Help Me With HIPAA

Everyone is ready for the great deals retailers offer on Black Friday and Cyber Monday. We have a list of low-cost and no-cost deals on HIPAA Security & Privacy tools for you! Episode 29: HIPAA Black Friday Sale More details at helpmewithhipaa.com/29

The Internet of Things (IoT) is already here, it isn't something that is coming. It is here and it is the future, it will just become more prominent in our daily lives.

If you expect your IT company to do certain things as a HIPAA compliant vendor you are more likely to have the level of support you need. If you don't ask then they may not be fully aware of what you need or what it requires to be HIPAA compliant themselves.

We review the latest OCR settlement CAP details.

This week we get in the Halloween spirit and share some scary stories that make you have those compliance nightmares.

Description Business Associates and required BAAs are discussed often but not resolved quickly. Let's talk about some ideas and issues that go with BAAs. Links FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes Who is a BA? A business partner who provides a service to a CE or BA that requires them to CReMaT PHI. Anyone with persistent access to ePHI whether they do anything with it or not is irrelevant - the fact that they CAN do things is what matters. Complexity is increasing Dietitians at hospital needs info on the scripts for the diet but the employer never stores, accesses, or has persistent access to it but the workforce needs to see it. CE should train them on Privacy rules.BA means it is not your data but you have it or have access to it from the owner of CE. Medical director could be a BA or could be workforce member depending on the contract they have with the employer. ACO formed by hospital as a completely separate legal entity But the ACO is staffed by hospital employees Plus the hospital provides IT services to the ACO legal entity Now that would make the hospital a BA of the ACO which is really the hospital. So, the hospital is a BA to itself Maintaining PHI vs. maintaining facilities with PHI Data center where you store your servers. Are they a BA? NO. They are just the landlord for your server - so they aren't a BA YES. Physical, Administrative, Technical Safeguards are used to protect it, though You are outsourcing part of your obligations because they are doing a all of the physical safeguards for you so you should make them a BA Can be argued both ways but 2 out of 3 lawyers said BA plus a poll of room says they are a BA not just a landlord BCBS of TN left drives at old office and landlord was securing the site Why is there was no BAA if that is the case was the OCR response Resolution didn't mention the BA argument but it was an expensive fine that clearly showed the OCR lawyers didn't see they were protected sitting in a closet of the facility you used to lease. If you sell server space and store encrypted PHI you are a BA under current guidance. Many will argue this point though. You have to be prepared to decide for yourself Even if you don't treat them like a BA, then you should have an agreement of some sort that protects the PHI OCR working on Cloud Computing Guidance Security Rule from early in this century couldn't really consider all the things that are done today Before cloud computing when everyone has their own servers in their offices or owned huge data centers You can't just counter this issue with making everyone sign a BAA, though. Bad for the business that signs them and either fails to comply or does the work they may not need to be doing. Bad for you because you are managing contracts that don't need to be managed and opening up cans of worms we haven't even found yet. Make a decision about your business and be prepared to explain your logic If you are doing the work of a BA you are still a BA without signing a BAA Included in BAA We are not lawyers but we are talking about the contracts just a little bit here Ask your attorney for advice on this stuff, don't relay on us or any other consultant for that advice Also, get a HIPAA attorney - not a tax attorney You should be reading these things, not just sign them Indemnification can be included and you need to know what you are committing to Insurance requirements Yours, mine, ours for cybersecurity What does it really cover - not just if you have it New complexity to negotiations because you don't cover a max level that your big groups need State law requirements 60 days - how far down the BA tail could it go with 60 days to notify Shorten the days but not too short But give them time to figure stuff out unless you want to know about incidents that turn out to be ok Breach notification responsibilities Can the BA notify a huge number of people within 60 days do they even have the resources to make that happen? De-identification of PHI clause is there to prevent selling of data They don't have to take out the doctor's name if they take out all other PHI That means some of your valuable info could end up in a file that gets sold because it has no PHI in it. Indemnification What liability limits are you going to include If I am acting reasonable then I shouldn't have to bear the whole burden but if I am reckless then it is fair to put most of the burden on you The Security Rule may not go far enough but you can up the ante in your agreements Should you require encryption be used both at rest and in transit Agreements may start to specify exactly what security standards you must adopt which creates new problems Assessing BAs I have a BAA so I don't have to worry - not a good idea Does HIPAA even apply if they are off shore? US Law doesn't apply in other countries - do you know where your PHI really lives? CE is not responsible for acts of BA with a signed BAA but If you are aware of a pattern of non-compliance then

Description We explained the concepts of encryption in Episode 2: Let’s Talk Encryption but people continue to ask more about what they really need to do with encryption. Links FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Episode 2: Let’s Talk Encryption The government and privacy advocates can’t agree on what ‘strong’ encryption even means Notes First, what can encryption do for you and what it can't do for you. VPN, HTTPS, SSL, SFTP, etc. Protect communications from prying eyes. Everything else is about encrypting data on the devices themselves. If you encrypt data on a device but you are hacked when you are logged into the device, encryption isn't too helpful. Encryption is helpful when someone tries to access the data on the device without your key (or password). Strong Encryption is also subjective - there is no solid authority on what is really strong encryption because law enforcement wants a back door. What does HIPAA say about encryption? Encryption (Addressable). Implement a mechanism to encrypt electronic protected health information whenever deemed appropriate. Not very helpful....... What does OCR say about it? At NIST / OCR HIPAA 2015 conference: If it moves it should be encrypted. Now that's a line that can be drawn. Encryption of your files stored in the cloud (certainly something that moves) File encryption by an app on the computer over specific files like 7Zip Windows built in encryption - Bitlocker, EFS NAS and Flash drives with built-in encryption Encryption on your phone built-in Cloud based encryption management - MDM - Alertboot, MaaS360, Manage Engine https://www.manageengine.com/mobile-device-management/ Create an encryption plan: Includes all devices - laptops, phones, external drives, etc. Specs required like AES 128 or FIPS should be written down Methods used for implementation on all types of devices Encryption key management plan Audits and verification plans

Cybersecurity coverage being challenged in court has some important points that all businesses should consider. Links FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Help Me With HIPAA Notes COLUMBIA CASUALTY COMPANY v. COTTAGE HEALTH SYSTEM Data breach occurred Breach announcement said: Between October 8, 2013 and December 2, 2013, PHI of approximately 32,500 patients on the CEs servers weredisclosed to the public via the internet. Hospital got voicemail message from a third party, who informed it that he was able to read the PHI online. Patients seen Sept. 29, 2009, to Dec. 2, 2013 included names, addresses, DOB, MR#, Acct#, diag, lab results and procedures performed. No financial information or Social Security numbers were involved Insync, their IT vendor at the time, left anonymous access for FTP traffic active on an internet servers on or about Oct. 8, 2012. The change allowed ePHI to become available to the public via Google's internet search engine. The server was taken offline immediately on Dec 2 once the call came in. Insync doesn't mention healthcare on their website any more People make mistakes even the IT folks - theirs are just big ones Law Suits and Investigations Civil Suit filed January 27, 2014 and settled December 2014 $4,125 million along with related expenses and attorneys'fees 50,917 patients included in the settlement On-going investigation for HIPAA violations currently Involves CA Dept of Justice and likely OCR The DOJ Proceeding will determine whether Cottage complied with itsobligations under HIPAA and any other pertinent state and federal laws and may potentially result in the imposition of fines, sanctions or penalties. Insurer Columbia Casualty filed suit Saying they shouldn't have to pay the claim for the $4.1 nor any expense they have or will incur over this case Columbia also seeks a declaration of its entitlement to reimbursement in full from Cottage for any and all attorney's fees or related costs or expenses Columbia has paid or will pay in connection with the defense and settlement of the class action lawsuit and any related proceedings and an award of damages consistent with such declaration. INSYNC, the IT company, does not maintain sufficient liquid assets to contribute towards the proposed settlement fund and does not maintain liability insurance that applies with respect to the privacy claims asserted in the Underlying Action. Why does Columbia think they shouldn't pay? The Columbia Policy contains the following exclusion: Whether in connection with any First Party Coverage or any Liability Coverage, the Insurer shall not be liable to pay any Loss: Failure to Follow Minimum Required Practices based upon, directly or indirectly arising out of, or in any way involving... Any failure of an Insured to continuously implement the procedures and risk controls identified in the Insured's application for this Insurance and all related information submitted to the Insurer in conjunction with such application whether orally or in writing; This Policy shall be null and void if the Application contains any misrepresentation or omission: a. made with the intent to deceive, or b. which materially affects either the acceptance of the risk or the hazard assumed by the Insurer under thePolicy. The Columbia Policy application contained the following questions that were answered by the hospital Do you check for security patches to your systems at least weeklyand implement them within 30 days? • Yes Do you replace factory default settings to ensure your informationsecurity systems are securely configured? • Yes Do you re-assess your exposure to information security andprivacy threats at least yearly, and enhance your risk controls inresponse to changes? • Yes Do you outsource your information security management to aqualified firm specializing in security or have staff responsible forand trained in information security? • Yes Whenever you entrust sensitive information to 3rd parties doyou... contractually require all such 3rd parties to protect thisinformation with safeguards at least as good as your own • Yes perform due diligence on each such 3rd party to ensure thattheir safeguards for protecting sensitive information meet your standards (e.g. conduct security/privacy audits or review findings of independent security/privacy auditors) • Yes Audit all such 3rd parities at least once per year to ensure thatthey continuously satisfy your standards for safeguardingsensitive information? • Yes Require them to either have sufficient liquid assets ormaintain enough insurance to cover their liability arising froma breach of privacy or confidentiality. • Yes (Which INSYNC did not) Do you have a way to detect unauthorized access or attempts toaccess sensitive information? • Yes Do you control and track all changes to your network to ensure itremains secure? • Yes Failure to Follow Minimum Required Practices is clear according to the ins company which is why they shouldn't have to pay fail

Show Notes If they were shocked that no one was actually watching for security holes at Ashley Madison you can bet they will be shocked that you haven't been looking because Healthcare is supposed to be private. Ashley Madison: Nobody was watching Top 10 Tech Companies with Ashley Madison Accounts What kinds of things do you need to do to actually be considered looking for them, though? HIPAA Compliant IT Router / Firewall test showed 600% Increase in Unique Vulnerabilities Discovered Last Year (OCR / NIST conference) Within hours or days of a release of software (firmware) vulnerabilities will be identified. Keep firmware up-to-date UTM - what is a UTM not just a router off the shelf at best buy IPS Antivirus Support Subscription! Reporting each month - look at what is going on - if you have IT they can do it but you should be asking them for reports. Printers / Copiers easy for hackers to get to first Smart TVs Patching helps when Hackers Start with "low hanging fruit" Beginning hackers look for easy challenges to practice their skills Vulnerabilities for sale to each other They just want in to see what you have and then see where they can go Hacktivist - target you because of who works there or who you treat or your type of business There is no way to know how many different parts of software are used from all over the world on any device or in any given application today No list of ingredients on the back of your router or mobile device None of this is new We have all talked about it but no one listening to the security people until it happens at your business, office, or home 10 vulnerabilities account for nearly 97% of all exploits Write little script yourself you could be opening a hole because you don't realize there are security implications to what you just wrote Doctor convicted of illegally accessing medical records Doctor having an affair and looked at the mistress' medical records. Looking to see if she had STDs. Plead guilty in federal court and kept his license but must be monitored.

Show Notes When it comes to securing anything the weakest link in the chain is always people. People are the ones who make mistakes, over-share, and are also the criminals. This episode talks about what people can manage to do so you have to think of all kinds of things outside the norm. University of Pittsburgh MC BA breach after being hacked the year beforeEmployee of the billing service call center copied personal information from the billing system. 2,259 patients were then passed on to a third-party. Notification that it happened came from FBI. Last year UPMC was hacked and employee information taken for all 62,000 employees. Over 800 employees reported ID theft. Oakwood Healthcare worker fired for HIPAA-violating Facebook commentsTerminated after posting disparaging comments about a patient on her Facebook page. Worked at a hospital that had to treat a suspect in a police shooting. Her posts were pointing out her disgust in having to treat him. It is still a violation. Roanoke, Va. Carilion Clinic - 14 employees admitted snooping Found it by random log reviews. Previously, only checked on patients where a big new story was happening. Physician Suffers Second 2015 Data Breach Break-in in Jan requires breach notification to 350 patients. Break-in again in March they got computers and patient charts. The computers were not encrypted and they had patient info OTHER THAN THE LETTERS to the 350 patients. This time the total patients involved are 1,342. At this point they hire a security guard who stops a third break-in. The doctor is moving their office to a new town. Encryption could have saved a lot here, increased security after the first break-in would be the most obvious requirement. That is a simple decision that was just not made. Now over 4 times the number of patients are involved. Doctor convicted of illegally accessing medical records Doctor having an affair and looked at the mistress' medical records. Looking to see if she had STDs. Plead guilty in federal court and kept his license but must be monitored. Final Note Medical is years and years behind other industries on security requirements and criminals are figuring that out. Plus, those that are way ahead are getting breaches like Home Depot, Target, and more. In all those cases there was a person somewhere involved in the process, in some cases several people made mistakes are took the wrong action.

Mobile devices are vulnerable just like your network, servers, laptops, and desktops. Your risk analysis should include checking on any types of messages, pictures, or access to your data that can be done on your smartphones. Even if you don't put PHI on them they may be able to be used against you in some way to crack your network and your PHI. Patches Android updates and know your version of Android Wipe leaves some stuff on old Android versions iOS updates and know your version Windows is so small market share but mention it Encryption Android Option to encrypt this device Lock screen setting to wipe device after X failed logins iOS data protection turns on with password set set to wipe if after X number failed logins MDM - Mobile Device Management What is it What can you do with it BYOD - Bring Your Own Device Set rules to follow Do checks for software updates Don't let kids play with phone MDM? Backup If you lose the phone or it dies will you lose important things? Figure out a backup plan but make sure it is properly secured too. Unsecured WiFi and Bluetooth Try not to use it unless necessary Bluetooth can be used to connect to your phone within 30 feet Personal WAN can be used to jump on your connection and use your data plans Final Notes Understand this is the new frontier for hackers. Ransomware and malware for smartphones are growing quickly

Let's review email systems and how they can be secured for ePHI and other sensitive data. Find Healthcare IT HIPAA For MSPs Kardon Compliance Alston Article on Email Security Notes Leigh from Florida sent us an email asking for us to explain some more specifics about email. She had been listening to Episode 8: HIPAA Myths Part 2 which mentioned it but she had specific questions how can email be secured. This couldn't be covered in a quick 5 minute HIPAA answer episode so we are doing a whole episode. How does email work - for "real people" to understand Compare to the post office since that is the way it was originally modeled to match Why that isn't secure at all, really http://www.healthcareitnews.com/news/hipaa-breach-letters-go-out-after-email-hack (article on email hacked and it had patient info in it) open transmissions and many different servers Misconceptions I use a password so it is secure I use https so it is secure I use TLS so it is secure I use updated Outlook with Hosted Exchange so that should be secure Secure email via End to end encryption tools - each party knows the key Messaging system - you get an email telling you to log in to get the secure email Hosted services that allow for specific types of messaging Hosted exchange Plug-in apps Secured internal only messaging systems Very specific set up to secure the mail database on your internal server Controls you have in place to prevent email to other domains outside the secure system (usually software required) Some systems are automatic encryption / others require you to hit a button on the mail to send it secured. Secure messaging systems for internal discussions that don't use email whole new way of communications in forums / chats instead of email Texting also matters but that is a different episode we can touch on it here A word about spear phishing - excellent example this week from a client

Links ComplyAssistant FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes Who is Gerry Blass Been in healthcare for the long ride Consultant for years Now consultant and software company ComplyAssistant - when did you start development and what was your vision for it? What kinds and size of clients do you have - hospital, practices, BAs and CEs of all types ComplyAssistant features Due Diligence for BAs Contract management Incident Management Project Management Documentation, Documentation, Documentation Management Importance of having a documentation and management system of some sort in place Why ComplyAssistant instead of using a spreadsheet / folder approach?

Culture of compliance is the phrase OCR uses when defining what they are looking for in an audit or investigation. They also use the phrase robust compliance program in the same manner. Using these steps is a great way to make sure your organization is following their lead. Links ComplyAssistant Compliance Management Solution Spher EHR Access Monitoring Solution FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes 7 steps to improving your Privacy & Security policies and procedures and nurturing a Culture of Compliance: Designate a Compliance (Privacy & Security) OfficerFirst, the law requires you do this. But, if no one is in charge then nothing will happen, we all know that to be the case. Or, in a vacuum of leadership someone else will take charge and handle things the way they think they should be done without the support of management. Train and educate your staff and BA partnersConstantly restating the same information over and over in a variety of ways may be annoying to some but that means they have heard it! Also, don't forget to work with your BA partners to confirm they actually understand what HIPAA compliance requires in their organizations. Implement an ongoing Compliance maintenance solutionThis is what we talk about using tools such as ComplyAssistant, Spher, and professional MSP monitoring and management applications. Either use the tools or develop manual internal controls and processes to accomplish those same documentation and audit tasks on a regular basis. Conduct regular and complete audits and monitoring of all ePHI systems If you are ignoring it then so will everyone else in your organization. Monitor and respond to Incidents in a timely manner (State & Federal regulations)We all freak out together as soon as we know something could havehappened to our PHI. Adhere to a strict breach remediation protocolDefine your breach plan and use it every time. After any case that it was used, then review it to make sure you don't need to change or add things in the plan. Create a open line of communication for management and staffThe law requires you to never retaliate towards any person who files a complaint or reports a problem including a breach. If you don't make it clear that you fully support that rule and all workforce members are free to ask any question, file any complaint, and report any concern then you will likely be missing things just because someone was afraid to tell.

In 2014 NIST introduced the National Cybersecurity Framework (CSF). It is designed for all businesses, large and small, to know things they should be doing to protect their businesses, data, customers, and more. Just how does it compare to HIPAA? Notes NIST Cybersecurity Framework DHS Getting Started for Small and Midsize Businesses (SMB) US Chamber of Commerce: Internet Security Essentials for Business 2.0 C3 Voluntary Program: Begin the Conversation: Understand the Threat Environment FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes It's not just HIPAA. All the different guides spell out the same basic concepts.For example: NIST - Cybersecurity Framework US Chamber of Commerce: Internet Security Essentials for Business 2.0 STRONG SECURITY IS SMART FOR BUSINESS AND THE NATION COMMON THREATS TO BUSINESS INFORMATION Hacking and Malware Lost or Stolen Physical Storage Media Insider Threat and Human Error Accidents and Natural Disasters CYBERCRIME ON THE RISEINTERNET SAFETY AND SECURITY FUNDAMENTALS Set Up a Secure System Protect Business Data Train Your Workforce Be Prepared ADD BUSINESS VALUE THROUGH INFORMATION SECURITY NATIONAL AND PRIVATE SECTOR PERSPECTIVES Cyber Essentials to Protect Your Business: Managing Cyber Risks in a Time of State and Non-State Threats to Business Security and Resilience - Hosted by US Chamber of Commerce FBI - Deputy Director DHS - Undersecretary for Cybersecurity Secret Service - Atlanta Office Cybersecurity Team Army Lt Col - Cybersecurity Command

An interview with Ray Ribble discussing the AMS Spher product. We learn how Spher can automatically "learn" what access patterns are normal and ask you when something isn't right. Your HIPAA compliance requirement to audit access logs may be solved with this tool. Your very own HIPAA Breach Detection Service! Links The AMS SPHER™ Solution FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes Who is AMS and Ray Ribble? Tell us about The AMS SPHER™ Solution. Behaviorial Analytics SPHER leverages pattern recognition algorithms to determine if there was suspicious behavior on the EHR. It does this by comparing past behaviors to behaviors in the audit log file SPHER is currently reviewing. For example, SPHER may have learned over the past months that an EHR user named John is typically active between 8 AM and 4 PM. In the current audit log file, SPHER notices that John was active on the EHR from 4 PM to 12 midnight which causes SPHER to send you an unusual time of access alert. It Learns! You know that John’s shift recently changed from 8 PM to 4 AM. Going through the SPHER incident resolution process, you indicate that this behavior is Normal and Permitted. Based on this feedback, SPHER has now learned that this is normal EHR behavior for John and will not send an alert the next time it sees EHR activity for John during this new time span. As normal behavior on your EHR changes, SPHER learns and does not send false alerts for behaviors you’ve already indicated are normal.

Description What a HIPAA Risk Analysis includes and why you need it for your cybersecurity risk management. Glossary CReMaT'ed - Create, Receive, Maintain, Transmit CIA - Confidentiality, Integrity, Availability Links JPP Medical Record OCR Guidance on Risk Analysis Training Documentation for this episode FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes Not a simple checklist it requires a lot of thought, data collection, and analysis. The analysis part Define where e-PHI is CReMaT'ed in your organization. Not just the server that holds the EMR. Cloud apps used, messaging tools, mobile devices, USB storage devices, home computers Practice Management system and data analysis tools Don't forget to include downloads folders and temp folders on all PCs. Do you need to worry about vendors or consultants - your BAs that may move data around your network, systems, etc. If they handle it for you do you even know where it is going? What are the threats to the CIA of the PHI that you have located and identified above? Human Natural Environmental What would be the impact to your business if the threat did act against your PHI? Would it be a bump in the road or a sinkhole? What is the likelihood this threat will actually act against your PHI? Very likely down to not likely at all With all this considered what level risk do you think this threat creates to your PHI? High, Medium, or Low Based on everything you know then you decide what you are going to do about the threat and the risk it presents? Accept the risk is just part of doing business Address the risk with some type of safeguards in your organization Outsource the risk by hiring another company to handle managing it for you The assessment part At this point, you review that plan you have just made to address risks against what you are actually doing Are doing everything you can to protect the PHI and meet your obligations under HIPAA laws from all those threats? If you are outsourcing threat management, have you made sure your BAAs are in order? If you are handling it internally do you have all the written policies and procedures Is your staff trained to respond accordingly? Once you complete that process you draw up your final report on what was determined during your analysis and assessment. What actions need to take place to address those threats and what priority should be applied to them? This is your full analysis and assessment report that you will use to inform your decision making process for your security policies and procedures. It is also the report you will review and update on a regular basis. Sometimes minor updates are needed but other times you will need to do most of the whole thing over if there is a major change in your business.

We have a listener who called in with an example situation to find out what we thought. Is the company a Business Associate? Listen to Donna's answer in Episode A2. These short "answer episodes" are released weekly on Tuesday mornings when we have them come in. Send us your questions and we will publish them with our thoughts and the best answers we can muster! Use the Website form or Speakpipe voicemail You can also find all our social media contact information at HelpMeWithHIPAA.com.

Description A Breach Response plan is a required element of your compliance program since HITECH became effective. Everyone must have a written plan and know what needs to be done. Glossary NIST National Institute of Standards and Technology Links NIST SP 800-61 Revision 2 - Computer Security Incident Handling Guide APDerm Resolution Agreement See item 2(2) FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes Establishing an incident response capability should include the following actions: Creating an incident response policy and plan Written required - already had an OCR resolution that mentioned not having one (APDerm - $150,000) Developing procedures for performing incident handling and reporting Who is your "go to" team for forensics Setting guidelines for communicating with outside parties regarding incidents PR will be critical for reputation managment Selecting a team structure and staffing model Someone has to be in charge of the whole thing and then others in charge of the parts. Establishing relationships and lines of communication between the incident response team and other groups, both internal (e.g., legal department) and external (e.g., law enforcement agencies) Bigger organizations need to know who is responsible for talking with each department. Determining what services the incident response team should provide How far is the team going through the process? Will they pass off follow up or will they do all the activity required from beginning to end. Again, large organizations need to worry about this. Staffing and training the incident response team Make a written list and have the team meet regularly to review how to respond to any incident that may come up in the organization.

How do I get rid of my printers properly? Find out in HIPAA Answers Episode A1. Thanks for our listener questions that are coming in! It took us a bit to work out the best way to get back to you, so sorry for the delay. Today we introduce, HIPAA Answers episodes. These short "answer episodes" will be released weekly on Tuesday mornings. Send us your questions and we will get them answered. Lots of ways to contact us below! Website form or Speakpipe voicemail Twitter LinkedIn Facebook Google+ Send us an email

Description A discussion of the findings in the recently released study concerning healthcare breaches in 2014. Glossary A managed service provider (MSP) is a third-party contractor that is under contract (usually a monthly fee) to provide on-going technology support to other organizations. Links Fourth Annual Benchmark Study on Patient Privacy and Data Security Criminal Attacks: The New Leading Cause of Data Breach in Healthcare FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes Represented in this study are 90 CE and 88 BAs. This year is the first time BAs were added to the study data. Previous fours years only CEs were included. A security incident is defined as a violation of an organization’s security or privacy policies involving protected information such as social security numbers or confidential medical information. A data breach is an incident that meets specific legal definitions per applicable breach law(s). Data breaches require notification to the victims and may result in regulatory investigation, corrective actions, and fines. Points to note: There has been a 125% increase in breaches due to criminal attacks on healthcare data over last 5 years. Only 40% of healthcare organizations and 35% of BAs are concerned about cyber attackers even though it is now the number one reason for breaches and increasing rapidly. Security incidents that aren’t breaches are also primarily criminal attacks: 78 percent of healthcare organizations and 82 percent for BAs security incidents. 87% of BAs had multiple security incidents in the past 2 years involving the exposure, theft or misuse of electronic information. 70% say they have had between 11 and 30 electronic information-based security incidents. Most involved the exposure of less than 100 PHI records. Medical identity theft has nearly doubled in five years, from 1.4 million adult victims to over 2.3 million in 2014. Employee negligence remains a top concern when it comes to exposing patient data inappropriately. Many victims of medical identity theft report they spent an average of $13,500 to: Restore their credit, Reimburse their healthcare provider for fraudulent claims and Correct inaccuracies in their health records. According to the findings of this research, the average cost of a data breach for healthcare organizations is estimated to be more than $2.1 million. No healthcare organization, regardless of size, is immune from data breach. The average cost of a data breach to BAs represented in this research is more than $1 million. Even though organizations are slowly increasing their budgets and resources to protect healthcare data, they continue to believe not enough investment is being made to meet the changing threat landscape. Interesting question details:

ONC recently published an updated guide for Privacy and Security of Electronic Health Information. This episode David and Donna discuss what that guide calls the Seven-Step Approach for Implementing a Security Management Process. Links Guide to Privacy and Security of Electronic Health Information FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes The 7 Steps Step 1: Lead Your Culture, Select Your Team, and Learn Assign your officers, make sure they are trained, show compliance is a top down commitment Step 2: Document Your Process, Findings, and Actions If you can't prove it then it didn't happen. Document your decisions, plans and activity Step 3: Review Existing Security of ePHI (Perform Security Risk Analysis) Review or perform your Security Risk Analysis and current security assessment Step 4: Develop an Action Plan The plan needs to address all the things you identified in your assessments, policies, and procedures Step 5: Manage and Mitigate Risks This is where your project management skills come into play making sure you have addressed all the risks in your Analysis and new ones aren't showing up Step 6: Attest for Meaningful Use Security­Related Objective If you are attesting make sure you have done the previous steps Step 7: Monitor, Audit, and Update Security on an Ongoing Basis Remember it isn't a project that has a beginning and ending date

We finish up our discussion about some common myths (or points of confusion) surrounding HIPAA compliance requirements. GlossaryMyth is a widely held but false belief or idea. Links HealthIT.gov Top 10 Myths of Security Risk AnalysisHealthIT.gov Guide to Privacy and Security of Electronic Health Information Analysis Notes 1 - 7 of 10 Covered in two previous episodes. HIPAA covers all PHI no matter who possesses the information. False. HIPAA law applies to entities that are health plans, healthcare clearinghouses, and most healthcare providers and the businesses that create, receive, maintain, or transmit PHI on their behalf. Not every person or organization that possesses PHI falls under the CE or BA categories of HIPAA. A one hour video course is all that a compliance officer needs to implement HIPAA in any organization. Mostly false. The law requires you have an educated person in charge of privacy and security compliance. It does not define what that education should contain. I can't imagine how anyone could do it with such little training. Nor do any others who do the job themselves. Training is essential to understanding the requirements enough to perform them. HIPAA training requirements are met with an annual training for all employees. Mostly false. It could be argued that all is required is a quick reminder/refresher course. However, the amount of training provided for privacy and security awareness is directly related to the results you will get from your workforce. If you don't worry about it more than once a year, neither will they.

We continue our discussion about some common myths (or points of confusion) surrounding HIPAA compliance requirements. GlossaryMyth is a widely held but false belief or idea. Links HealthIT.gov Top 10 Myths of Security Risk AnalysisHealthIT.gov Guide to Privacy and Security of Electronic Health Information Analysis Notes 1-3 In previous episode Communicating with patients via email, fax, or telephone violates HIPAA. Actually, not true. But.... reasonable and appropriate safeguards must be in place. HIPAA compliance is just like all the other compliance rules for other industries. You learn the requirements and you do what they say. Not at all true. HIPAA rules were designed to allow for every size and type of healthcare entity and business associate to use one set of regulations. That means there are phrases like "reasonable and appropriate" thrown all over them. Every single organization can determine what is reasonable and appropriate for their environment as long as they document how they are addressing the standards. Not even a risk analysis has one method to be performed across all organization. A website is HIPAA compliant if it uses HTTPS. False. There are two parts of electronic compliance security. You must secure data in motion (like when it is transmitted to a web page via HTTPS). You must also secure the data at reset (what happens to the data once it gets to the server on the other end). Just letting a web designer throw up a registration form or appointment request form will not meet the compliance standards for HIPAA by simply adding HTTPS. If a vendor signs a Business Associate Agreement there is nothing else for me to worry about concerning them. False. If you have knowledge that a vendor is not compliant and you continue to use their services simply because they signed a BAA you aren't much better off than if you never signed one. Your liability is still tied to the fact that you don't have a compliant BA. By working with them while knowing (or doubting) their compliance understanding and commitment makes you complicit in any failures they may have with PHI. Perform a due diligence of some sort to get assurances they actually have a compliance program in place. 8-10 In next episode

we discuss some common myths (or points of confusion) surrounding HIPAA compliance requirements. Glossary Myth is a widely held but false belief or idea. Links HealthIT.gov Top 10 Myths of Security Risk AnalysisHealthIT.gov Guide to Privacy and Security of Electronic Health Information Analysis Notes Providers are not allowed to share information about a patient with others unless authorized by the patient to do so. False. Providers can share: With anyone the patient identifies as a caregiver When the information is directly relevant to the involvement of spouse, family member, friends, or caregivers. (Ebola for example) When necessary to notify a caregiver about a change in condition or location of a patient (as long as the patient doesn't object) When in the best interest of the patient regardless of their ability to object or not The security risk analysis is optional for small providers and business associates. False. Everyone is required to abide by the Security Rule which specifically requires a security risk analysis. A checklist will suffice for the risk analysis requirement. False.Checklists are tools for doing the analysis and gathering your data but they aren't enough to meet the risk analysis requirement. A Security Risk Analysis must include three main elements (according to OCR guidance): A. Identification of all PHI sourcesB. Human, electronic and environmental threats to the PHIC. Review of current security measures to protect the PHI from those

In this episode we discuss technology support requirements under HIPAA and why professional, HIPAA compliant IT services are an important part of managing your security compliance. The Security Rule has so many specific technical things to consider it really requires professional technology services to handle it properly. We discuss why that is needed and what to expect from a HIPAA Compliant IT company. Glossary A managed service provider (MSP) is a third-party contractor that is under contract (usually a monthly fee) to provide on-going technology support to other organizations. Links FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes

In this episode we discuss the importance of documentation for your HIPAA compliance program. You can be doing everything right but without documentation there is now way for you to show anyone else that is the case. If you can't prove it then you aren't doing it as far as OCR is concerned. Glossary A managed service provider (MSP) is a third-party contractor that is under contract (usually a monthly fee) to provide on-going technology support to other organizations. Links FindHealthcareIT HIPAAforMSPS.com KardonCompliance.com ComplyAssistant.com Notes OCR says "don't just tell me you are compliant, show me you are" What do you need to document Policies and Procedures, including archive history Risk Analysis and Risk Assessment Training for workforce (who, what, where, when) Risk Mitigation project plans Issue/Incident details BAAs and BA Due Diligence Activity monitoring reports and logs Audit plans and results Assessment plans and results Inventories of software, hardware, etc Breach response plans and documentation Spreadsheets and documents in folders or document management tools Compliance Management tools

In this episode we discuss how to take the first steps to building a "culture of compliance" in your organization. Every project has to start somewhere but where do you start with something as big and complicated as HIPAA? Well.... Just like the joke goes "How do you eat an elephant?" "One bite at a time." How do you break HIPAA Compliance into bite sized pieces and get your project moving? We have some tips for you. Glossary A culture of compliance is when an organization establishes standards, rules, and policies that aren't simply distributed to the workforce. The organization as a whole takes their compliance serious at a personal level. Each person agrees to abide by the standards, rules, and policies set forth and holds themselves accountable to each other for doing so. This culture can only be accomplished if it is done from the CEO all the way down the organization to the volunteers and/or temporary employees. Links Posts From Donna's Blog SmallProviderHIPAA.com How do you create a culture of HIPAA compliance? HIPAA Documentation AKA Telling Your Compliance Story How long will it take to get HIPAA compliant? Simple HIPAA Checklist – Well Sort of 5 Tips to Just Get Your Risk Analysis Done Please, Just Do My HIPAA For Me! Notes What is a culture of compliance? What are the parts I need to build a culture of compliance? Established and supported by Senior Mgmt Integrated into all training and education done for the workforce Programs are designed to reward compliance Sanctions are applied equally to all levels for failure to comply All technology is reviewed and managed with compliance in mind Every decision, project, addition, and subtraction to the business includes considerations for compliance How can you really break HIPAA into small bites? Documentation management plan Business Associates Privacy Security Breach How to motivate myself to take the first bite of the elephant? Every single week start with one task that must be completed Policy or procedure reviewed BA evaluated and audited Procedure audited Training class attended Allocate time to complete a task each week It isn't something you do last, it should be something that is as important as completing you accounting reports, payroll, accounts receivable management, etc. Build the habit or assign it to someone who has the time to apply to getting it done. Build on what you started HIPAA compliance is never "done"

HIPAA requires encryption in transit and lists encryption at rest as addressable. What does all that mean?

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In this episode we discuss the definition of a Business Associate. How do you find your Business Associates and what should your process for managing them include. Glossary A managed service provider (MSP) is a third-party contractor that is under contract (usually a monthly fee) to provide on-going technology support to other organizations. Notice of Privacy Practices (NPP) is the document CEs provide to patients when they begin treatment or coverage. It is the document that defines the CEs Privacy, Security, and Breach Rule commitments to the patient. Links WEDI BA Decision Tree WEDI Business Associates & HITECH Deep Dive FindHealthcareIT HIPAAforMSPS.com Kardon Compliance Notes 1. Anyone that CReMaTs PHI on behalf of a CE or another BA Another way to think of it Produced, Received, Saved, Transferred 2. Upstream and Downstream BAs 3. BAAs and what they really mean 4. What are BAs supposed to do? Security Rule, Breach Plan, Portions of the Privacy rule. OCR - do what CEs are required to do. 5. BA Due Diligence 6. Finding them in your organization. 1099s, subcontractors, software vendors. 7. Don't go crazy making everyone a BA - Incidental exposure applies for electricians and others.