Author: Suze Shaffer

Suze Shaffer is the owner and president of Aris Medical Solutions. She specializes in HIPAA compliance, risk management, and cyber security. She believes that by educating her clients in understanding why and what needs to be done to protect their practice they have a better outcome. Suze has been instrumental in helping clients nationwide with risk management, implementing privacy and security rule policies and procedures, and ultimately protecting patient data. She includes state and federal regulatory requirements to ensure clients are protected in all areas. She has spoken at numerous conferences and functions. She continues to educate organizations how to minimize the risks of data breaches. HIPAA compliance is not an option, it is mandatory for every organization that comes in contact with protected health information to have reasonable and appropriate security measures in place. Unfortunately, most organizations don’t realize they are not compliant until they suffer a data breach or they are faced with an audit or investigation. Did you know that the Office for Civil Rights (OCR) is the agency that investigates data breaches? Have you seen the heavy fines that have been imposed for non-compliance? All 50 states now have their own set of privacy laws and the State's Attorney General may also investigate privacy violations!

2019 HIPAA Updates

Suze Shaffer February 12, 2019June 29, 2022

As we start this new year we must reflect what we have learned from 2018 in order to make 2019 a success.

The Office for Civil Rights (OCR) has gained momentum in enforcing HIPAA violations. With that said HIPAA is an ongoing process and once is not enough. It is not considered done unless it is documented. At the annual conference this past year, the OCR admitted they are adamant on ensuring your patient’s information is protected. Therefore, you must document your compliance. If you say you did something, they will ask for your documentation. If you do not have documentation, you will be fined.

Companies located in United States are now required to adhere to the General Data Protection Regulation (GDPR) if they market goods and services to citizens of the European Union (EU). You must ensure the security of the data as well as inform visitors to your website how you intend to use their data. This must be clearly written in your privacy notice on website. This is not to be confused with your Notice of Privacy Practices that you give to your patients. If you plan on marketing to visitors from your website, you must offer them a free opt-out option. We could go on in more detail on this subject, but since many medical clinics do not market to international patients, you may contact us for more information.

Here are a few things to review and update as necessary:

Risk analysis and risk management plan, this is your documentation to demonstrate what risks you have (had) and how you have mitigated them or plan to mitigate them.
Replacing or updating any outdated technology, hardware and software require updates from time to time. You can be fined for utilizing outdated hardware/software that is no longer supported by the manufacturer.
Adding a second authentication process for access to ePHI as well as for online personal accounts.
HIPAA training, ensuring your employees understand how to protect your data is also part of this training.
Making sure you have all of the necessary privacy and security policies, procedures, and forms in place. This means reading and dating them to demonstrate they were actually implemented.
Retaining your documentation for the required time limit, including correspondence with patients that are considered to be part of their medical record.
Reviewing your website, determining if your site collects any data and how it is transmitted and stored.

If you see something in your workplace that looks suspicious, tell your HIPAA Compliance Officer, you could be the one to prevent a data breach or stop a data breach from becoming a major breach (over 500 patient records). Keeping data secure is everyone’s business. Being mindful of our surroundings and educating others helps all of us in this crazy world we live in now!

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Do you have all of your HIPAA training documented?

Suze Shaffer January 7, 2019June 29, 2022

What do you know about HIPAA enforcement?
Just imagine you were investigated by CMS or the OCR, what would they find?
How confident are you in your medical and/or HIPAA documentation?
Do you have the appropriate documentation to protect your organization?

The Office for Civil Rights (OCR) is very serious about ensuring your organization is educating employees on patient rights and securing PHI. During a recent investigation in Florida an organization was fined $100K for each year they could not produce documented HIPAA training. The first year they only had 3 employees! They were fined for five years, $500K. Once you are under investigation, they review ALL of your documentation, not just what they originally requested. You do not want to end up being in the willful and wanton neglect category. This is where the big fines are calculated.

If you have a patient complaint or suffer a data breach, the best advice is to document, document, AND document! OH, did I mention… DOCUMENT? Next, cooperation. If they ask for something, give it to them. Nothing more, nothing less, but give them what they ask for. Show the OCR you are trying to do the right thing. After all, how would you like it if the information that was compromised was yours? Wouldn’t you want the organization to do what they could to stop the breach or prevent another one from happening?

Remember the MD Anderson in Texas fines? They had multiple devices lost containing unencrypted ePHI. They claimed that they were not obligated to encrypt its devices, and stated that the ePHI that was involved was for “research,” and thus was not subject to the HIPAA non-disclosure requirements. They challenged the OCR and the Judge ruled in favor of the OCR and MD anderson was ordered to pay $4,348,000 in civil money penalties. The quote from OCR Director Roger Severino: “OCR is serious about protecting health information privacy and will pursue litigation, if necessary, to hold entities responsible for HIPAA violations”.

At the NIST/OCR conference in Washington DC, the director along with other members of the OCR staff reminded organizations about enforcement. This is NOT going away. Patient information is extremely valuable to criminals. The days of just a slap on the wrist because you didn’t conduct risk assessment, conduct HIPAA training, or you can’t prove your HIPAA compliance is over. Every organization that has anything to do with patient information must get on board and understand HIPAA. There is NO certificate to prove you are HIPAA compliant, the proof is in your documentation. So I ask one more time… How well do you trust your HIPAA documentation?

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Data breaches of 2018

Suze Shaffer December 21, 2018June 29, 2022

We hear on the news about data breaches almost daily. Some are credit card theft, our personal information being sold, and then are medical data breaches. These are extremely worrisome as this is where identity theft can start. The medical community is a major target for that very reason, medical records are the main source of complete information to steal personal information.

Do you know how many individual patient records have been compromised in 2018?

11,785,675 patient records were reported as breaches to the Office of Civil Right (OCR) in 2018 that were over 500 records per incident. Keep in mind this does NOT include breaches under 500 records.

https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf;jsessionid=3F3012CA56DF3E4D79031A59CCBBBA4D

Plus 944,595 patient records that had been exposed that have already been archived according to the OCR portal.

At the NIST/OCR October conference, they talked about how medical offices use the excuse… “I didn’t know”. They also said that was not an acceptable answer any longer. They can and will fine organizations that are not HIPAA compliant. You are 4 times more likely to get hacked than to have your equipment stolen and this does not even include the breaches caused by unauthorized access. Needless to say data breaches are on the rise no matter what angle you are looking at.

So as we close out 2018 and venture into 2019…
You MUST be diligent and keep up to date on the latest technology for data security.
You MUST make sure your employees are WELL educated on data security.
You MUST document your compliance efforts.

In the words from the Office for Civil Rights, “If it’s not documented, it doesn’t exist”!

Be safe out there in the World Wide Web… it’s a wonderful but dangerous place!

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Spoofing, Phishing, and how to avoid getting caught in the middle

Suze Shaffer November 15, 2018June 29, 2022

After attending the Office for Civil Rights (OCR) annual webcast, many things were confirmed that we thought may have been rumors. First of all, medical offices are targets of hacking because you hold everything needed for identity theft.

What is identity theft? Most people think of it as their credit card being stolen, or even their tax returns. True, that is identity theft but there is also another component that is not often talked about. That is, assuming someone else’s identity for health care purposes. Imagine someone assumes your identity and has a surgery and “corrects” your medical record and changes your blood type. Then, you are involved in a car accident and receive a blood transfusion but it’s the WRONG blood. Yes, this can happen. We are not sure how often, but with the rise of medical records being stolen we could see this happen more often. Knowing where your data is located and how it is stored is a starting point in protecting this valuable information. Conducting a risk analysis and having an ongoing risk management is mandatory under HIPAA. During this process you will uncover potential vulnerabilities. Once you mitigate these risks, you may be able to avoid a data breach.

Protecting yourself and your organization is one in the same. Practice these safety tips at work and at home:

Make sure your operating system updates are current as well as your anti-virus and anti-malware.
Scan for viruses and malware after every update.
If you use personal devices to access ePHI or work files, be sure to use enterprise versions of anti-virus and anti-malware. Free versions typically are not robust enough.
NEVER use free Wi-Fi even if you are not accessing any patient information. You could pick up malware from someone that has spoofed the Wi-Fi network that you thought you were logging into.
NEVER click on links within emails that claim to be urgent or a free offer of some type. Typical phishing expeditions start in this manner. After you click, they ask for certain information they are lacking about you or they may ask for everything! Sometimes, this is merely a tactic to get you to go to a certain website and place malware on your computer and you never even know it.
NEVER click on a link within an email asking you to verify your identity. You wouldn’t show a stranger on the street your driver’s license just because they asked to see it, then why would you “verify” your identity with someone invisible in your email? Again, this is how spear phishing starts.
NEVER click on an attachment within an email unless you are expecting it, even if you know the person that sent it. Their email could have been hacked and you are being spoofed into thinking it is from them. This includes messages from FedEx, UPS, and the IRS. Best practices is to open your web browser and go to their website and sign in.
NEVER click on links in text messages unless you are expecting one, such as you just signed up for text messages from a service provider. Bank customers are being spoofed into clicking on links in text messages and taking you to what looks like your bank. Guess what… it’s NOT your bank but looks like it!

I have said this before… the World Wide Web (WWW) is the new Wild Wild West. The only difference is, in the old wild wild west you could see danger coming on the horizon and prepare. The World Wide Web, the dangers are there, but they are invisible.

Be safe out there!

To find out more about how our automated HIPAA compliance platform can help your organization click here:

https://arismedicalsolutions.com/aris-hipaa-service-automated-platform/

Or to schedule a demo click the contact us tab and scroll down.

“Simplifying HIPAA through Automation, Education, and Support”

Passwords – why you need to change them and not reuse previous ones!

Suze Shaffer August 20, 2018June 29, 2022

Just as the eyes are the window to our soul, passwords are the gateway to our inner most kept secrets.
Passwords are used to gain access to YOUR information, but what happens when your passwords are responsible for other people’s information? Did you know that by having your email hacked, you could potential expose not only your personal information but that of others?

Recently, I receive a text from a friend of mine saying “LOL, your email was hacked, just got a fake email from you!” Since she knows that I work in medical offices and with HIPAA compliance, she thought this was funny. However, the problem was, it was HER email that was hacked and they spoofed my address in hopes that she would fall for it. This is just one of the many ways that hackers “get in”. Some hacks start with this type of phishing email that someone falls for, depending on the hackers intentions… the sky’s the limit!

Did you know that a hacker that could get into your email would have the ability to change your access codes to many different resources and you not even know it? Many sites verify your identity through your email address. For instance, if you use the same password across different platforms, once they gain access to your email, they can try that password on other sites. Then they can change YOUR credentials and even change banking information.

So.. what can you do to protect your information and that information that you are responsible for…

Here are some suggestions that you may use. Maybe not all of them, but incorporate as many as you can.

Use STRONG passwords, preferably pass phrases.
Change them at least them at least every 90 days.
Do not share your passwords.
Do not use the same password/phrase phrase across multiple platforms.
Do not reuse the same passwords.
Enable two step authentication wherever offered.
Utilize an encrypted file and copy/paste passwords instead of typing them each time.
Make sure the network that you are accessing information from is secure.

Although nothing in this day is 100% safe, by simply adding a few precautionary measures you can protect yourself and the patient information that you are responsible for as much as possible!

If you would like to schedule a HIPAA training course customized to your facility, or if you need to update any of your HIPAA security needs call 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

Cost of cyber attacks on healthcare are steadily rising

Suze Shaffer August 1, 2018June 29, 2022

Why are so many medical offices being attacked? Simple, this is a one stop shop for everything needed for identity theft and many medical practices do not have appropriate safeguards in place. Business associates have even been the target or the entry point. HIPAA requires certain security safeguards to be in place to ensure the safety and security of Protected Health Information (PHI).

There have been 188 data breaches of 500 or more patient records in the first 6 months of this year, and in April alone there were 42. Thirteen of the 188 have already been resolved. https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf
These breaches include small medical practices, business associates, and hospitals. Small and large. Paper and electronic. No one is immune. Many organizations think they are too small to get hit, but the fact is the most common problem is untrained staff that unknowingly cause this to happen. Education is the key to avoiding this catastrophe from destroying your reputation. Of course you still need to certain technical safeguards in place, but even then it only takes one click of a mouse to bring your network down.

Here are some areas to consider:

How would you process a data breach?
How would you handle the reputation management of the breach?
How would you pay for the cost of breach and the investigations?

Having a breach notification plan in place before a breach occurs is critical to reducing the damage. You must have processing in place to shut the system down, continue manually, and report to the appropriate authorities.

Consider the lack of trust from your patients since their information was compromised from your office. No matter if it was your fault or that of a business associate this could have a negative impact on your patient database.

Breaches are costly on many fronts, the first being the cost of the notification of the patients, investigations, downtime, and the mitigation of the source of the breach. In 2013 the Ponemon Institute reported that a data breach cost $233 per medical record, now in the 2018 the report states a healthcare breach can cost on average $408 per medical record.
https://www.ibm.com/security/data-breach

Keep in mind if you do not know which records were breached then everyone must be included in the notification process. What could turn out to be the most costly is the fines and penalties associated with the breach. Depending on how and when you processed the breach is one determining factor. Also once the investigation is complete, if it is discovered this was an ongoing problem and was not mitigated, then you could be found in willful and wanton neglect. This is NOT a place you want to find yourself! The Office for Civil Rights (OCR) can also fine you for not conducting a thorough enough risk analysis thus leaving vulnerabilities untouched. How well do you trust your efforts in securing your data? Have you conducted a risk assessment to determine if what you have in place is sufficient?

How can Aris help?

First of all we conduct a thorough risk analysis that uncovers vulnerabilities and create a risk management plan so that you can mitigate those risks.
Since written documentation is also part of HIPAA compliance, we provide the necessary privacy and security policies, procedures, and documentation needed for state and federal regulatory requirements.
We also offer HIPAA training that includes privacy and security and any custom requests.
If you are one of the many organizations that simply do not have the time to implement your HIPAA program, we can do that for you as well. Month to month, no long term contracts!

If you would like a free HIPAA checkup call 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

Software Patches and Updates – Why they are so important.

Suze Shaffer July 17, 2018June 29, 2022

Whether you work in a medical office or are a business associate, they all rely heavily on the software they use for patient care. The reason software developers send out periodic updates is because more than likely a vulnerability has been discovered and the “patch” or “update” will mitigate the issue. Vulnerabilities come in a variety of types including electronic health records (EHRs), operating systems, custom software, databases, email, and even Java and Adobe Flash. Each program will have its own type of vulnerabilities. Unpatched software poses to a threat to ePHI and updating is required under HIPAA. Routers, phones, servers, and even some refrigerators have firmware that must be updated as well.

When discussing routers, it is important to mention that all routers come with default settings, including a username and password. These must be changed, otherwise they can be hacked. Routers also need to be rebooted or reset sometimes, depending on the type of vulnerability that has surfaced. Malware can infect not only your phone and computers, but also your router. It is imperative that you have an experienced IT professional that is current on these issues. Long gone are the days of plug and play. Although it is not difficult to set up a computer or a network, securing it is a whole new game.

Even if you utilize a cloud based system, the devices you use to access your system can be compromised. If you haven’t done so already, you should invest in a qualified IT vendor that will secure and monitor your computers and network. The data that your patients have entrusted you with is sought after in many areas. It is required under HIPAA to have reasonable and appropriate safeguards in place, but besides that… it’s the right thing to do!

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

“Simplifying HIPAA through Partnership, Education, and Support”

Workstation Security

Suze Shaffer June 19, 2018June 29, 2022

HIPAA Compliance is more than just about a patient’s right to access their information. Although the HIPAA Privacy Rule is how most of this began, it is so much more now! The HIPAA Security Rule outlines administrative safeguards, physical, and technical security. Most organizations are so busy trying to figure out how to protect themselves from the unknown (technical concerns) that they forget about the actual physical security. We are not just talking about building security systems, but how you secure the individual devices that are utilized within your facility and those who travel with portable devices.

Here are some helpful ideas to review with your particular situation:

Although utilizing a security system that has motion sensors is better than nothing, using security cameras usually discourages theft.
Conduct a walk through of your facility and create an inventory list of all devices that access or store ePHI. Knowing what you have, where it is located, and if it contains ePHI is essential in securing your data. This includes portable devices and small electronic media. Remember, printers, copiers, and scanners can store data as well.
Review the location of all devices that access or store ePHI. Ensure they are not located in an area that could be easily accessed by an unauthorized person or utilize cable locks. If screens are viewable and cannot be relocated, the use of privacy screens are highly recommended. Encryption is recommended on any device that contains ePHI. If the devices are transported they should be encrypted even if they do not contain ePHI. If they are ever lost or stolen and the encryption is engaged, it would not be a reportable breach.
If your USB drives are not used, locks should be installed. This is an inexpensive method to protect the network. If your workstations utilize CD/DVD drives, these should be disabled as well. Another option would be to configure this through a Microsoft Group Policy.
Make sure paper PHI is not left in areas that could be accessed by another as well. This includes where you store your excess paper charts. These areas should be locked when not in use. It is also recommended to utilize signage instructing “Employees Only”.
Employees can be your biggest asset or your largest liability. Training your employees on computer security is an ongoing process. Annual HIPAA training should include the HIPAA privacy rule and HIPAA security rule. Also, add monthly security reminders to keep HIPAA fresh in their minds. Continuing education is the key to safety.
HIPAA Policies and procedures are the backbone of an organization. Properly trained employees know and understand what is required and needed. The data that a health care provider has in its possession is priceless. This data must be secure physically and technically. All of this is necessary to avoid a data breach.

If an organization fails to secure patient information the Office for Civil Rights (OCR) will open an investigation and the organization can end up with massive fines. These fines have ranged from $250K to $3.5M. Although the fines are based on the organization’s ability to pay, the days of receiving just a $50K fine seems to be over. Best practices would be to review your HIPAA risk analysis and make sure it is thorough. Some online risk assessments unfortunately do not uncover all of your vulnerabilities. The OCR could consider this as willful neglect even though you didn’t know. Make sure you update your risk management plan and mitigate those vulnerabilities. Small oversights could cost you a fortune.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

“Simplifying HIPAA through Partnership, Education, and Support”

General Data Protection Regulation: What does this mean to the US

Suze Shaffer April 15, 2018February 2, 2024

By Aris Medical Solutions

You may have already heard about the GDPR (General Data Protection Regulation) from the EU (European Union) that will affect many organizations here in the United States.

Our personal information has been being sold for years. Some with and some without our knowledge. Many organizations require a person to “accept” their terms and conditions with long legal agreements that we must agree to before using their software, joining their network, or downloading an app to name a few. Most people do not read this very important disclosure because it is simply too long and too legal. They collect data from us in order to enter a sweepstakes, win a prize, or simply to gain access to a forum. This information can be sold to other organizations so they can market their good and services to us. I will be explaining in my next notification how to poison this information and make it useless. For now we need to concentrate on how to understand this new regulation.

With the GDPR from the EU becoming effect May 25, 2018, organizations must become compliant by May 25, 2018.

Here is a basic summary of what you need to know:

Organizations that provide goods or services to anyone located within the European Union regardless of where the company is located must adhere to this new regulation. This also includes companies that process and store personal data of an EU citizen. This is similar to our individual state laws we currently have in the United States.
Personal data is anything that can be used to identify a person, directly or indirectly. This includes name, photo, email address, bank details, medical information, computer IP address, and even posts on social media.
You must have clear full consent to use a person’s information. No lengthy vague legal forms; just clear plain language. Nothing short of an opt-in will be acceptable.
Just like HIPAA, there is a tiered sanction policy. Organizations can be fined up to 4% of annual global income for breaching the GDPR. This is for severe violators. Organizations can be fined up to 2% for not having their records in order, not notifying a supervising authority, not notifying the person that is affected by a data breach, or not conducting an impact assessment.
These rules will apply to both cloud data controllers and processors and will not be exempt from GDPR enforcement.
Data breaches must be reported within 72 hours.

What do you need to do to prepare:

Review your client/patient database.
Do you have any European clients/patients?
Review where all of your data is stored.
Do you use a cloud system?
Do you have a BA agreement in place with the data processor/center?
Update your breach notification plan.

For more information on the GDPR: https://www.eugdpr.org/

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467.

“Protecting Organizations through Partnership, Education, and Support”