Data Breach, News Events, Risk Analysis/Risk Management

Sutter Health Breach Update

This past week, Sutter Health released a statement stating that they are notifying 2,582 patients that personal information was included in billing documents a former employee emailed to their personal account without authorization. For all but two of the affected patients, no Social Security numbers, financial information or driver’s license data were included.

Despite the incident occurring on April 23, 2013, the breach was only discovered “during a thorough review of the former employee’s email activity and computer access.” The internal investigation began on August 27, 2015, more than two years after the incident. What stands out in this instance was the inability for Sutter Health to discover, mitigate, and remediate this incident within a reasonable timeframe. When it comes to HIPAA, breaches must be reported to HHS and the individuals affected without unreasonable delay and in no case later than 60 days following discovery of a breach or when it reasonably should have been known that a breach occurred.

The last point is key and clearly indicates the need for tools that allow organizations to better understand when PHI or other types of sensitive data leave their network. The best option to track and stop data from leaving your network is a Data Loss Prevention (DLP) solution. In this incident, the third large data breach involving Sutter Health, they have found “no evidence that any of the patient information was used or disclosed to others.” Since the data was sent to a personal email account, it is unlikely, truly impossible, that Sutter Health can determine with 100% certainty that the patient information was not disclosed inappropriately and this is reflected in their offering affected individuals one year of free credit monitoring.

In some other breach cases, however, data is available to forensically determine with certainty what happened after a breach occurred, and sometimes long after a breach occurred. If this is the case, then the information existed when the breach actually occurred. The takeaway in those instances is that logs or other forensic data were not reviewed proactively to catch the breach sooner.  In a digital information world with bigger and bigger data hurtling down the road faster and faster, no one seems to be watching the gauges for trouble!

With the many tools available and the ease with which an employee can move data outside of an organization, a DLP solution is a necessity. Not only would your organization be able to watch sensitive information flowing into, throughout, and out of your network without impacting performance, you can lock down many of those outlets for data leakage. In addition to performing a HIPAA Risk Analysis and publishing policies and procedures, DLP can help your organization maintain compliance with regulations such as HIPAA, Red Flags Rule, PCI, and other state and Federal privacy regulations. As the costs for remediating a breach rise, DLP becomes a more prudent decision that can offer real value as well as peace of mind.

If you are interested in learning more about DLP or other related services, contact RISC Management and Consulting, LLC at 800.648.4358 or visit www.RISCsecurity.com.

 

References

http://news.sutterhealth.org/2015/09/11/sutter-health-informs-patients-of-unauthorized-document-handling-by-former-billing-unit-employee/

http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/

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Cyber Security, Data Breach, Education, HIPAA / HITECH Enforcement, Meaningful Use, News Events, Risk Analysis/Risk Management, Tip of the Week

Challenges of Meaningful Use

Challenges of Meaningful Use

Meaningful Use (MU) is the adoption of a certified Electronic Health Record (EHR) technology with a focus on improving quality, safety, efficiency, and reducing health disparities in the clinical/hospital setting. The idea is to increase patient engagement to improve care coordination while maintaining the privacy and security of the patient’s Protected Health Information (PHI).

According to Milan (July 27, 2015) “After a day spent hearing from health IT experts about information blocking practices, Republican Sen. Lamar Alexander, chair of the Senate Health, Education, Labor & Pensions Committee, said Thursday afternoon that he’s asked HHS to consider a delay of Stage 3 meaningful use”. The Department of Health and Human Services (HHS) is the U.S. government’s main agency for enhancing and protecting the health and well-being of all Americans.

Here are some quotes from Senator Lamar Alexander:

“Let’s not impose on physicians and hospitals a system that doesn’t work…”

“We want something physicians buy into, rather than something they dread…”

It is important to update and improve our current way of keeping health records as well as a more appropriate way to share health information with other providers. The quality of the EHR tool becomes the most desirable trait it seems. Remembering HIPAA where the importance of assessing all of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of all Protected Health Information (PHI) is required. However, each medical provider is unique in their operational environment with their own set of variables and must be factored in to the equation.

Another important piece of information according to McCarthy (July 22, 2015):

“Stage 3 of meaningful use for EHR implementation requires providers to send electronic summaries for 50 percent of patients they refer to others, receive summaries for 40 percent of patients that are referred to them and reconcile past patient data with current reports for 80 percent of such patients. If other providers do not send electronic summaries, however, the provider who was supposed to receive them will fail to meet the second and third requirements.”

Probst (2014) mentioned from an interview that Intermountain Healthcare is Stage 2 Certified in 2014 but will not be attesting at this time.

The Agency for Healthcare Research and Quality (AHRQ, March 26, 2015) provided some research data on barriers to meeting the stage 3 criteria for Meaningful Use:

  • Lack of provider and practice staff time – 69%
  • Complexity of required workflow changes – 68%
  • Difficulty with electronic exchange of information – 65%
  • Direct Financial Costs – 54%
  • EHR design and functions do not easily support care coordination – 51%

Readiness to meet criteria results:

  • Only 11% of those who participated in the research are able to meet all of the criteria

AHRQ’s mission is to “bring about evidence to improve health care quality and safety, increase accessibility, equitability and affordability within the HHS and other partners. Their objective is to ensure that the evidence is understood and employed.

Stages of MU

For more information on Stages of Meaningful Use Click the link above

These are only some views on the subject of Meaningful Use, but there are many standards, policies, ideas that are available from other organizations that might be helpful.

Our work here at RISC Management has enabled us to view firsthand the privacy and security challenges of Meaningful Use, and of course HIPAA and HITECH. These are significant challenges that the Providers must meet, but they are reasonable and attainable.

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For more information on Risk Analysis Click the link above

References

Agency for Healthcare Research and Quality. (March 26, 2015). Informing stage 3 meaningful use requirements through evidence: Webinar. Retrieved from https://www.youtube.com/watch?v=nQrMKcq0VAM

McCarthy, Jack. (July 22, 2015). Stage 3 meaningful use ignores market realities. Retrieved from http://www.healthcareitnews.com/news/brookings-meaningful-use-stage-3-ignores-market-realities

Meaningful Use. (2015) Definition. Retrieved from http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives

Miliard, Mike. (July 23, 2015). Senate suggests stage 3 MU delay. Retrieved from http://www.healthcareitnews.com/news/senate-call-stage-3-mu-delay?mkt_tok=3RkMMJWWfF9wsRohuKTPZKXonjHpfsX57e8uUKOylMI%2F0ER3fOvrPUfGjI4GRMVkI%2BSLDwEYGJlv6SgFQ7LHMbpszbgPUhM%3D

Probst (2014). CIO on MU stage 2: Certified but not attesting. Retrieved from http://bcove.me/kt82385m