Help Me With HIPAA

Donna shares information from the 2016 NIST/OCR Annual Conference on Safeguarding Healthcare Information. Learn what she thought was interesting to share with you. More information at https://HelpMeWithHIPAA.com/78

We tour the HIPAA haunted house in this year's Halloween episode! Cybersecurity has become a big concern over the last 18 months. Breaches in 2015 have given way to ransomware along with more daring breaches in 2016. What is really happening on your computers, networks, and the Internet every second is terrifying in several ways. There are plenty of amazing and good things happening at the speed of light but so are the bad ones..... For more details go to HelpMeWithHIPAA.com/77

Ransomware and HIPAA have been a topic on the podcast multiple times. They are some of our most popular episodes, in fact. Recently, we realized we haven't discussed the OCR guidance on ransomware and HIPAA. On July 11, 2016, HHS.gov featured a new post from Jocelyn Samuels the Director of the Office for Civil Rights (OCR). The title is catchy: Your Money or Your PHI: New Guidance on Ransomware. This episode is a review of that post and the fact sheet with OCR guidance on ransomware and HIPAA that the post announced. . For more information http://HelpMeWithHIPAA.com/76

Everything going on today with hurricanes and such makes it is a great time to talk about this. We mention it all the time but this episode is going to be just about what DR/BC means and what you can do to be prepared in advance. So, this episode covers disaster recovery planning under HIPAA but any business can learn from our topics! What is DR/BC Planning? Who should do it? Is this another big expense? What is involved in building and maintaining DR/BC plans? General elements of a plan Get more details at http://HelpMeWithHIPAA.com/75

Last year Sen. Lamar Alexander and Sen. Patty Murray asked for answers to some questions concerning cybersecurity in healthcare. They were interested in understanding what CMS and HHS were doing to protect patients from fraud. It seems as though they were wondering if HIPAA security updates where needed. We discussed the Senators request in episode 31 : https://helpmewithhipaa.com/episode-31-enforcement-efforts-ocr-increase-2016/ Their letter asked: What CMS and HHS is doing to monitor medical identity fraud What is CMS and/or OCR actually doing, if anything, to track cases of ID theft and fraud OCR uses the data collected from covered-entities to monitor potential breach victims and find out if their data have in fact been used by criminals They also want to know whether any education materials or help are offered to breach victims by the CMS and OCR The report was presented to the committee on August 6, 2016 and made public on Sept 26.

BAs are in the HIPAA spotlight now more than ever. TheDarkOverlord was clearly using some BA applications to infiltrate networks and exfiltrate PHI. OIG reviewed Alaska VA system after breaches and the report specifically points to the need to monitor BAs OCR audits of BAs are about to start. Previously said end of September but now saying October In this episode we discuss what all this means. More at HelpMeWithHIPAA.com/73

Did you hear that maximum penalties for HIPAA violations are being adjusted for inflation? It has quietly happened. Here is how. Check out the Federal Register entry from September 6, 2016. If you aren't in to reading yourself, don't worry, you know Donna did it. Well, at least the HIPAA parts. Learn more at: HelpMeWithHIPAA.com/72

OCR recently released another memo concerning compliance enforcement efforts. They say effective August 2016, they have started an initiative to more widely investigate breaches involving under 500 patients. That means that OCR small breach investigations will begin happening immediately. In the past, the policy had been to investigate all breaches over 500 patients but not under. More information at HelpMeWithHIPAA.com/71

OCR published a memo on Aug 1, 2016. The title is "Do you know who your employees are?". It is a great reminder about insider threats that we should all worry about regularly. Quoted directly from the memo. ============================ Although all insider threats are not malicious or intentional, the effect of these threats can be damaging to a Covered Entity and Business Associate and have a negative impact on the confidentiality, integrity, and availability of its ePHI. According to a survey recently conducted by Accenture and HfS Research, 69% of organization representatives surveyed had experienced an insider attempt or success at data theft or corruption. Further, it was reported by a Covered Entity that one of their employees had unauthorized access to 5,400 patient's ePHI for almost 4 years. For more visit: HelpMeWithHIPAA.com/70

So far in 2016 there have been 10 resolution agreements announced. One more and this year will equal the number of agreements in all of 2015 & 2014! The latest two also include the largest one announced yet - $5.5m with Advocate Health. Before that though was The University of Mississippi Medical Center - Ole Missto those of us in the SEC world. It wasn't something to "shake a stick at" with a$2.75m resolution amount. The total amount for those 10 announcements so far in 2016 = $20,314,800 Of course the details are what we usually pay more attention to since it tells us exactly what OCR has a problem with in each case. It makes it clear what OCR wants all of us to learn from these folks mistakes. For more visit HelpMeWithHIPAA.com/69

The OCR audits have begun. On Wednesday, July 13, audit selected CEs where invited to a webinar. OCR staff walked through the processes they can expect for the audit and expectations for their participation. The OCR published information from the webinar so we had to check it out and share what we learned with you guys. For more details visit HelpMeWithHIPAA.com/68

Say it ain't so! Pokemon and a HIPAA breach really? REALLY! Creatures are showing up in offices and hospitals just like everywhere else. The concept of keeping people active and engaged with their surroundings while playing a video game seems like a great idea from a healthcare standpoint. And then you actually do a risk assessment of it - this is where the wheels fall off that good idea train. Get more details as HelpMeWithHIPAA.com/67

We first talked about this in Ep 62. Darknet sale of healthcare records. Now, more information is coming out and it gets more unfortunate for patients every time we read more. Deep Dot Web broke the news: https://www.deepdotweb.com/2016/06/26/655000-healthcare-records-patients-being-sold/ We picked it up on Data Breaches.net because they were trying to figure out who the entities actually were in each case: https://www.databreaches.net/damn-anyone-know-what-facilities-these-are/ Get more info at https://HelpMeWithHIPAA.com/66

What happened? March 23, 2013 Oregon Health & Science University notified HHS of a breach due to a stolen unencrypted laptop. May 1, 2013 OCR notifies them they are investigating the incident July 28, 2013 Oregon Health & Science University notified HHS of another breach resulting from storing ePHI at an internet-based service provider without a business associate agreement November 8, 2013 OCR notifies them they are investigating the new incident July 18, 2016 settlement announced for $2.7 million and a 3 year CAP What can we learn from this? Go to Help Me WithHIPAA.com/65

OCR recently sent out a message on their listserv asking if your CE or BA was ready for an incident. We have been discussing security incidents a lot lately so it is nice that OCR has brought it up. Because we have seen various Incident response reports recently, so we were working on an episode anyway. So this episode is a review of Security Incident Response Plan development. Let's first be clear, this isn't just about HIPAA. We also have been reviewing the Economist Intelligence Unit 2013 (EIU) report: Cyber incident response: Are business leaders ready?, which is asking the very same question. For more information go to HelpMeWithHIPAA.com/64

There has been a lot of news and industry discussions about Medical Device security. Medical Devices are just like a computer, so they also need security to protect the information on them. For more go to HelpMeWithHIPAA.com/63

A business associate is getting this OCR resolution, $650,000 and a two-year settlement. CHCS in Philadelphia is a BA to 6 skilled nursing clinics in the Philadelphia area. Entities like this do the business part of healthcare and the other clinics don't have to worry about it. An unencrypted iPhone that wasn't password protected had PHI on it. Patterson Dental Supply Inc. helps manage dental practice information for various providers. One of the clinics they help service is Massachusetts General Hospital, and 4,300 patients had their PHI hacked and compromised. For more info: HelpMeWithHIPAA.com/62

Since 2010, ID Experts has sponsored this Ponemon Institute study which has been tracking data breach trends of patient data at healthcare organizations. The annual economic impact of a data breach has risen over the past six years, as has the frequency of data breaches. Criminal attacks and internal threats are the leading cause of healthcare breaches. Evolving cyber attack threats such as ransomware and malware are of primary concern for 2016. At the same time, internal issues such as employee negligence, third-party snafus, and stolen computing devices continue to put patient data at risk. For more info on this episode go to helpmewithhipaa.com/61 28w47ezq

As always, during times of crisis and chaos things do become confused and incorrect statements are made. It is a normal occurrence in troubling situations. But, we need to address it specifically to clear up a few points. There was no "special waiver from the White House". There was no need for one at all. People, even in a crisis, should not be invoking HIPAA over caring for the patient properly. The hospitals talked about implementing their crisis plan - why wasn't HIPAA addressed in the plan. It should be! For more details go to HelpMeWithHIPAA.com/60

Today's podcast is a little different from our normal ones. We are covering a wide variety of subjects involving HIPAA, OCR, HHS, and PHI rather than one specific topic. For more go to HelpMeWithHIPAA.com/59

Preventing ransomware is a major concern for every business today. If not, it should be. This episode covers understanding ransomware and methods for preventing it. Is ransomware a phi breach? April record number of cases and not slowing down 8 hospitals (more by the time we record) already hit. Training and vigilance is best defense Ransomware attacks continue to evolve to be "smarter" For more see HelpMeWithHIPAA.com/58

HIPAA policy and procedure templates seem to be a panacea to many people who are just trying to meet the standards and move on. However, these are not the droids you seek! Templates can be the basis for what you need to do but they shouldn't be the solution to the written policy and procedure requirements under HIPAA. See HelpMeWithHIPAA.com/57

Two reasons for today's topic: A question we received from a listener about understanding antivirus software and a news report about a malware scan that interrupted a medical procedure. Between those two cases it felt like it was time to discuss malware protection under HIPAA. Suzie from Savannah: I would like to have a podcast or a quick answer to the different between anti-virus software releases and anti-virus definitions being up-to-date. I understand the AV definitions up to date but a little fuzzy on AV software releases and examples please.... Report came out about malware scan stopping a medical procedure

We always look at the security rule aspects of HIPAA because they deal with the easier parts for people to deal with when it comes to lowering their risk, but today we are diving into some privacy rule guidelines, because there is new HIPAA privacy guidance that has just been published. Get more info at HelpMeWithHIPAA.com/55

Recently, we ended up in several discussions about HIPAA access logs and what they really require with our clients. As per usual, any topic that comes up multiple times in my "real job" becomes a discussion for HMWH. So, today we are talking about HIPAA access logs to attempt to clear up some confusion we have encountered. There are multiple types of HIPAA access logs being created in most environments and you should be dealing with pretty much all of them in some manner. Get more at HelpMeWithHIPAA.com/54

We talked about OCR audits recently because they are in the news. The audit protocol is a perfect guide for developing and maintaining your HIPAA compliance programs. In fact, the audits have been a hot topic in the industry this month. However, the fact that only 200 audits will take place really means the audit protocol is more important as a guide for what your program should look like in the event you have a breach or complaint investigation. Statistically, you are much more likely to need it for that reason. Read more at HelpMeWithHIPAA.com/53

We really appreciate the support and feedback we have received for our little HIPAA podcast project known as Help Me With HIPAA. This episode marks one complete year of weekly HIPAA podcasts (counting the special bloopers holiday episode). We certainly learned a great deal since we started this little DIY project last year. Granted, David was a convert to the idea much quicker than Donna. Here we are one year later and our little HIPAA podcast is starting to gain some real momentum. That is all thanks to you, our listeners, for sticking with us through our growing pains as we fumbled through figuring it all out. Keep on sending in your questions and suggestions, we appreciate your help and support! Also, a special shout out to the silent member of our team Bojan Sabioncello for making us sound so much better once he came on board! After saying all of that, what are we doing for this special episode? We are interviewing each other to discuss how we ended up together and what we do in our "real jobs". this HIPAA podcast is a huge part of what we do but it isn't the only thing you get from us. For more information go to HelpMeWithHIPAA.com/52

We often talk about doing the "work" of compliance. Some people seem to have the attitude that all I need to do some is annual staff training and hand out a Notice of Privacy Practices to do small office HIPAA compliance. When we try to explain there is more to it than that we often get pushback about the requirements. We always hear comments like: we don't have time, we don't have resources, we can't be expected to do this. So, how DO you do small office HIPAA compliance? Today we are going to talk to someone who is definitely doing the work of HIPAA compliance in a small office. We are doing an interview with Erien Fryer of Medical Direct Care in Clarksville, TN to discuss small office HIPAA compliance issues, obstacles, and how to just get it done. For more details go to HelpMeWithHIPAA.com/51

Every website needs security. What questions should you be asking about your business websites and who should you be asking? Website security can be an open hole in your security plans. It can also be the source of lots of problems for your business if you don't pay attention to the site content or securing your message. More info on the website at helpmewithhipaa.com/50

The recent release of the new OCR audit protocol gives us new guidance on what they expect from HIPAA compliance programs. There is a great deal of information to sift through if you are so inclined. To make it easier for you we are discussing some of the details and things we have learned from reviewing it for you! So, here is our review of the new OCR audit protocol! For more details go to our website article helpmewithhipaa.com/49

In the first episode in our Disaster Recovery series that we will be doing this year we are discussing planning disaster recovery plans for flooding. This episode is an interview with Ginger McCleish who experienced a real world disaster recovery flooding in the St. Louis, MO area in December 2015. Hear more at HelpMeWithHIPAA.com/48

The latest HIPAA buzz is about things like Interoperability, Data Governance, Patient Access Rights, and, of course, OCR random audits. Donna attended HIMSS and the National HIPAA Summit recently. In this episode we discuss what kinds of things are happening in the industry relating to HIPAA. For more details visit our website at helpmewithhipaa.com/47

So far in 2016, we have seen four HIPAA enforcement cases resolved by OCR. One involved only the second Civil Money Penalty ever assessed. The three others were resolution agreements. Add those cases to what was done in 2015 and you have the most active 12 month period of HIPAA enforcement ever. Certainly, the first quarter of 2016 has been the most active quarter ever when it comes to HIPAA enforcement announcements. In this episode we discuss the cases resolved so far in 2016 and more thoughts on what is coming up for 2016. Read more at our website HelpMeWithHIPAA.com/46

Many times people ask: Why do we need HIPAA? Is HIPAA really necessary? The short answer is yes, we do need HIPAA and the reason is without it there is no baseline for protecting patient privacy. Learn more at http://helpmewithhipaa.com/45

Social media can be the source of many issues if you don't have a clear policy for use. HIPAA social media policies requires some serious thought and commitment from your management staff. What things are good use of social media and what things should be avoided through policy enforcement? Read more about HIPAA Social Media Policies at our website: helpmewithhipaa.com/44

It is clear that HIPAA disaster recovery and business continuity plans should include some level of ransomware response planning after the attack that shut down Hollywood Presbyterian Hospital. What kinds of issues should you expect and how can you mitigate the damage from a ransomware attack? Read more about our ransomware attack planning discussion on our website at helpmewithhipaa.com/43

To be certain you are protecting the health information in your organization you must identify where it lives and moves about around the network and workforce. A risk analysis can't be done properly without making that list first. Where should you look for PHI? If you don't store it do you store access TO it? Get more information for this podcast at HelpMeWithHIPAA.com/42

Trust but verify is the new standard when it comes to Business Associate relationships today. Yes, they must sign a BAA but you really need to ask some questions to confirm those BAs understand and are doing the things they have agreed to do for you. Covered Entities (CEs) haven't really worried about the details of the contracts too much as along as the vendors would sign them. Many vendors have signed, and continue to sign, BAAs without any concerns at all for what the contract actually says they are going to do in their business. For so many years a BAA was just something you had to sign in order to do the work in healthcare. It didn't matter at all if you did anything with it other than put it in the file with other ones you had signed. The new world of HIPAA compliance, huge data breaches, and civil fines and penalties means neither side of the contract can function that way any longer. It is imperative that HIPAA compliant vendors are vetted in some manner to confirm you really are protecting your patients, clients, business, and reputation. Get all the details at http://helpmewithhipaa.com/41

Get all the details at HelpMeWithHIPAA.com/40

More notes and links on the website at HelpMeWithHIPAA.com/39

More details on our website Also at the Atlanta's Most Trusted Advisors page:

Brittney Wilson, The Nerdy Nurse, joins us to discuss the clinical staff's HIPAA perspectives. More details at helpmewithhipaa.com/38

More details at helpmewithhipaa.com/37

HIPAA may show up in areas you haven't seen before. If you are assessed by any other organization or for any other reason, HIPAA questions may start showing up. We have heard about it being brought up in many areas: Insurance Policy Applications Partnership Negotiations Funding discussions URAC accredidation (formerly known as the Utilization Review Accreditation Commission) This episode is a discussion on why it is showing up in other places and why we expect that trend to continue. More details at helpmewithhipaa.com/36

ID Experts is in the business of dealing with privacy breaches. They have a variety of incident response services and tools. We discuss breach topics with Jeremy Henley, Director of Breach Services, ID Experts in today's episode. Detailed notes from the show can be found on our website at helpmewithhipaa.com/35

New Years Resolutions can be simple commitments to yourself and your compliance program effectiveness. When you have so many job responsibilities compliance often gets set to the side or "on the front left corner of my desk". These tiny changes can help you keep things moving forward without forcing you to spend a day or two a week. Detailed notes on the show can be found on our website at helpmewithhipaa.com/36

Since this episodes is being released on a holiday for all of us at Help Me With HIPAA, we are sharing a special blooper episode our audio editor Bojan Sabioncello created specially for us. When you hear our recordings from his perspective, you will see what a great job he does making us sound so professional.

Compliance officers need all kinds of help to get their jobs done. We came up with a list of ideas for gifts to help them out this holiday season. More details at helpmewithhipaa.com/32

Enforcement of HIPAA is changing There are many indicators that make us believe that we will see a distinct uptick in OCR enforcement activity. The last two OIG reports say OCR isn't doing enough, the news points out issues with enforcement, and even Congress is getting in the mix. In this episode, we discuss why this makes us think you don't want to wait around to see IF OCR starts doing anything differently. More details at helpmewithhipaa.com/31

The HIPAA legislation itself does not include the option for individual patients to sue any CE or BA that may violate their privacy protections included in the law. HITECH added the ability for the States Attorney General offices to file a cased on behalf of their constituents, however. The biggest change, however, is the ruling by several State Supreme Courts that allows a complaint to use HIPAA as a legal standard of care. That opens the door for all kinds of options. More details at helpmewithhipaa.com/30