breach Archives

Heavy fines demonstrate the importance of a network security audit…

Suze Shaffer July 1, 2019February 2, 2024

When we discuss IT security, we generally think of a company that maintains our computer network. That is partially true, but that is just the beginning. There is a difference between maintaining your network and securing it. There are a lot of companies that are eager to maintain your network because you pay them a monthly fee to do so. Maintaining a network is making sure updates are done, anti-virus / anti-malware are current, upgrading any technology that is outdated or about to be unsupported. A network security company tests to see if there are any open vulnerabilities that could affect or infect your network. There is a huge difference between the two.
For example, a misconfigured settings of a Windows operating system permitted access to files containing PHI without requiring a username or password. Then two years later a second breach occurred when a server was misconfigured following an IT’s response to troubleshooting an issue, this time it exposed patient information over the internet. These two breaches cost Cottage Health a $3M fine. The Office for Civil Rights (OCR) investigation found that they had not conducted an accurate and thorough assessment and failed to implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level based on the size of their organization. Even though they had an IT company maintaining their ePHI system, they failed to obtain a signed business associate agreement.

Cottage Health fined $3M

Another breach that happened in 2014 has just been settled by the OCR. Touchstone Medical Imaging has been ordered to also pay $3M. The OCR and the FBI informed Touchstone in 2014 that one it’s FTP servers allowed uncontrolled access to ePHI. The uncontrolled access permitted search engines to index the patients personal information, which remained visible after the server was taken offline.

Touchtone Medical Imaging fined $3M

The lesson here is, what you do today can affect your business in the years to come. Make sure you are doing what is reasonable and appropriate to safeguard your patient information. One more keep point, these are just the federal fines. All 50 states now have their own set of privacy laws to protect personal identifiable information that doesn’t have anything to do with health information. Since we work in healthcare, we must adhere to state and federal privacy laws. No longer can you ignore the elephant (HIPAA) in the room, HIPAA is here to stay and you need to choose wisely who you work with to secure your data.

If you haven’t conducted an audit this year, now is a good time to schedule one to ensure your data is secure. If you would like more information on network security audits, contact us at 877.659.2467 or complete the contact us form.

Malicious code, websites, and data breaches

Suze Shaffer March 15, 2019June 29, 2022

When we conduct HIPAA training most employees are discouraged when we tell them not to surf the web on work computers. There is a very good reason for this… malicious code can be found on websites that have not been updated and maintained properly. Websites, just like any other technology device you use, must be updated and maintained to avoid being hijacked. Website developers sell templates, this makes it very easy to create a website. When vulnerabilities are discovered in the design of the site or one of the plug-ins, updates are pushed out. It is so important that you have a webmaster that stays on top of this! How would you feel if your website was used to infect your web traffic? Image how embarrassing it would be if your patients got a virus or malware from your website?

That brings us to another very important issue when it comes to healthcare; remote users. Home computers are more likely to be infected, in fact 68% of infections were on consumer computers. Are your employees using their own computers at home to access patient data? Was the RDP set up properly? Are the devices properly maintained by an IT professional? Do employees bring their devices from home into your office? Do your employees use their smartphones to connect to your WiFi? These are all areas that need to be reviewed and addressed to ensure your data is not at risk. This is not about restricting employees computer usage because the employer is being unreasonable. This all about protecting your organization from cyber attacks and protecting patient data.

Well educated employees are your best asset and together with proper security you can protect your organization from a data breach. The average data breach cost is $3.8 million and healthcare being one of highest at $380 per patient record. Keep in mind, if you can’t determine which patient records were breached, they are all considered to be breached and are included in the process. Between the cost of the breach and loss of confidence most organizations do not survive past 1 year after a breach.

Our business partner is nationally known and has mitigated some of the largest data breaches. They work with your IT professional to secure your network BEFORE you suffer a data breach. Let us know if you would like a quote on a network security audit.

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”

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”

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”

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”