition to the impermissible disclosure of ePHI on the internet, OCR’s investigation found that neither NYP nor CU made efforts prior to the breach to assure that the server was secure and that it contained appropriate software protections. Moreover, OCR determined that neither entity had conducted an accurate and thorough risk analysis that identified all systems that access NYP ePHI. As a result, neither entity had developed an adequate risk management plan that addressed the potential threats and hazards to the security of ePHI. Lastly, NYP failed to implement appropriate policies and procedures for authorizing access to its databases and failed to comply with its own policies on information access management.

NYP has paid OCR a monetary settlement of $3,300,000 and CU $1,500,000, with both entities agreeing to a substantive corrective action plan, which includes undertaking a risk analysis, developing a risk management plan, revising policies and procedures, training staff, and providing progress reports.

For information about the basics of HIPAA Security Risk Analysis and Risk Management, as well as other compliance tips, visit: http://www.hhs.gov/ocr/privacy/hipaa/understanding/training

The New York and Presbyterian Hospital Resolution Agreement may be found at: http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/ny-and-presbyterian-hospital-settlement-agreement.pdf

The Columbia University Resolution Agreement may be found at: http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/columbia-university-resolution-agreement.pdf