During 2014, the Office for Civil Rights (OCR) of the U.S. Department of Health & Human Services initiated six enforcement actions in response to security breaches reported by entities covered by the Health Insurance Portability and Accountability Act (HIPAA) (covered entities), five of which involved electronic protected health information (EPHI). The resolution agreements and corrective action plans resolving the enforcement actions highlight key areas of concern for OCR and provide the following important reminders to covered entities and business associates regarding effective data protection programs.
1. Security risk assessment is key.
OCR noted in the resolution agreements related to three of the five security incidents, involving QCA Health Plan, Inc., New York and Presbyterian Hospital (NYP) and Columbia University (Columbia), and Anchorage Community Mental Health Services (Anchorage), that each entity failed to conduct an accurate and thorough assessment of the risks and vulnerabilities to the entity’s EPHI and to implement security measures sufficient to reduce the risks and vulnerabilities to a reasonable and appropriate level. In each case, the final corrective action plan required submission of a recent risk assessment and corresponding risk management plan to OCR within a relatively short period after the effective date of the resolution agreement.
2. A risk assessment is not enough – entities must follow through with remediation of identified threats and vulnerabilities.
In the resolution agreement related to Concentra Health Services (CHS), OCR noted that although CHS had conducted multiple risk assessments that recognized a lack of encryption on its devices containing EPHI, CHS failed to thoroughly implement remediation of the issue for over 3-1/2 years.
3. System changes and data relocation can lead to unintended consequences.
In two of the cases, the underlying cause of the security breach was a technological change that led to the public availability of EPHI. A press release on the Skagit County incident notes that Skagit County inadvertently moved EPHI related to 1,581 individuals to a publicly accessible server and initially reported a security breach with respect to only seven individuals, evidentially failing at first to identify the larger security breach. According to a press release related to the NYP/Columbia security breach, the breach was caused when a Columbia physician attempted to deactivate a personally-owned computer server on the network, which, due to lack of technological safeguards, led to the public availability of certain of NYP’s EPHI on internet search engines.
4. Patch management and software upgrades are basic, but essential, defenses against system intrusion.
OCR noted in its December 2014 bulletin on the Anchorage security breach (2014 Bulletin) that the breach was a direct result of Anchorage’s failure to identify and address basic security risks. For example, OCR noted that Anchorage did not regularly update IT resources with available patches and ran outdated, unsupported software.
5. HIPAA policies and procedures that merely sit on the shelf are not sufficient.
OCR noted the failure of two covered entities to follow policies and procedures that each entity had adopted. In the NYP resolution agreement, OCR noted that, with respect to a data sharing arrangement with Columbia, NYP had “failed to comply with its own policies on information access management.” Similarly, OCR noted in the 2014 Bulletin that its investigation of Anchorage revealed that Anchorage “had adopted sample Security Rule policies and procedures in 2005, but [that] these were not followed.”