Cyber threats continue to grow and evolve, but most share a similar origin: phishing. Phishing emails, seemingly innocuous or legitimate emails used to infiltrate an organization, are a common source of malware and are used for scams in which a criminal impersonates another individual to obtain sensitive information. A study released in March by PhishMe estimated that up to 93% of phishing emails contain ransomware.
Although the damage phishing emails can do is tremendous, security officers can help their organizations turn the tide by using a combination of technical controls and targeted education.
The danger and the success of phishing emails lies in their ability to manipulate the individual on the receiving end. Phishing emails may be sent from domains that are a near-identical match for an organization's and come with what appear to be legitimate and urgent attachments or links. It's a simple scheme that criminals can use for a variety of purposes.
"They hope to get malware installed so they can control the computers they infect or even the entire network. They hope to get network or application login credentials. They hope to trick people into performing certain actions, i.e., a wire transfer of money," Kevin Beaver, CISSP, independent information security consultant at Principle Logic, LLC, in Atlanta, says. "The possibilities are endless."
The Office for Civil Rights (OCR) stepped up HIPAA enforcement in a big way this year. The agency handed down more than $5 million in HIPAA settlement fines in one week in March, and in July reached a HIPAA violation settlement with Advocate Health Care in Illinois that carried a $5.55 million monetary payment. OCR kicked off phase two of its HIPAA Audit Program and will likely complete desk audits of covered entities (CE) and business associates (BA) by the end of the year. Comprehensive on-site audits may occur early in 2017.
However, breaches continue to come at a relentless pace and questions have been raised about OCR's handling of HIPAA violations, particularly repeat HIPAA offenders. And a truly permanent HIPAA audit program may not yet be in sight: OCR states that phase two audits will help the agency plan for a permanent audit program but doesn't state when that might launch.
In a September 2015 report (https://oig.hhs.gov/oei/reports/oei-09-10-00510.pdf), the Office of Inspector General (OIG) said OCR—and HHS as a whole—should strengthen its oversight of CEs and be proactive rather than reactive in its approach to HIPAA enforcement. The report found that in 26% of closed privacy cases, OCR did not have complete documentation of corrective actions taken by CEs. In addition, OCR's case tracking system has significant limitations and makes it difficult for the agency's staff to check if a CE under investigation has been the subject of previous investigations.
All of this may make some CEs and BAs feel that HIPAA compliance is merely optional, and that leads to a weaker privacy and security culture throughout the industry. Although OCR does take action to make its presence felt, it could do more, Frank Ruelas, MBA, principal of HIPAA College in Casa Grande, Arizona, says.
"I do believe that OCR is trying to let people know that it considers HIPAA compliance an important objective," he says. "With its guidance and ongoing alerts about the occasional enforcement actions here and there, I see OCR's enforcement a small step above being a paper tiger in terms of how seriously people take it."
Threats to PHI are coming fast and furious. Although many organizations are ready to take HIPAA compliance seriously, it requires sustained attention and resources for organizations to protect PHI. That can't happen if privacy and security officers aren't being heard by the board and senior leaders.
In July, OCR announced it reached a HIPAA breach settlement with Oregon Health and Science University (OHSU), an academic health center. In its statement on the settlement, the agency drew attention to the vital role hospital executives and senior leaders play in HIPAA compliance. OHSU did complete risk analyses and identify vulnerabilities, including those that caused the two massive breaches named in the settlement, but no action was taken to mitigate these vulnerabilities. Without support from the top, OHSU's security risks remained unaddressed until it was too late. Failure to address these risks came with a $2.7 million price tag, a strict three-year corrective action plan, and the kind of bad press that's difficult to put a positive spin on.
Privacy and security officers need executive support, but obtaining it may be a challenge. Alliances with key staff and an understanding of the concerns senior leaders face can be a win for privacy and security in the boardroom.
Growing threats to PHI, particularly ransomware, have drawn attention to privacy and security this year. Senior leaders and members of the board may be feeling the pressure to change the way their organizations operate and step up security measures.
There are no federally recognized HIPAA certification standards for covered entities (CE) and business associates (BA) and it's unlikely one will be. However, that doesn't stop larger CEs from requiring some form of certification to demonstrate compliance with HIPAA and proof that BAs have implemented sound information security programs. The Health Information Trust Alliance (HITRUST) published its first common security framework (CSF) in March 2009 with the goal of focusing on information security as a core pillar of the broad adoption of health information systems and exchanges. Larger CEs, primarily large health plans, now require their BAs to become HITRUST certified.
Q: We recently received a request for a patient's records. The patient transferred to another provider several years ago and we subsequently transferred all the patient's records to the new provider. Should I direct the request to the provider the patient transferred to? I'm unsure that we should be responsible for retrieving and releasing information for this patient since we transferred the patient's entire record to the new provider.
A: If you sent a copy of the patient's records to the new provider and still have the original records, it would be appropriate for you to respond to the request. If you transferred all records to the new provider and no longer have the patient's information, refer the request to the new provider.
Editor's note: Mary Brandt, MBA, RHIA, CHE, CHPS, is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Opinions expressed are those of the author and do not represent HCPro or ACDIS. Email your HIPAA questions to Associate Editor Nicole Votta at firstname.lastname@example.org.