Even organizations with sound policies, procedures, training, and safeguards can experience a breach. When?not if?a breach occurs, traditional insurance may not be enough to cover the damages. Ensuring that your organization has adopted the appropriate cyber insurance can be valuable in the event of a breach.
Q: As part of the audit controls policy at my organization, we hired an external security vendor to collect and review logs from several critical servers. The vendor creates tickets for our IT staff when a potential incident is discovered during the daily log review. This supplements our own activity reviews of internally generated reports, and the vendor then uses them for its own review. Our internal staff never sees the reports the vendor uses for its review. Do the reports the vendor uses fall under the HIPAA requirement for retaining logs for six years? Should we compel the vendor to retain these reports?
Q: My facility no longer registers patients under aliases, but will allow them to opt out of the patient directory. However, opting out of the registry will not exclude our patients from the operating room (OR) list. At one time, the facility's CEO received the daily OR list with full patient names so he could visit board members, donors, or others whom he knows at our facility. HIM changed this practice so that patients' names would not be on the OR schedule provided to the CEO. The CEO took this matter to the hospital attorney, who said the names could be included because the use of PHI by the CEO to determine whether and when a patient visit is appropriate is permitted by HIPAA as it is part of healthcare operations. Is it a violation of HIPAA for the CEO to use PHI to track patients in this manner?
While organizations should focus on performing regular risk assessments and analyses, there are also other ways in which they must review their systems for compliance. Often, these other evaluations are overlooked despite their value, says Kevin Beaver, CISSP, an information security consultant in Atlanta. In particular, organizations should be careful not to forget about performing vulnerability assessments and penetration tests, which are components of an overall risk assessment or analysis, says Beaver, who is a BOH editorial advisory board member.
