Scrypt has put out the infographic below to help summarize the guide to Privacy and Security of Electronic Health Information that HHS put out. Of course, the full guide is 62 pages of detailed information, but this will give you a flavor for what’s in the guide.
Scrypt has put out the infographic below to help summarize the guide to Privacy and Security of Electronic Health Information that HHS put out. Of course, the full guide is 62 pages of detailed information, but this will give you a flavor for what’s in the guide.
If this post feels like groundhog day, then you are probably remembering our previous post about Windows XP being retired and therefore no longer HIPAA compliant and our follow up article about a case where “unpatched and unsupported software” was penalized by OCR as a HIPAA violation.
With those posts as background, the same thing applies to Microsoft ending support for Windows Server 2003 on July 14, 2015. Many of you are probably wondering why I’m talking about a 2003 software that’s being sunset. Could people really still be using this software in healthcare? The simple answer is that yes they are still using Windows Server 2003.
Mike Semel has a really great post about how to deal with the change to ensure you avoid any breaches or HIPAA penalties. In his post he highlights how replacing Windows Server 2003 is a much larger change than it was to replace Windows XP.
In the later case, you were disrupting one user. In the former case, you’re likely disrupting a whole group of users. Plus, the process of moving a server to a new server and operating system is much harder than moving a desktop user to a new desktop. In fact, in most cases the only reason organizations hadn’t moved off Windows XP was because of budget. My guess is that many that are still on Windows Server 2003 are still on it because the migration path to a newer server is hard or even impossible. This is why you better start planning now to move off Windows Server 2003.
I also love this section of Mike Semel’s post linked above which talks about the costs of a breach (which is likely to happen if you continue using unsupported and unpatched software):
The 2015 IBM Cost of a Data Breach Report was just released and the Ponemon Institute determined that a data breach of healthcare records averages $ 398 per record. You are thinking that it would never cost that much to notify patients, hire attorneys, and plug the holes in your network. You’re right. The report goes on to say that almost ¾ of the cost of a breach is in loss of business and other consequences of the breach. If you are a non-profit that means fewer donations. If you are a doctor or a hospital it could mean your patients lose trust and go somewhere else.
I’m sure that some will come on here like they did on the Windows XP post and suggest that you can keep using Windows Server 2003 in a HIPAA compliant manner. This penalty tells me otherwise. I believe it’s a very risky proposition to continue using unsupported and unpatched software. Might there be some edge case where a specific software requires you to use Windows Server 2003 and you could set up some mix of private network/firewalls/access lists and other security to mitigate the risk of a breach of the unsupported software. In theory, that’s possible, but it’s unlikely most of you reading this are in that position. So, you better get to work updating from Windows Server 2003.
Recently, I’ve been re-watching the blockbuster TV series hit “Breaking Bad” courtesy of Netflix. For those who haven’t seen it, the show traces the descent of a seemingly honest plain-Joe suburbanite from high school chemistry teacher to murderous king of a multi-state crystal meth business, all kicked off by his diagnosis of terminal lung cancer.
As the show clearly intends, it has me musing once again on how an educated guy with a family and a previously crime-free life can compromise everything that once mattered to him and ultimately, destroy nearly everything he loves.
And that, given that I write for this audience, had me thinking just as deeply what turns ordinary healthcare workers into cybercriminals who ruthlessly exploit people’s privacy and put their financial survival at risk by selling the data under their control.
Sure, some of data stealing is done by black-hat hackers who crack healthcare networks and mine them for data at the behest of organized crime groups. But then there’s the surprises. Like the show’s central character, Walter White, some healthcare cybercriminals seem to come out of the blue, relative “nobodies” with no history as gangsters or thieves who suddenly find a way to rationalize stealing data.
I’d bet that if you dug into the histories of those healthcare employees who “break bad” you’d find that they have a few of the following characteristics in common:
* Feeling underappreciated: Like Walter White, whose lowly chemistry-teacher job was far below his abilities, data-stealing employees may feel that their talents aren’t appreciated and that they’ll never “make it” via a legitimate path.
* Having a palatable excuse: Breaking Bad’s dying anti-hero was able to rationalize his behavior by telling himself that he was doing what he did to protect his family’s future well-being. Rogue employees who sell data to the highest bidder may believe that they’re committing a victimless crime, or that they deserve the extra income to make up for a below-market salary.
* Willful ignorance: Not once, during the entire run of BB, does White stop and wonder (out loud at least) what harm his flood of crystal meth is doing to its users. While it doesn’t take much imagination to figure out how people could be harmed by having their medical privacy violated — or especially, having their financial data abused — some healthcare workers will just choose not to think about it
* Greed: No need to explain this one — though people may restrain naturally greedy impulses if the other factors listed above aren’t present. You can’t really screen for it, sadly, despite the damage it can do.
So do you have employees in your facilities on the verge of breaking bad and betraying the trust their stewardship of healthcare data conveys? Taking a look around for bitter, dissatisfied types might be worth a try.
As I see it, rules giving mental health and substance abuse data extra protection are critical. Maybe someday, there will be little enough stigma around these illnesses that special privacy precautions aren’t necessary, but that day is far in the future.
That’s why a new bill filed by Reps. Tim Murphy (R-PA.) and Paul Tonko (D-N.Y.), aimed at simplifying sharing of substance misuse data between EMRs, deserves a close look by those of us who track EMR data privacy. Tonko and Murphy propose to loosen federal rules on such data sharing such that a single filled-out consent form from a patient would allow data sharing throughout a hospital or health system.
As things currently stand, federal law requires that in the majority of cases, federally-assisted substance abuse programs are barred from sharing personally-identifiable patient information with other entities if the programs don’t have a disclosure consent. What’s more, each other entity must itself obtain another consent from a patient before the data gets shared again.
At a recent hearing on the 21st Century Cures Act, Rep. Tonko argued that the federal requirements, which became law before EMRs were in wide use, were making it more difficult for individuals fighting a substance abuse problem to get the coordinated care that they needed. While they might have been effective privacy protections at one point, today the need for patients to repeatedly approve data sharing merely interferes with the providers’ ability to offer value-based care, he suggested. (It’s hard to argue that it can’t be too great for ACOs to hit such walls.)
Clearly, Tonko’s goals can be met in some form. In fact, other areas of the clinical world are making great progress in sharing mental health data while avoiding data privacy entanglements. For example, a couple of months ago the National Institute of Mental Health announced that its NIMH Limited Datasets project, including data from 23 large NIMH-supported clinical trials, just sent out its 300th dataset.
Rather than offer broader access to data and protect individual identifiers stringently, the datasets contain private human study participant information but are shared only with qualified researchers. Those researchers must win approval for a Data Use Certification agreement which specifies how the data may be used, including what data confidentiality and security measures must be taken.
Of course, practicing clinicians don’t have time to get special approval to see the data for every patient they treat, so this NIMH model doesn’t resolve the issues hospitals and providers face in providing coordinated substance abuse care on the fly.
But until a more flexible system is put in place, perhaps some middle ground exists in which clinicians outside of the originating institution can grant temporary, role-based “passes” offering limited use to patient-identifiable substance abuse data. That is something EMRs should be well equipped to support. And if they’re not, this would be a great time to ask why!
Today I stumbled across an article which I thought readers of this blog would find noteworthy. In the article, Art Gross, president and CEO at HIPAA Secure Now!, made an important point about BYOD policies. He notes that while much of today’s corporate computing is done on mobile devices such as smartphones, laptops and tablets — most of which access their enterprise’s e-mail, network and data — HIPAA offers no advice as to how to bring those devices into compliance.
Given that most of the spectacular HIPAA breaches in recent years have arisen from the theft of laptops, and are likely proceed to theft of tablet and smartphone data, it seems strange that HHS has done nothing to update the rule to address increasing use of mobiles since it was drafted in 2003. As Gross rightly asks, “If the HIPAA Security Rule doesn’t mention mobile devices, laptops, smartphones, email or texting how do organizations know what is required to protect these devices?”
Well, Gross’ peers have given the issue some thought, and here’s some suggestions from law firm DLA Piper on how to dissect the issues involved. BYOD challenges under HIPAA, notes author Peter McLaughlin, include:
* Control: To maintain protection of PHI, providers need to control many layers of computing technology, including network configuration, operating systems, device security and transmissions outside the firewall. McLaughlin notes that Android OS-based devices pose a particular challenge, as the system is often modified to meet hardware needs. And in both iOS and Android environments, IT administrators must also manage users’ tendency to connected to their preferred cloud and download their own apps. Otherwise, a large volume of protected health data can end up outside the firewall.
* Compliance: Healthcare organizations and their business associates must take care to meet HIPAA mandates regardless of the technology they use. But securing even basic information, much less regulated data, can be far more difficult than when the company creates restrictive rules for its own devices.
* Privacy: When enterprises let employees use their own device to do company business, it’s highly likely that the employee will feel entitled to use the device as they see fit. However, in reality, McLaughlin suggests, employees don’t really have full, private control of their devices, in part because the company policy usually requires a remote wipe of all data when the device gets lost. Also, employees might find that their device’s data becomes discoverable if the data involved is relevant to litigation.
So, readers, tell us how you’re walking the tightrope between giving employees who BYOD some autonomy, and protecting private, HIPAA-protected information. Are you comfortable with the policies you have in place?
Full Disclosure: HIPAA Secure Now! is an advertiser on this website.
Dr. Deborah Peel from Patient Privacy Rights always keeps me updated on some of the latest news coverage around privacy and government surveillance. Obviously, it’s a big challenge in healthcare and she’s the leading advocate for patient privacy.
Today she sent me a link to this John Oliver interview with Snowden. The video is pretty NSFW with quite a bit of vulgarity in it (It’s John Oliver on HBO, so you’ve been warned). However, much like Stephen Colbert and John Stewart, they talk about some really important topics in a funny way. Plus, the part where he’s waiting to see if Snowden is going to actually show for the interview is hilarious.
The humor aside, about 10 minutes in John Oliver makes this incredibly insightful observation:
There are no easy answers here. We all naturally want perfect privacy and perfect safety, but those two things cannot coexist.
Either you have to lose one of them or you have to accept some reasonable restrictions on both of them.
This is the challenge of privacy and security. There are risks to having data available electronically and flowing between healthcare providers. However, there are benefits as well.
I’ve found the right approach is to keenly focused on the benefits you want to achieve in using technology in your organization. Then, after you’ve focused the technology on the benefits, work through all of the risks you face. Once you have that list of risks, you work to mitigate those risks as much as possible.
As my hacker friend said, “You’ll never be 100% secure. Someone can always get in if they’re motivated enough. However, you can make it hard enough for them to breach that they’ll go somewhere else.”
The following is a guest blog post by Asaf Cidon, CEO and Co-Founder of Sookasa.
The news that home care provider Amedisys had a HIPAA breach involving more than 100 lost laptops—even though they contained encrypted PHI—might have served as a wake-up call to many healthcare providers. Most know by now that they need to encrypt their files to comply with HIPAA and prevent a breach. While it’s heartening to see increased focus on encryption, it’s not enough to simply encrypt data. To ensure compliance and real security, it’s critical to also manage and monitor access to protected health information.
Here’s what you should look for from any cloud-based solution to help you remain compliant.
- Centralized, administrative dashboard: The underlying goal of HIPAA compliance is to ensure that organizations have meaningful control over their sensitive information. In that sense, a centralized dashboard is essential to provide a way for the practice to get a lens into the activities of the entire organization. HIPAA also stipulates that providers be able to get Emergency Access to necessary electronic protected health information in urgent situations, and a centralized, administrative dashboard that’s available on the web can provide just that.
- Audit trails: A healthcare organization should be able to track every encrypted file across the entire organization. That means logging every modification, copy, access, or share operation made to encrypted files—and associating each with a particular user.
- Integrity control: HIPAA rules mandate that providers be able to ensure that ePHI security hasn’t been compromised. Often, that’s an element of the audit trails. But it also means that providers should be able to preserve a complete history of confidential files to help track and recover any changes made to those files over time. This is where encryption can play a helpful role too: Encryption can render it impossible to modify files without access to the private encryption keys.
- Device loss / theft protection: The Amedisys situation illustrates the real risk posed by lost and stolen devices. Amedisys took the important first step of encrypting sensitive files. But it isn’t the only one to take. When a device is lost or stolen, it might seem like there’s little to be done. But steps can and should be taken to decrease the impact a breach in progress. Certain cloud security solutions provide a device block feature, which administrators can use to remotely wipe the keys associated with certain devices and users so that the sensitive information can no longer be accessed. Automatic logoff also helps, because terminating a session after a period of inactivity can help prevent unauthorized access.
- Employee termination help: Procedures should be implemented to prevent terminated employees from accessing ePHI. But the ability to physically block a user from accessing information takes it a step further. Technical tools such as a button that revokes or changes access permission in real-time can make a big impact.
Of course encryption is still fundamental to HIPAA compliance. In fact, it should be at the center of any sound security policy—but it’s not the only step to be taken. The right solution for your practice will integrate each of these security measures to help ensure HIPAA compliance—and overall cyber security.
About Asaf Cidon
Asaf Cidon is CEO and co-founder of cloud security company Sookasa, which encrypts, audits and controls access to files on Dropbox and connected devices, and complies with HIPAA and other regulations. Cidon holds a Ph.D. from Stanford University, where he specialized in mobile and cloud computing.
This post is part of the #HIMSS15 Blog Carnival which explores “The Future of…” across 5 different healthcare IT topics.
Security is on the top of mind of most healthcare boards. I think the instruction from these boards to CIOs is simple: Keep Us Out of the News!
That’s an order that’s much easier said than done. If Google and Anthem can’t stay out of the news because of a breach, then a hospital or doctor’s office is fighting an uphill battle. Still don’t believe me, check out this visualization of internet attacks. It’s pretty scary stuff.
The reality is that you don’t really win a security battle. You can just defend against attacks as well as possible with the limited resources you have available. What is clear is that while still limited, healthcare will be investing more resources in security and privacy than they’ve ever done before.
The future of effective security in healthcare is going to be organizations who bake security into everything they do. Instead of hiring a chief security officer that worries about and advocates for security, we need a culture of security in healthcare organizations. This starts at the top where the leader is always asking about how we’re addressing security. That leadership will then trickle down into the culture of a company.
Let’s also be clear that security doesn’t have to be at odds with innovation and technology. In fact, technology can take our approach to security and privacy to the next level. Tell me how you knew who read the chart in a paper chart world? Oh yes, that sign out sheet that people always forgot to sign. Oh wait, the fingerprints on the chart were checked. It’s almost ludicrous to think about. Let’s be real. In the paper chart world we put in processes to try to avoid the wrong people getting their hands on the chart, but we really had no idea who saw it. The opposite is true in an EHR world. We know exactly who saw what and who changed what and when and where (Note: Some EHR are better than others at this, but a few lawsuits will get them all up to par on it).
The reality is that technology can take security and privacy to another level that we could have never dreamed. We can implement granular access controls that are hard and fast and monitored and audited. That’s a powerful part of the future of security and privacy in healthcare. Remember that many of the healthcare breaches come from people who have a username and password and not from some outside hacker.
A culture of security and privacy embraces the ability to track when and what happens to every piece of PHI in their organization. Plus, this culture has to be built into the procurement process, the implementation process, the training process, etc. Gone are the days of the chief security officer scapegoat. Technology is going to show very clearly who is responsible.
While I’ve described a rosy future built around a culture of privacy and security, I’m not naive. The future of healthcare security also includes a large number of organizations who continue to live a security life of “ignorance is bliss.” These people will pay lip service to privacy and security, but won’t actually address the culture change that’s needed to address privacy and security. They’ll continue the “Just Enough Culture of HIPAA Compliance.”
In the future we’ll have to be careful to not include one organization’s ignorance in a broad description of healthcare in general. A great example of this can be learned from the Sutter Health breach. In this incident, Sutter Health CPMC found the breach during a proactive audit of their EHR. Here’s the lesson learned from that breach:
The other lesson we need to take from this HIPAA breach notification is that we shouldn’t be so quick to judge an organization that proactively discovers a breach. If we’re too punitive with healthcare organizations that find and effectively address a breach like this, then organizations will stop finding and reporting these issues. We should want healthcare organizations that have a culture and privacy and security. Part of that culture is that they’re going to sometimes catch bad actors which they need to correct.
Healthcare IT software like EHRs have a great ability to track everything that’s done and they’re only going to get better at doing it. That’s a good thing and healthcare information security and privacy will benefit from it. We should encourage rather than ridicule organizations like CPMC for their proactive efforts to take care of the privacy of their patients’ information. I hope we see more organizations like Sutter Health who take a proactive approach to the security and privacy of healthcare information.
In fact the title of the blog post linked above is a warning for the future of healthcare IT: “Will Hospitals Be At Risk for HIPAA Audits If They Don’t Have HIPAA Violations?”
Security and privacy will be part of the fabric of everything we do in healthcare IT. We can’t ignore them. In order for patients to trust these healthcare apps, security will have to be a feature. Those in healthcare IT that don’t include security as a feature will be on shaky ground.
Not long ago, health insurance giant Anthem suffered a security breach of historic proportions, one which exposed personal data on as many as 80 million current and former customers. While Anthem is taking steps to repair the public relations damage, it’s beginning to look like even its $100 million cyber security insurance policy is ludicrously inadequate to address what could be an $8B to $16B problem. (That’s assuming, as many cyber security pros do, that it costs $100 to $200 per customer exposed to restore normalcy.)
But the full extent of the healthcare industry hack may be even greater than that. As information begins to filter out about what happens, a Forbes report suggests that the cyber security intrusion at Anthem may be linked to another security breach — exposing 4.5 million records — that took place less than six months months ago at Community Health Systems:
Analysis of open source information on the cybercriminal infrastructure likely used to siphon 80 million Social Security numbers and other sensitive data from health insurance giant Anthem suggests the attackers may have first gained a foothold in April 2014, nine months before the company says it discovered the intrusion. Brian Krebs ‒ Anthem Breach May Have Started in April, 2014
Class action suits against CHS were filed last August, alleging negligence by the hospital giant. Anthem also faces class action suits alleging security negligence in Indiana, California, Alabama and Georgia. But the damage to both companies’ image has already been done, damage that can’t be repaired by even the most favorable legal outcome. (In fact, the longer these cases linger in court, the more time the public has to permanently brand the defendants as having been irresponsible.)
What makes these exploits particularly unfortunate is that they may have been quite preventable. Security experts say Anthem, along with CHS, may well have been hit by a well-known and frequently leveraged vulnerability in the OpenSSL cryptographic software library known as the Heartbleed Bug. A fix for Heartbleed, which was introduced in 2011, has been available since April of last year. Though outside experts haven’t drawn final conclusions, many have surmised that neither Anthem nor CHS made the necessary fix which would have protected them against Heartbleed.
Both companies have released defensive statements contending that these security breaches were due to tremendously sophisticated attacks — something they’d have to do even if a third-grade script kiddie hacked their infrastructure. But the truth is, note security analysts, the attacks almost certainly succeeded because of a serious lack of internal controls.
By gaining admin credentials to the database there was nothing ‒ including encryption ‒ to stop the attack. The only thing that did stop it was a lucky administrator who happened to be paying attention at the right time. Ken Westin – Senior Security Analyst at Tripwire
As much these companies would like to convince us that the cyber security breaches weren’t really their fault — that they were victims of exotic hacker gods with otherworldly skills — the bottom line is that this doesn’t seem to be true.
If Anthem and CHS going to point fingers rather than stiffen up their cyber security protocols, I’d advise that they a) buy a lot more security breach insurance and b) hire a new PR firm. What they’re doing obviously isn’t working.
Last year, Microsoft stopped updating Windows XP and so we wrote about how Windows XP would no longer be HIPAA compliant. If you’re still using Windows XP to access PHI, you’re a braver person that I. That’s just asking for a HIPAA violation.
It turns out that Windows Server 2003 is 5 months away from Microsoft stopping to update it as well. This could be an issue for many practices who have a local EHR install on Windows Server 2003. I’d be surprised if an EHR vendor or practice management vendor was running a SaaS EHR on Windows Server 2003 still, but I guess it’s possible.
However, Microsoft just recently announced another critical vulnerability in Windows Server 2003 that uses active directory. Here are the details:
Microsoft just patched a 15-year-old bug that in some cases allows attackers to take complete control of PCs running all supported versions of Windows. The critical vulnerability will remain unpatched in Windows Server 2003, leaving that version wide open for the remaining five months Microsoft pledged to continue supporting it.
There are a lot more technical details at the link above. However, I find it really interesting that Microsoft has chosen not to fix this issue in Windows Server 2003. The article above says “This Windows vulnerability isn’t as simple as most to fix because it affects the design of core Windows functions rather than implementations of that design.” I assume this is why they’re not planning to do an update.
This lack of an update to a critical vulnerability has me asking if that means that Windows Server 2003 is not HIPAA compliant anymore. I think the answer is yes. Unsupported systems or systems with known vulnerabilities are an issue under HIPAA as I understand it. Hard to say how many healthcare organizations are still using Windows Server 2003, but this vulnerability should give them a good reason to upgrade ASAP.