Kusserow on Compliance: The OIG on Health IT security

Many are not aware of the fact that the HHS OIG boasts having an A-class team that focuses on IT controls and engages in what they refer to as penetration testing or “hacking” into IT systems and networks. With 100 million health care records already compromised and medical records serving as a top target for hackers, healthcare related cybersecurity has become a high priority for the OIG. Health IT offers some unique challenges, in that health records are for a lifetime, whereas credit cards may have a shelf life, if they’re compromised, of just a day or two. This makes them very valuable for criminals that can often realize 60 times more than what a stolen credit card can yield on the dark web. Compromised health information could have wide-ranging consequences, including affecting credit and even someone filing a false tax return with the information. In addition to people’s personal information, there is concern about health care provider and managed care proprietary information.

The OIG IT audits begin with setting an audit objective, which varies according to what they are trying to accomplish. The OIG desires to provide transparent and objective assessments of the security posture of the systems within HHS and those that receive funding from HHS. The OIG engages in penetration testing, as a means to help strengthen IT vulnerabilities. By engaging in penetration testing or “hacking into” IT networks, the OIG is able to provide chief information officers, and sometimes CFOs, with information regarding particular vulnerabilities. Among the common testing of IT systems is determining whether passwords are being changed periodically.  The OIG stated guiding philosophy is that “what gets checked gets done.” By identifying vulnerabilities, they draw management attention to addressing them and raising their awareness to cybersecurity.

The OIG wants to ensure that funds for cybersecurity, and ultimate for technology, are being used judiciously, and overall the OIG is working every day to protect sensitive personal and proprietary data. The OIG is using its resources to enhance awareness around cybersecurity.  The OIG focuses much of its resources on IT controls for the Medicare enrollment database; however the OIG does not confine its work to the Medicare and Medicaid space. The OIG is also looking at IT security at NIH, Indian health hospitals throughout the country, and FDA information on drugs and medical devices. The OIG typically addresses reports to senior level personnel, such as the CEO and Chief Information Officer, and often addresses reports to state administrators for Medicare and Medicaid.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.

IT experts say foreign actors, human error biggest threats to health record security

Foreign hackers and human error are two of the most significant threats to protected health information (PHI) and other health records that providers and health care entities must prepare for, according to four information technology experts speaking at a conference sponsored by Becker’s Hospital Review. They all agreed that breaches and cyberattacks will continue, so health care institutions must be diligent about security systems, audits, training, insurance, and adequately responding to breaches to mitigate punishment and quickly recovery from an attack..

Weakest link 

Aaron Miri, chief information officer for Imprivita, and Michael Leonard, director at Commvault, both noted that regardless of the tools and systems put in place to ward off breaches, malware, ransomware, and other cybersecurity threats, people will always be the weakest link. Leonard noted that when it comes to an institution’s cybersecurity program, “people training has to be continuous and repetitive.”

Katherine Downing, senior director at the American Health Information Management Association (AHIMA), highlighted one type of “insider threat”—physicians who do work arounds that bypass the security features of electronic health record (EHR) systems (like texting PHI about patients to each other). Although David Miller, CEO of HCCIO Consulting, LLC, was blunter when asked what the biggest threat was to PHI and other health records—”Russia and China.”

Jurisdictions

Miri noted that providers must deal with a “wide disparity of laws” regarding the security and privacy of health information, not just federal and state laws, but, starting in May 2018, the General Data Protection Regulation (GDPR) issued by the European Union. The GDPR replaces a framework of different information security measures that mainly affected just European companies with a national network and information security strategy that will impact American life sciences and healthcare entities that collect and/or use any data concerning health, genetic data, or other types of protected health information (PHI).

Audits

Miller expressed amazement at how many health care institutions have not had a HIPAA audit in the previous two years. The HHS Office for Civil Rights (OCR) reviews organizations’ compliance with the HIPAA Privacy, Security, and Breach Notification Rules and looks for documentary proof that entities have conducted risk assessments and created and implemented policies and procedures governing areas including the shielding of PHI. Miller noted that providers must continually educate and re-educate staff on policies related to HIPAA. But he added that providers can also “take advantage of a breach situation to talk to senior management to increase security measures.”

Record retention

In addition to protecting PHI, health care entities have to make decisions about destroying records after record retention periods have ended. Katherine Downing, senior director at the American Health Information Management Association (AHIMA), noted that entities “can’t keep everything forever.” Downing noted that health care entities already have the expense of saving, backing up, and securing required health records; doing the same for older records that no longer have to be retained is just an added expense.

In the end, Miri noted that these are the questions that health care entities have to ask: What are they willing to spend to avoid a breach? What are they willing to risk regarding their reputations?

Kusserow on Compliance: Defending against ransomware threat

Cyber attacks have risen to dramatic levels over the last two year and are likely averaging one attack a day, with the most disturbing trend involving ransomware. A survey by the American Health Lawyers Association indicated that virtually all healthcare lawyers believe they will be involved with cyber security matters with their client and the threat will continue to increase over the coming years. Data breaches include actions by those inside the organization, as well as external attacks including phishing, hacking, and ransomware. Ransomware typically involve a sophisticated computer virus introduced into a victim’s system that encrypts the system’s data.  The attackers threaten to delete the private key needed to decrypt the files unless the owners of the information pay a ransom, typically in an untraceable digital currency such as Bitcoin. The healthcare industry, particularly hospitals, have proven to be a soft target, as they need to have immediate access to their patient information and many have paid the ransom to regain control over it. The healthcare sector is considered a “soft target” for Ransomware attacks, particularly hospitals that are the perfect mark for this kind of extortion in that they provide critical care and rely on up-to-date information from patient records. As such, compliance officers need to consider this a compliance high-risk area where ongoing monitoring and auditing applies.  Simply assuming that someone in IT is addressing this problem area can be a big mistake. At the same time, the compliance office is not responsible for the program, but is responsible to ensure that those that have that responsibility are doing their job, including IT and human resource management (HRM).

According to new studies reported, healthcare now ranks as the second highest sector for data security incidents, after business services. The “2017 Internet Security Threat Report” found that in healthcare (a) over half of emails contained spam; (b) one in 4,375 emails being a phishing attempt; and (c) email-borne ransom-ware spiked 266% over the previous year.  The Ponemon Institute further found breaches could be costing the healthcare industry $6.2 billion annually. All these studies indicate that the biggest vulnerability to cyber attacks is employees that let-down their guard when opening or responding to emails from unknown sources. Often “scammers” create the appearance of legitimate sites, including using similar names, emblems of companies and even government agencies, etc. (including the OIG and IRS). Once someone opens the door, all kinds of bad things can happen.

Practical Tips

  1. Implement policies and procedures on taking precautions against malware and train all covered persons on them.
  2. Ensure ongoing (repeated) training of employees to keep them aware and being on guard against allowing software breaches by clicking on an email link or attachment, or responding to “pfishing” inquiries.
  3. Don’t entirely rely upon employees to always do the right thing and provide assistance by configuring email servers to block zip or other files that are likely to be malicious.
  4. Restrict permissions to areas of the network by limiting the number of people accessing files on a single server, so that if a server gets infected, it won’t spread to everyone.
  5. Limit employee access to systems on a need to know standard.
  6. Security efforts should focus on those files that are most critical, patient records.
  7. Conduct a risk analysis to identify ePHI vulnerabilities and ways to mitigate or remediate these identified risks.
  8. Maintain disaster recovery, emergency operations, and frequent data backups to permit restoring of lost data in case of an attack.
  9. Move quickly on any report of an attack to prevent the malware from spreading, by disconnecting infected systems from a network; disabling Wi-Fi, and removing USB sticks or external hard drives connected to an infected computer system.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.

 

Kusserow on Compliance: OCR has a record number of significant settlements so far in 2017

The HHS Office for Civil Rights (OCR) has posted about 2,000 major breaches and more than a quarter million small breaches since 2009. The common denominator for many of the cases in which there was a settlement was that the covered entity or business associate (BA) suffered one or more breaches affecting more than 500 individuals sometime between 2011 and 2013. The OCR has jumped off the 2017 year with a record number of significant settlements. The most recent is CardioNet, a wireless health services provider, who provides remote mobile monitoring of and rapid response to patients at risk for cardiac arrhythmias. The provider entered into a settlement for $2.5 million and implemented a corrective action plan for disclosure of unsecured ePHI on a laptop that was stolen from a parked car. CardioNet had an insufficient risk analysis and risk management processes in place at the time of the theft and their HIPAA Security Rule policies and procedures had not been implemented. The OCR has entered into a number of other significant settlements. Others who paid settlements for violating HIPAA requirements so far this year include Memorial Health Systems ($5.5 million); Children’s Medical Center in Dallas ($3.2 million); MAPFRE, a Puerto Rico life insurance company ($2.2 million); Presence Health in Chicago ($475,000); and Community Provider Network of Denver ($400,000). In all these cases, there was the requirement to take corrective actions.

2016 OCR Results

  • There were 329 Data Breaches greater than 500 Individuals (a new record).
  • 225 OCR Phase 2 of HIPAA compliance audits conducted of covered entities and BAs.
  • No onsite audits were conducted.
  • No findings or notifications from the audits have been made.
  • The OCR intends to use the results from these audits to prepare for a new and better tool in the future.
  • There was a large jump in fines imposed for HIPAA violations that totaled about $24 million (versus a little more than $6 and $8 million in for 2105 and 2014 respectively)

OCR in 2017

  • The OCR stated intention is to conduct only a few onsite audits in 2017.
  • To date the OCR has nearly achieved the level of 2016 in terms of penalties imposed.
  • To date about 100 data breaches impacting greater than 500 Individuals have been reported.
  • About a half million individuals have been impacted in reported data breaches so far this year.
  • Only a relatively few BAs were involved in any of the reported data breaches.

The enforcement actions most often come from the OCR when investigations into the root cause of the breach found systemic, often profound, failures of organizational programs to safeguard protected health information.  This includes the failure to perform an information security risk assessment or to have a risk management plan to address gaps in the safeguards for information systems, both required actions under the HIPAA Security Rule. Tied to this has been insufficient development of policies and procedures for HIPAA Compliance.  Other actionable problems that resulted in the OCR imposing HIPAA corrective action plans (CAP) included inappropriate delay in data breach reporting (reported after 60 days from the date of discovery); and inappropriate oversight into user set up and user management. There is also the continuing problem of organizations not implementing encryption technology on mobile devices.

Camella Boateng, a HIPAA consultant reminds everyone that the recently enacted 21st Century Cures Act amends the HITECH Act to extend an individual’s right to access their PHI to data held by business associates. As such, it is more important than ever that entities give a priority for engaging in a self-audit, so vulnerabilities can be detected and resolved before they come to the attention of the government. Furthermore, with a shifting focus toward BA, it is important to avoid any potential partner that will not commit to signing a BAA.

Strong HIPAA Compliance Program Evidence

  • HIPAA policies and procedures;
  • HIPAA requests forms for patient’s rights;
  • a complete notice of privacy practices;
  • established technical, physical, and administrative safeguards;
  • conducting a regular HIPAA risk analysis;
  • developed a risk management plan to address gaps in the safeguards for PHI;
  • strong workforce education;
  • effective user management and oversight into systems with PHI;
  • auditing practices for verification of compliance;
  • ongoing evaluation of current safeguards established by the organization;
  • strong oversight into user set up and user management;
  • implementing encryption technology on mobile devices; and
  • ensuring partners have signed BAAs.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on
Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.