What does “Recognized Security Practices” mean?

We have talked in the past about the Office for Civil Rights conducting a minimum of a 12 month look back for data security/ HIPAA compliance efforts. If an organization suffers a breach, with proper documentation fines may be waived. This is known as “Recognized Security Practices”. Every organization will have different documentation based on their network configuration and how data flows in and out of your information systems. This isn’t really anything new since data security requirements have been in place since the Security Rule was enacted. There have been updates over the last few years, and they are making some new revisions requiring covered entities and business associates to document their efforts now more than ever. NIST SP800-66 Rev. 2

This includes ensuring your policies and procedures are documented and followed by your staff. Our online system makes this task must easier by enabling the HIPAA compliance officer to download and share certain policies for employees to review. Plus, the confidentiality and acceptable use agreement that is signed via DocuSign demonstrates you have advised your employees they must follow your policies and procedures.

Another part of this documentation should be reports from your IT department/vendor. Again, depending on how you access ePHI (electronic protected health information), reports will vary from practice to practice. Some suggested reports are:

  1. Managed devices. You can use this as your inventory list instead of completing the list in your package. However, we still recommend documenting which devices have been used to access and/or store ePHI.
  2. In the report above, this may contain operating systems, patches / updates that have been applied, IP addresses, User ID, and a device name. All of this is useful information, and if the report does not contain this information, you need to look for another report.
  3. Software lists are very important since you can see if any employee has downloaded unauthorized software or if a computer has been compromised.
  4. Device health reports typically include information on anti-virus, last log in, some record failed logins, or that is in a different report. These are must have reports.
  5. Access logs may be located within the software the IT vendor utilizes to manage your network, within your domain controller, and within your EHR/PM software. These reports must be reviewed to ensure employees are only accessing ePHI based on their job function and to look for outside intrusions.
  6. Backup reports should demonstrate when backups are performed and to ensure they are successful.
  7. Summary reports are useful, but you must make sure you review them, and they can be lengthy.

There are times when certain devices cannot be updated or upgraded due to the nature of the equipment and the cost to do so. This would not necessarily be a violation if you demonstrate other means to protect your system. For example, either removing the outdated equipment from internet access or placing it on a separate network so it would not be accessible by other drives that contain ePHI. Your IT vendor should be able to guide you through the proper process based on your particular network.

Annual audits by a third party are highly recommended unless your IT vendor specializes in network security. Often, these two types of companies work well together. The IT vendor handles the day-to-day operations, and the network security companies hardens the systems.

Some organizations complain that this costs too much money. Trust me, this is much less expensive than a data breach. Plus, if you plan on obtaining cyber liability insurance, carriers are now asking detailed questions about data security and compliance efforts. If you do have a data breach and you do not have “qualified documentation”, your claim could be denied. Of course, the term “qualified documentation” is open to interpretation. They do have an outlandish wish list from what I have seen. Although I have always been a proponent of this insurance, I am starting to believe unless you already have a policy, you may not be able to obtain one. If you do apply now, you will need to have HEAVY data security in place. Which you should have anyway!

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”

How to protect your organization from phishing attacks

It is a known fact that hackers target the healthcare sector because the data is so valuable. The cost of healthcare data breaches increased from a total average of $7.13M in 2020 to $9.23M in 2021. The average breach cost rose $1.07M for those who had remote access. Organizations in the U.S. has lost $2.4B to business email scams. They have estimated that cybercrime topped $6T worldwide.

So, how do hackers get in and what can you do to protect yourself?

Remember, there isn’t ONE magic setting to protect you from all threats, it takes layers of security!

Organizations must have solid network security in place. Firewalls are a necessity in today’s world. You can set specific parameters to ensure employees can go where they need to, and block where they do not. You can also set security policies that block other countries.

Utilizing real-time anti-virus and anti-malware software also helps. This won’t help if an employee clicks on a link or picks up malware on the internet unless the system alerts the user BEFORE they click! For example, if an employee is surfing the web (and no they should not surf on a work computer), and they visit a website that has been infected, your anti-virus / anti-malware software should alert you with a warning.

Although there are brut attacks, but most hackers come in via through a phishing attempt. Often, an employee makes a simple mistake like clicking on a link or an attachment in an email. Even though I talk about this ALL the time and say NEVER do this…people still do.
Email scammers use several ways to trick employees to gain access to information. Including getting employees to send wire transfers, send a list of employee’s social security numbers, or to make purchases they are not aware of. Alan Suderman at Fortune cited a case where thieves hacked the email account of the organization’s bookkeeper, then inserted themselves into a long email thread, sent messages asking to change the wire payment instructions for a grant recipient, and made off with $650,000.
You think this can’t happen to you, but I know of a practice that someone hacked an email account and changed the bank information for payments from an insurance carrier, they lost about $100K.

I know of a company that the CEO email was hacked and being monitored, once the scammers knew who they talked to on the phone and who they did not, then the call came in to make a $65K wire transfer. POOF! Just like that $65K was gone.
YES, THIS HAPPENS! Keep in mind, if the caller or the email is asking for private information or money, verify BEFORE releasing it.

• Unless you are expecting an email from someone, DO NOT CLICK!
• If you get an email from someone you know and were not expecting it, pick up the phone and call them!
• If there is a link, open a web browser and open your account from there.
• If it is URGENT and requires you to act immediately, it is more than likely a hacker/spammer.
• If it says your credit card has been charged for something and you didn’t charge it, call your card company or your bank, do not call the number in the email or call the number in the voice mail.
• If they have all your information except the code on the back and ask you to verify the card by giving them the number, DO NOT.
• Government, state, and local authorities will not call you and demand payment immediately. Ignore these completely.
• Again, if money or personal information is involved, VERIFY!

Scammers share their success stories with other scammers, while ransomware hackers will hit you again if you pay. There is no honor among thieves.

All sizes of organizations need to be on high alert, from large hospitals to small single provider practices. I have used this analogy before, the World Wide Web it the modern version of the Wild Wild West. The biggest difference is you can’t see the bad guys coming into town to prepare. You must prepare for the unknown and the unseen.
There are companies that offer Phishing training. Then, they try to get your employees to take the bait. This has been a success at most companies. Educating your staff is JOB ONE! They can be your best ally, or your weakest link. You can build a fortress around your data, and one click can bring it down.

Continuous security awareness training is vital in your fight against these bad actors. Organizations must teach employees to be watchful for phishing attacks and stopping them by simply not engaging in emails and on the web.

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”

Healthcare Cyber Attacks went up almost 90% in 2017

By Aris Medical Solutions

There were 132 reported breaches under investigation from Health and Human Services’ (HHS) Office for Civil Rights (OCR) in 2017 related to Hacking/IT Incident. As you review the report you can see how many were related to email and desktop computers.

Click here to see a list of current data breaches: OCR breach portal

So how does this happen? More than likely it has been caused by an unsuspecting employee. Healthcare is typically targeted with ransomware through social engineering. Practices need to be vigilant in educating their staff to be extremely careful when it comes to clicking on emails or surfing the web with their work computers. That is why we always recommend work computers be used exclusively for work. Plus, personal email addresses should never be utilized to communicate with patients or vendors for a number of reasons, this being just one!

There were many server attacks as well. This can happen in the same manner, especially when someone is logged in with administrative rights when they should be logged in as a user instead.

When it comes to cloud storage or cloud based EHRs, these too can be hacked although it is not as common. Most of the time this is caused by a misconfiguration in the network.

What can you do to prevent this from happening to you?

First of all, conduct a full HIPAA Security Risk Analysis, you need to know where your data is in order to create a Risk Management Plan to protect your organization.
Secondly, continual education on new threats to inform your employees how to be diligent.
Most of all, make sure your IT professional is a network security specialist. Doing your own network security is not longer an option, you must utilize a professional to ensure your network is secure. This includes your websites and cloud services.

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Data call 877.659.2467 or click here to contact us.

“Protecting Organizations through Automation, Education, and Support”

File sharing and cloud computing, is it permitted under HIPAA?

 

By Aris Medical Solutions

 

With all of the new technology that we have access to, many vendors are targeting healthcare with promises of ease of use and the ability to communicate with other healthcare providers. Before you agree to “share” or open your “portal” you must ensure the vendor or service you are going to use actually understands HIPAA and the requirements.

File sharing and cloud computing are here to stay. As we move forward with sharing patient data amongst our peers, you will need to be vigilant with your security.

Here are a few things to review:

  1. Network misconfigurations are very common, review your data flow, including how data is transmitted and stored.
  2. Backup your data!
  3. When access is given to an employee, contractor, or vendor, once the need for access is no longer required, terminate their access credentials immediately.
  4. Although most providers do not think hackers are a problem for them, they are! Your network security is vital and you must use a trained professional to set up your network and your file sharing configuration. If your IT professional does not specialize in network security, then hire a network security auditor to conduct a vulnerability scan after you have implemented your systems. A good vendor will mitigate your risks as they scan your network.
  5. Make sure you have a HIPAA compliant business associate agreement in place.
  6. Review the service agreement. Make sure it includes specific business expectations.
  7. Invest in cyber liability insurance.

File sharing and cloud computing are wonderful tools that can be used in healthcare if setup properly and securely.

 

For more information on how Aris Medical Solutions can help your organization with HIPAA Compliance and Protecting your Practice call 877.659.2467 or click here to contact us.

“Protecting Organizations 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