HIPAA Compliance Officer Responsibilities

Most practices cannot afford to hire a HIPAA Compliance Officer. So, practice owners often assign their Office Manager or their Practice Administrator for the HIPAA Compliance Officer Responsibilities. These responsibilities are so much more than just a title. Compliance Officers responsibilities include creating, implementing, maintaining, and enforcing compliance. Since they are not trained as a Compliance Officer, many times, HIPAA is placed on the back burner. There is not enough time in the day to keep up with the responsibilities of the “normal” work. Then they need to address the elephant in the room called “HIPAA”. The easiest way to manage this is to hire a HIPAA consulting company that will do the heavy lifting and be there to assist when needed. Policies, procedures, and documentation is the backbone of HIPAA compliance. This includes both the HIPAA privacy and security rules. Unfortunately, the rules can change. You must keep your policies up to date. For example, information blocking and exceptions have been added to the rules, and the right of access time limit may be reduced to 15 days.

If you do not have a company to assist you, let Aris Medical Solutions offer you a complimentary consultation. We want to be your HIPAA partner!

Here are some areas that need to be implemented:

  1. Conduct a system wide risk analysis. This will include administrative, physical, and technical safeguards. There are free tools available to assist you, but keep in mind this is only a starting point. These tools do not include the remediation processes, policies and procedures, and documentation forms.
  2. From the Risk Analysis, you will create a Risk Management Plan to document your mitigation process. This document will also include the reasonable and appropriate safeguards you have in place.
  3. All entities (medical practices and business associates) that access or store Protected Health Information (PHI) must monitor audit logs from either their EHR/EMR software or a device which connects a user to Electronic Protected Health Information (ePHI). The purpose behind this requirement is to look for abnormal activity. This abnormal activity could be the result of a rogue employee or a cyber-attack. This is a time-consuming task and you may need to hire a third party to monitor these logs for you.
  4. Every practice must have a Breach Notification Plan and Security Incident Form. Most importantly, you must have an IRT (Incident Response Team) in place that includes an IT Professional, a Forensic IT Company, and a Healthcare Attorney along with your own personnel. After you suffer from a Data Breach is not the time to put this team together. Time is of the essence when notifying your patients. Federal law states you have 60 days to notify your patients that are involved in a Data Breach. However, some states are much more stringent, therefore State law would overrule Federal law. Some states now even require the State Attorney General be notified as well. Know your state law! For example, Florida state law requires a 30-day notice.
  5. Even if you utilize an IT vendor that is responsible for your data, you will still need to have a contingency plan in place in the event of a disaster or data problem. You will work hand in hand with your vendor, but it is your responsibility to have the documentation available.
  6. Medical practices that utilize the services of business associates are required under HIPAA to ensure the business associate is HIPAA compliant. Be sure to obtain a signed business associate agreement (BAA) with all your vendors that create, receive, maintain, or transmit protected health information (PHI). This agreement should include security requirements and information blocking criteria. If a practice does not have a BAA in place and the vendor causes a data breach, the practice may receive a fine for the violation. With a BAA in place, the practice may bear the financial burden of the breach but may not receive a fine. We recommend a BAA with indemnification and requirement that the business associate carry cyber liability insurance. Keep in mind, if your business associate utilizes subcontractors, the HIPAA rules apply to them as well.
  7. The Compliance Officer will need to work with their IT department/vendor to determine the flow of data in and out of your systems. With this information you will be able to determine where ePHI is located. Your network configuration will define which technical safeguards need to be in place. Some of these are “required” under HIPAA and others are “addressable”. Keep in mind, addressable does not mean optional. It means that you must have reasonable and appropriate safeguards in place based on your data flow and size of your organization. Although the Compliance Officer may not understand the technical requirements, it is required for the Compliance Officer to have the documentation. Also, what procedures and documentation will be needed when it is time to replace computers and equipment. Documentation includes reports from the IT department/vendor. These reports can be utilized to document the recognized security practices you have in place such as: status reports, access logs, security patches, and an inventory of devices. For instance, even though encryption is not a “required” security standard, if your server, computer, or laptop is lost or stolen and it is not encrypted, you could be faced with a $1.9M fine.

Policies, procedures, and documentation are the backbone of HIPAA compliance.

This includes both the HIPAA privacy and security rules. Unfortunately, the rules can change. You must keep your policies up to date.

Many organizations have had a data breach or have been hit with ransomware. How likely is your staff to give out information? If a stranger walked up to you and asked you to verify your identity, would you give them any information? Of course not, but that is exactly what we are doing when we receive an email, text message, or phone call from someone or somewhere, we trust that it is legitimate. In the old wild wild west, you could see danger on the horizon and prepare. The world wide web (WWW) is the new wild wild west, now dangers are invisible, and you have no way to prepare unless you have processes in place.

When a healthcare organization has a breach, it typically takes about 2 years for the Office for Civil Rights to complete their investigation. During that time, the organization will be required to submit documentation on their data security and what they will do to prevent this from happening in the future.

Now more than ever all organizations need to make sure their HIPAA Compliance Officer understands what is needed for data security. The FBI has stated cybercrime is on the rise. The hackers have become very sophisticated in their attacks!

The OCR is famous for saying… If it’s not documented, it didn’t happen and doesn’t exist. Documentation must be stored for a minimum of six (6) years; however, it can be digitally stored and not necessarily on paper.

Let’s all work together to keep patient data safe and secure. If you need assistance with HIPAA Compliance, check out our HIPAA Keeper. It’s an online compliance system that has everything you need to get compliant and stay compliant! Best of all you will have a HIPAA security analyst to guide you every step of the way!

For more information or to speak to someone about HIPAA Compliance call us at 877.659-2467 or use the contact us form.

“Simplifying HIPAA through Automation, Education, and Support”

Can a Medical Practitioner be sued for a HIPAA Violation or a Data Breach?

With so many data breaches in the news many medical practitioners are asking if they can be sued over HIPAA violations or from a data breach.

HIPAA rules state there is no private right of action, therefore, a patient cannot sue for a HIPAA violation. With that said, it is possible if there were privacy violations under state law, legal action may be taken. All states have their own set of privacy laws that encompasses more than just the healthcare sector. State privacy laws vary from state to state and define what is considered private information. HIPAA and state laws require covered entities to secure protected health information (PHI) with administrative, physical, and technical safeguards. Business associates and subcontractors are required to do the same.

If a patient wants to file a lawsuit, the patient must be able to prove negligence and damage caused harm by the violation or data breach. The Omnibus Rule removed the harm threshold when it came to covered entities reporting data breaches, but a patient has the right to claim harm. On another note, if a patient joins a class action lawsuit, it may make a stronger case. However, many class action lawsuits are filed based on the exposure to future harm. Without evidence of harm this may reduce the case. This can be a costly endeavor and patients should consider this and review what they hope to gain before taking legal action. Keep in mind, this is not a quick lawsuit. In the end, there is no guarantee of any monetary gain for the patient.

Many times, the practice can discuss the issues with the patient and avoid legal action altogether. It is recommended that if a practice has a disgruntled patient, the HIPAA privacy officer should talk to the patient if given the opportunity. Sometimes, an upset patient merely wants to be heard. Depending on the circumstances, the practice may be required to report the incident to the Department of Health and Human Services Office for Civil Rights (OCR).

If a patient feels as though their protected health information has been violated, they do have the right to file a complaint with the OCR. The complaint from the patient must be filed within 180 days of the incident. In some cases, an extension may be permitted. The complaint is reviewed to determine if it is justifiable. If it is, then the OCR will contact the practice and try to resolve the issue in the most suitable manner. This may include technical assistance, a resolution agreement, and/or ongoing compliance documentation. The average investigation timeline for a data breach takes 1½ – 2 years. Of course, for more complex breaches, it may take even longer. The outcome of the investigation will depend on the severity and nature of the violation, if this was a repeated offense, and the number of patients affected. Depending on the documentation of the incident and how it was handled, a practice may be able to avoid a desk audit. Remember, if it’s not documented, it does not exist. The patient may also file a complaint with the State Attorney General. Some complaints are referred to the Department of Justice (DOJ) if the investigation results in criminal violations. I hope this helps you to understand how important it is to keep patient data secure, and the documentation that demonstrates your efforts. If you have any questions on data security, how to handle a patient complaint, or how to handle a security incident, we are here to help.

To find out more about how our online HIPAA Keeper™ can help your organization with HIPAA Compliance click here:

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

“Simplifying HIPAA through Automation, Education, and Support”

Data Breaches in Healthcare are Increasing

Since 2015 the number of data breaches in healthcare has steadily been rising. This includes medical offices, health plans, and business associates. These breaches range from unauthorized access, loss, theft, but mostly from hacking. Hacking was determined to be from emails, network servers, desktop computers, to electronic medical records. No office is immune. Starting with a system wide HIPAA risk analysis is the first step in protecting your data. Modern technology helps us in many ways, but it is ever so important to keep up with data security. Many medical offices think once their office is set up, they are set for life or at least “a while”. Technology is growing faster and faster, and you must be diligent to keep up. This is not a do-it-yourself job anymore!

Let’s look at some of the numbers from the data breaches over 500 patient records that were reported:

From January – July 2022 there have been 380 breaches reported.

In 2021 there are 457 still being investigated and 258 that have been archived, that is a total of 715 reported.

In 2020 there are 63 still being investigated and 601 that have been archived, totaling 663.

In 2019 there were 512 reported breaches.

In 2018 there were 368.

In 2017 there were 357.

In 2016 there were 329.

In 2015 there were 270.

I think it is important to note that the number of breaches are increasing each year. Now more than ever anyone involved in healthcare must approach HIPAA compliance and data security as necessary as having insurance to protect your organization. Instead of being reactive to “when” this happens, being proactive can help this “from” happening.

To find out more about how our online HIPAA Keeper™ can help your organization with HIPAA Compliance click here:

https://arismedicalsolutions.com/aris-hipaa-compliance-system-for-medical-offices/

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

“Simplifying HIPAA through Automation, Education, and Support”

Why it is so important to secure emails that contain PHI

We have advised our clients for years to only transmit protected health information (PHI) if it is encrypted. We have also recommended encryption for the data at rest. With the rise of hacking, this is never more important. There are many problems that can arise from compromised email accounts.

It only takes one employee’s email account to get hacked, then the hacker can view what the user has stored, who they communicate with, and who they do not speak with directly. Let’s review each one:

  1. Contents of email. Of course, you do not want an unknown person reading your emails, but it is even worse if your email account contains PHI. The hacker can take that information, sell it, or even target your patients to gain more information.
  2. The hacker can also see who you are communicating with and now they can target your co-workers into giving them information by impersonating you.
  3. They also know who you only communicate with via email. This sets the stage for phone conversations since you do not know what this person sounds like. The hacker can request wire transfers, employee lists, patient lists, the amount of information that they are willing to request is only limited by their imagination.

These attacks may be targeted for financial gain, identity theft, or medical insurance theft. Regardless of the hackers’ motives, they all can be devastating to a practice. Just last year an Orlando practice had 4 email accounts compromised and over 447K patients were affected. When considering the methods to secure email accounts, you must also consider which devices are used to access email. This furthers the security requirements. A thorough risk analysis will uncover potential vulnerabilities and give you the opportunity to avoid a data breach.

That brings me to the next topic… if you don’t need to store it, DO NOT. If you can move the needed documentation to a secure server or your EHR, then do. If there isn’t a “need” to store patient information (or any sensitive information) in email, then remove it. This also applies to “old” patient records in databases or software. There is a reason behind medical record retention requirements, and when it is safe to dispose of medical records, then do! This too reduces your liability!

To find out more about how our online HIPAA Keeper™ can help your organization with HIPAA Compliance click here:

https://arismedicalsolutions.com/aris-hipaa-compliance-system-for-medical-offices/

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

“Simplifying HIPAA through Automation, Education, and Support”

Looking back at 2020 and HIPAA Compliance Violations

During this pandemic, the Office for Civil Rights (OCR) relaxed some of the requirements for Telehealth. This has since been retracted. Make sure the service you are using is in fact HIPAA compliant and you have a business associate agreement (BAA) in place. We also encourage you and all your business associates (BA) to carry cyber liability insurance. Data breaches and mishaps are part of our everyday life it seems. Although your medical malpractice insurance may offer a token amount of coverage, it is probably not enough. Keep in mind, if you cannot determine WHICH patient’s data has been breached, you must notify all your patients. This is where is can be very costly. When selecting an agent, make sure they are well versed in this type of insurance, as we have seen some policies are not worth the paper they are written on. Read the exclusions!

Below are some HIPAA violation highlights from 2020. This is not meant to scare you, but to remind you of how important adhering to HIPAA really is. The Office for Civil Rights (OCR) enforcement actions are designed to send a message to the health care industry about the importance and necessity of compliance with the HIPAA Rules.

The OCR investigation found longstanding, systemic noncompliance with the HIPAA Security Rule including failure to conduct a risk analysis, and failures to implement information system activity review, security incident procedures, and access controls.

“The health care industry is a known target for hackers and cyberthieves.  The failure to implement the security protections required by the HIPAA Rules, especially after being notified by the FBI of a potential breach, is inexcusable,” said OCR Director Roger Severino.

The OCR investigation discovered longstanding, systemic noncompliance with the HIPAA Privacy and Security Rules including failures to conduct a risk analysis, implement risk management and audit controls, maintain HIPAA policies and procedures, secure business associate agreements with multiple business associates, and provide HIPAA Privacy Rule training to workforce members.

“Hacking is the number one source of large health care data breaches. Health care providers that fail to follow the HIPAA Security Rule make their patients’ health data a tempting target for hackers,” said OCR Director Roger Severino.

The OCR investigation revealed that a former employee returned eight days after being terminated, logged into her old computer with her still-active user name and password. Additionally, OCR found that the former employee had shared her user ID and password with an intern, who continued to use these login credentials to access PHI after the employee was terminated. The investigation determined that the entity failed to conduct an enterprise-wide risk analysis, and failed to implement termination procedures, access controls such as unique user identification, and HIPAA Privacy Rule policies and procedures.

“Medical providers need to know who in their organization can access patient data at all times. When someone’s employment ends, so must their access to patient records,” said OCR Director Roger Severino.

The OCR investigation revealed that in addition to the impermissible disclosures, Aetna failed to perform periodic technical and nontechnical evaluations of operational changes affecting the security of their electronic PHI (ePHI); implement procedures to verify the identity of persons or entities seeking access to ePHI; limit PHI disclosures to the minimum necessary to accomplish the purpose of the use or disclosure; and have in place appropriate administrative, technical, and physical safeguards to protect the privacy of PHI.

“When individuals contract for health insurance, they expect plans to keep their medical information safe from public exposure. Unfortunately, Aetna’s failure to follow the HIPAA Rules resulted in three breaches in a six-month period, leading to this million-dollar settlement,” said OCR Director Roger Severino.

The OCR has settled twelve investigations for HIPAA Right of Access denials. This is not to be confused with a medical summary at the end of a patient encounter. A patient’s request for a copy of their medical record (their designated record set) either by them or from a third party must be handled in a timely manner.

“It shouldn’t take a federal investigation to secure access to patient medical records, but too often that’s what it takes when health care providers don’t take their HIPAA obligations seriously.  OCR has many right of access investigations open across the country, and will continue to vigorously enforce this right to better empower patients,” said Roger Severino, OCR Director.

“No one should have to wait over a year to get copies of their medical records.  HIPAA entitles patients to timely access to their records and we will continue our stepped up enforcement of the right of access until covered entities get the message,” said Roger Severino, OCR Director.

“The OCR is committed to enforcing patients’ right to access their medical records, including the right to direct electronic copies to a third party of their choice. HIPAA covered entities should review their policies and training programs to ensure they know and can fulfill all their HIPAA obligations whenever a patient seeks access to his or her records,” said Roger Severino, OCR Director.

“For too long, healthcare providers have slow-walked their duty to provide patients their medical records out of a sleepy bureaucratic inertia. We hope our shift to the imposition of corrective actions and settlements under our Right of Access Initiative will finally wake up healthcare providers to their obligations under the law,” said Roger Severino, OCR Director.

The OCR investigation determined that there was systemic noncompliance with the HIPAA Rules including a failure to encrypt ePHI on laptops after Lifespan ACE determined it was reasonable and appropriate to do so.  OCR also uncovered a lack of device and media controls, and a failure to have a business associate agreement in place with the Lifespan Corporation.

“Laptops, cellphones, and other mobile devices are stolen every day, that’s the hard reality.  Covered entities can best protect their patients’ data by encrypting mobile devices to thwart identity thieves,” said Roger Severino, OCR Director.

A breach report regarding the impermissible disclosure of protected health information to an unknown email account. The breach affected 1,263 patients.  OCR’s investigation revealed longstanding, systemic noncompliance with the HIPAA Security Rule.  Specifically, they failed to conduct any risk analyses, failed to implement any HIPAA Security Rule policies and procedures, and neglected to provide workforce members with security awareness training until 2016.

“Health care providers owe it to their patients to comply with the HIPAA Rules.  When informed of potential HIPAA violations, providers owe it to their patients to quickly address problem areas to safeguard individuals’ health information,” said Roger Severino, OCR Director.

“All health care providers, large and small, need to take their HIPAA obligations seriously,” said OCR Director Roger Severino. “The failure to implement basic HIPAA requirements, such as an accurate and thorough risk analysis and risk management plan, continues to be an unacceptable and disturbing trend within the health care industry.”

HIPAA covered entities and business associates are required to conduct an accurate and thorough assessment of the risks to the ePHI it maintains. Identifying, assessing, and managing risk can be difficult, especially in organizations that have a large, complex technology footprint. Understanding one’s environment – particularly how ePHI is created and enters an organization, how ePHI flows through an organization, and how ePHI leaves an organization – is crucial to understanding the risks ePHI is exposed to throughout one’s organization. As technology changes, risk assessments must be updated and reflected in a risk management plan. Reviewing policies and procedures may also need to be updated depending on the type of changes in technology. As we get ready to close out 2020, set your schedule to review your updates and planned upgrades for 2021.

To read about enforcement and the resolution agreements, click on the link below:

https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/index.html

If you need assistance with HIPAA Risk Management or guidance with your HIPAA Compliance contact us at 877.659.2467 or complete the contact us form.

Responsibilities of a HIPAA Compliance Officer

While the nation was shut down and people were suffering, hackers were busy at work. It is coming to light how many organizations have had a data breach and have been hit with ransomware.

Now more than ever all organizations need to make sure their HIPAA Compliance Officer understands what is needed for data security. The FBI has stated cybercrime in 2020 has surpassed 2019 and we still have a few months to go. The problem is the hackers have become very sophisticated in their attacks. Whereas it used to be easy to spot a fake email, that is no longer the case. Between email and text efforts, they are gaining access to our information and we are the ones permitting it. Also, user credentials are compromised and used to gain access to your network or to send false emails to gather personal information. These scams typically involve a criminal that has hacked a legitimate email address. For example, a person would receive a message that appears to be from someone within their organization or a business associate with which that person knows. The message will request a payment, wire transfer, gift card purchase, or even a list of employees with social security numbers that seems legitimate. The compliance officer should be notified, and the transaction verified BEFORE it is completed. Every office needs to have a verification process in place before releasing ANY data.

We have said this before… if a stranger walked up to you and asked you to verify your identity would you give them any information? Of course not, but that is exactly what we are doing when we receive an email or text message from someone or somewhere, we trust. Trust, but verify.

With more and more people working remotely, that brings us to another vulnerability. Covered entities that utilize the services of business associates are required by HIPAA to ensure the business associate is in fact HIPAA compliant. The starting point is to ensure you have a business associate agreement in place with all your vendors that create, receive, maintain, or transmit protected health information (PHI). This agreement should include security requirements to ensure they are protecting your patient data. If a covered entity does not have a BA agreement in place and the vendor causes a data breach, the covered entity will more than likely receive the fine. With a BA agreement in place, it is still typical the covered entity bears the financial burden of the breach but may not receive the fines. That is why a BA agreement should include an indemnification and requiring the business associate to carry cyber liability insurance. Recently, a business associate was fined $2.3 million for a data breach that was caused by a hacking incident. If the covered entities did not have BA agreements in place, they could have been the ones who received this hefty penalty. Also, recently an orthopedic clinic was fined $1.5 million after a journalist notified them that a database of their patient information was posted for sale online. For this reason, we recommend covered entities should carry their own policies as well. “Hacking is the number one source of large health care data breaches. Health care providers that fail to follow the HIPAA Security Rule make their patients’ health data a tempting target for hackers,” said OCR Director Roger Severino. Many electronic and portable devices are used to process and store PHI. Anyone with access to such devices could potentially have the ability to change configurations, install malicious programs, change information, or access information that are not authorized to. Any of these actions has the potential to affect the integrity of patient information. HIPAA requires covered entities and their business associates to implement and follow policies and procedures to limit access to only those who are authorized.

Risk management should be at the top of everyone’s list. Preventing data breaches and securing patient data is everyone’s responsibility, but the OCR requires someone to be the point person, hence the HIPAA Security or Compliance Officer title. This responsibility is so much more than just a title. HIPAA Compliance Officers responsibilities include creating, maintaining, and enforcing compliance. This includes the staff, management, and even the medical providers.  I hear too often that the compliance officer gets push back from the doctors or owners. This is so unfortunate since they are only trying to do their job that is required under state and federal law. They are the frontline defense in keeping your practice alive and well. The owners of the practice may suffer the financial loss, but sometimes everyone does if the practice closes. Let’s all work together to keep patient data safe and secure.

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”

HIPAA in 2020 – How the protection of our privacy maybe changing

By Suze Shaffer

HIPAA Compliance TrainingJanuary 15, 2020

Hindsight is always 2020, as we begin this new year, let’s try to make that a current sight!

By now, those of you who have been using Windows 7 computers and 2008 Servers have been getting notifications that the end of life was coming. Time is here. January 14, 2020, Microsoft no longer will be supporting these operating systems. What this means is they will no longer send out security updates. Each time a security update is issued, it is because someone has found a vulnerability that could be exploited. This is why hackers lay in wait for unsuspecting people to ignore this. Of course, it is doubtful that you will get hit on January 15, but the chance is there and will increase with each passing day. If you are hacked and this causes a data breach, you WILL be fined for using outdated software. At the conference in October, the OCR specifically discussed this.

All 50 states have their own set of privacy laws to protect their residents. In Healthcare we have to adhere to HIPAA, the Federal law, but also must follow state law when it is more stringent. Sometimes, this means flipping back and forth and it becomes very confusing. The good news is that lawmakers are trying to come up with a Federal privacy law to help stop the confusion. Although they haven’t come up with a firm plan yet, they are working on it. This is partly due to the GDPR (General Data Protection Regulation) being enforceable in the United States. Some people view this a cost guzzling law, but we are all consumers and we should have the right to know who is collecting our data, how they are storing our information, and if they are selling our information. Hopefully, our Federal lawmakers will come up with a law that will allow consumers to opt out if we don’t want our information sold. In healthcare, our information may be sold by EHRs and other healthcare companies, when it is de-identified. Medical practitioners are required to obtain a patient’s authorization before they share patient information. Other businesses should be required to do the same and be fined for selling our personal information if we do not permit the disclosure.

To learn more on what is being discussed in legislation , click here:

https://cdt.org/collections/federal-privacy-legislation/

If you would like to learn more about the legislative proposal, click here:

https://cdt.org/insights/statement-of-michelle-richardson-examining-legislative-proposals-to-protect-consumer-data-privacy/

In June 2018 California passed a consumer privacy law, AB 375, that may be more stringent than the GDPR. The California Consumer Privacy Act (CCPA) went into law January 1, 2020. Although the law isn’t as stringent as the GDPR on timeline notifications, it does have some very tight restrictions that go even further. Any company that have at least $25 million in annual revenue and serves California residents must comply with the law. Also, companies of any size that have personal data on at least 50,000 people or that collect more than half of their revenues from the sale of personal data fall under this law. Companies don’t have to be based in California to fall under the law. They don’t even have to be based in the United States.

We believe more states will follow California unless we can agree on a Federal law to help all consumers. Most of us are patients at a medical facility somewhere, and we are ALL consumers everywhere! By enacting a Federal privacy law, this is a good thing, not a bad!

Happy New Year and praying for good things to come!

If you would like more information, contact us at 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

RIPlace technique allows malware to bypass anti-malware programs

By Suze Shaffer

HIPAA Ransomware

Like we don’t have enough to worry about, now this!

Security researchers are saying this new technique is effective even against systems that are patched and run anti-virus scans. This process allows ransomware to encrypt files on Windows based systems. The way most ransomware gets into our systems is by unsuspecting users or hi-jacked user credentials. Of course it can happen from a disgruntled employee as well. Once this happens, the ransomware opens and reads an original file, then deletes or destroys the original by encrypting it. Within a short amount of time the hacker can invade your systems and crawl through your entire network. Taking everything down and literally destroying your livelihood.. Of course, there is more to this and if you want, you can research this. The main reason why I wanted to share this with you is because… as I have said many times, employees are your first line of defense! Well educated employees can prevent this from happening in your organization. Here is what you need to do TODAY to prevent a data breach:

  1. Remind every user of your system that the computers are for business purposes ONLY. Clicking on infected websites can infect your network.
  2. Remind users do not click on any links or attachments that are not expected even if it comes from someone they know.
  3. Do not permit anyone access to your systems without confirming their identity. This includes service providers. If you do not have an appointment, call and verify the person is still employed there.
  4. Remove user access for terminated employees IMMEDIATELY. Before terminating a person, have this process set and ready.
  5. Conduct a criminal background check on ALL new hires. This needs to be included in your employee manual, and state that a background check can be performed at anytime during their employment.
  6. Contact a network security professional and have them run an audit on your system. This will ensure you do not have any open ports or vulnerabilities.
  7. Be sure to have a backup of your system that is NOT connected to your network.

I know I have said this in the past, but I have to say it again… The World Wide Web (WWW) is the new Wild Wild West, the difference is, danger is invisible until it is too late. Be careful out there.

If you would like more information, contact us at 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

Are you sharing TMI – Too Much Information?

By Suze Shaffer

HIPAA Doctors

When designing your website we all think it’s a great idea to “share” who are team is. Although, it is necessary in healthcare because patients want to see who your staff is and get to know them, be careful not to give out TMI – too much information. Hacker and spammers troll websites looking for information they can use. Think about this… when you post on your website your favorite flower, favorite food, or where you were born, these can be used as security questions or used to figure out other details of your life.

Another area of concern is when a business associate calls your office and asks for information and you didn’t request them to call or contact you. Make sure that person is still employed there and verify the call before giving out any information, sending any information, or permitting access to your systems. Recently, a friend of mine told me about an IT company who had one of their employees impersonated on the phone. Luckily the hacker wasn’t able to get anything since the computer wasn’t connected to the network. Just think what could have happened if it were!

Best practices in protecting your information.

  1. Although you want to be “real” and connect with your patients online, give out information sparingly. What you post online is read by ANYONE!
  2. When creating your security questions, don’t answer the questions truthfully. When asked what is your favorite flower, make something up! You just have to remember what you made up! For example: Favorite flower, Mexican – name a food instead. Favorite food, Pink Roses – name a flower instead. Mix it up a bit!
  3. When anyone calls and asks for any confidential or patient information. Verify before giving out any information. Make sure that employee still works there and they have been requested to perform whatever they are requesting.
  4. Never let anyone that calls on the phone have access to your computer, server, or any electronic device until they have been verified.
  5. Do not permit any transactions to be processed until what is requested has been verified.

I know this sounds like a lot of extra work, but think about the consequences and the time that will be spent correcting a mistake. Not to mention the cost if you have a data breach!

If you would like more information, contact us at 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

Ransomware is a REAL threat…

By: Aris Medical Solutions

HIPAA Ransomware arismedicalsolutions.com

We all hope that we do not fall victim to ransomware, but we need to do more than just hope. All businesses, especially healthcare must have a contingency plan that includes data recovery in the event their systems are encrypted. If you have a backup that is NOT connected to your network, your downtime will be minimal. Keep in mind, you may need to go through the breach notification process based on your state and federal HIPAA law.

A Michigan ENT and Hearing practice refused to pay $6,500 in ransom and the hackers wiped their systems. With no chance of recovering this data, they chose to close the practice.
Most recently, a California Medical Practice was unable to recover their data after ransomware encrypted their systems including their backups. As a result, they will close their practice December 17, 2019.
I could keep adding to the list, but I would rather educate you on how to avoid this!

Best practice is of course to PREVENT ransomware in the first place. This starts with a solid network security program and education for your workforce. Most malware is introduced by an unsuspecting employee. Truly, one click of a mouse can cause a tumbling effect leading to the loss of your business. I know that sounds a bit dramatic, but most small to medium sized organizations that suffer a data breach do not survive.

Healthcare is a major target, in fact, 71% of ransomware attacks are towards small to medium sized practices since they do not have adequate network security in place.

  1. Your first line of defense is an enterprise version firewall device. This means, do not purchase one that has parental controls!
  2. Second, have a network security specialist set up your firewall and set custom security controls. It is fairly simple to set up a “network”, but it takes someone who truly understands network security to secure your network. This includes computers, servers, access points, etc.
  3. Depending on the size of your organization, you may need to set up an onsite server as a domain controller. Once this is in place, all users are authenticated through the domain. Security permissions can be set all at once and can’t be changed by the users.
  4. Phishing education for all employees including providers, and management. Business email addresses are targeted typically between Tuesday and Thursday according to the analysis from Barracuda. Phishing emails impersonate a trusted entity, they try to get the recipients to click on the links or attachments, share account credentials, and typically have some sort of urgency associated with the email. These emails often bypass traditional email security since they originate from reputable senders.
  5. Ensuring you have business associate agreements in place before releasing any PHI. This will protect you from fines and penalties in the event they have a data breach. It is advisable to carry cyber-liability insurance. If your business associate causes a data breach, it will still be your responsibility to go through the breach notification process. Best practice is to require your business associate to carry cyber liability as well.
  6. Physical security is often overlooked when we talk about data security. Portable devices need to be secured when left unattended. Printers and fax machines should not be located where they can be accessed by an unauthorized person. Servers should be in a locked room or cabinet. Computers should not be located near exits. Keeping an up to date inventory list and reviewing it regularly is critical in knowing if anything is missing. Lastly, a security system that has cameras and access logs is recommended.
  7. Organizations that have well defined policies and procedures are less likely to have a data breach. Employees are educated on what they can and cannot do with business equipment. Knowing what to do in the event of a security incident can actually STOP a data breach from becoming a major breach. Plus, most large fines are because the organization did NOT have a policy or plan in place. Just make sure you have read and dated them!

Remember HIPAA is not a once and done process, as technology changes and employees come and go, you need to keep track and update accordingly. Use your Risk Management Plan to track your progress! Let us know if you need any help with implementation.

If you would like more information, contact us at 877.659.2467 or complete the contact us form.

“Simplifying HIPAA through Partnership, Education, and Support”

©2024 Aris Medical Solutions – HIPAA Risk Management | HIPAA Compliance Consultants | All Rights Reserved | Terms and Conditions | Privacy Policy
The content and images on this website is owned by Aris Medical Solutions and their owners. Do not copy any content or images without our consent.
Powered by Bandwise LLC