HIPAA Breach: Who You Gonna Call?

Everyone knows that you call a plumber for a leaking pipe, a mason for a cracked stonewall, and an electrician to fix faulty wiring. However, when faced with an actual or suspected HIPAA data breach, many folks struggle with determining whom to call. Failure to have contacts lined up ahead of time may pose more than an inconvenience–any delay in bringing in experienced advisors to assist with breach investigation, response and mitigation may result in significant financial and legal consequences. HIPAA covered entities and business associates should have a written breach response policy and protocol. The policy and protocol should provide clear guidance to the covered entity’s or business associate’s…

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Final Rule: Modified Definition of Breach

January 28, 2013.  Today, we want to explore the modified definition of breach in the Final HIPAA/HITECH Act Privacy, Security, Breach Notification, and Enforcement Rule published in the Federal Register on Friday, January 25, 2013. Here is the modified definition [45 CFR 164.402, Definitions, effective March 26, 2013; 78 Federal Register 5695]: Breach means the acquisition, access, use, or disclosure of protected health information in a manner not permitted under subpart E [HIPAA Privacy Rule] of this part [Part 164] which compromises the security or privacy of the protected health information. (1) Breach excludes: (i) Any unintentional acquisition, access, or use of protected health information by a workforce member or…

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ONC Touts its 10 Step Plan for Meeting Meaningful Use Privacy and Security Attestation Requirements

In a recent Tweet, the Office of the National Coordinator for Health Information Technology (ONC) stated:  “Move into the 21st Century and check out the Privacy & Security 10-Step Plan before you implement an Electronic Health Record.”  ONC makes the following recommendation to an Eligible Professional (EP) covered entity participating in the Medicare and Medicaid Financial Incentive Program for Adoption and Meaningful Use of Certified Electronic Health Record (EHR) Technology:  “An EP must meaningfully use certified EHR technology for an EHR reporting period, and then attest to CMS [the Centers for Medicare & Medicaid Services] that he or she has met meaningful use for that period.  Start your 10-step process at…

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CMS and ONC Publish Final Rules for Meaningful Use Stage 2 Security in Federal Register

September 4, 2012.  The Department of Health and Human Services (HHS) entities:  Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC), published their Final Rules for Meaningful Use Stage 2 in today’s Federal Register.  This posting focuses on the preamble relating to the following Stage 2 security objective in the CMS Final Rule entitled Medicare and Medicaid Programs; Electronic Health Record Incentive Program:  “Protect electronic health information created or maintained by the Certified EHR Technology [CEHRT] through the implementation of appropriate technical capabilities.”  Reference numbers in brackets refer to the page number(s) in the September 4, 2012,  Federal Register. Associated with this objective…

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OCR’s Publicly Disclosed Large Breaches Now Top 20 Million Impacted Individuals

May 16, 2012.  The Department of Health and Human Services’ (HHS) HIPAA/HITECH Act privacy and security enforcement arm, Office for Civil Rights (OCR), is responsible under the HITECH Act to publicly disclose privacy and security breaches that affect 500 or more individuals on its Breach Notification Web site.  With the now reported Utah Department of Health hacking/IT incident breach occurring in the period March 10-April 2, 2012 and affecting a reported 780,000 individuals, the total number in 435 breaches reported since September 22, 2009, now totals 20,079,189 impacted individuals.  Of the total number of breaches where location of breached information is known (e.g., electronic or hard copy source), 72% of…

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OCR Penalizes Physician Practice for HIPAA Privacy and Security Rule Violations

April 18, 2012.  Late last week, the Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS) executed a Resolution Agreement and included Corrective Action Plan (Appendix A) as a settlement for violations of HIPAA Privacy and Security Rules by a physician practice, Phoenix Cardiac Surgery, P.C., of Phoenix and Prescott, AZ. In its April 17, 2012, News Release, HHS stated: “The incident giving rise to OCR’s investigation was a report that the physician practice was posting clinical and surgical appointments for its patients on an Internet-based calendar that was publicly accessible. On further investigation, OCR found that Phoenix Cardiac Surgery had implemented few policies and…

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CMS Publishes Stage 2 Meaningful Use Incentive Program NPRM

On March 7, 2012, the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register its 132-page notice of proposed rule making (NPRM):  Medicare and Medicaid Programs; Electronic Health Record Incentive Program–Stage 2.  Comments to the Department of Health and Human Services (HHS) may be made until 5 PM on May 7, 2012. The summary of the NPRM is included here: “This proposed rule would specify the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments.  In addition, it would specify payment adjustments under Medicare for covered…

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HITECH Act Breached Individuals Skyrocket in Latest OCR Web Site Posting

Under the Health Information Technology for Economic and Clinical Health Act (HITECH Act), enacted as part of the American Recovery and Reinvestment Act of 2009, covered entities are required to report to the Secretary of the U.S. Department of Health and Human Services (HHS) any privacy or security breach affecting 500 or more individuals within 60 days of discovery of the breach by the covered entity or its business associate.  The HHS Office for Civil Rights (OCR), which is responsible for privacy and security enforcement under the Health Insurance Portability and Accountability Act (HIPAA) and HITECH Act provisions that strengthened privacy and security enforcement, is required to post those breaches…

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HITECH Act Privacy and Security Final Rules Needed Now

Since September 23, 2009, the enforcement arm of the Department of Health and Human Services (HHS), the Office for Civil Rights (OCR), has been required to publicly disclose breaches involving 500 or more individuals discovered and reported by covered entities and their business associates. As of October 25, 2011, OCR has reported 345 such breaches involving a total of 11,959,488 individuals.  Not reflected yet in the OCR disclosed breaches are two involving 6.5 million individuals:  a Nemours breach of 1.6 million individuals and a TRICARE breach involving 4.9 million individuals.  Together, these two recently reported breaches represent 54.4% of the total number of individuals affected by the publicly disclosed breaches…

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Over 10 Million Individuals Now Affected by Large Data Breaches, as Reported on OCR Web site

Under the Health Information Technology for Economic and Clinical Health Act (HITECH Act), enacted as part of the American Recovery and Reinvestment Act of 2009, covered entities are required to report to the Secretary of the U.S. Department of Health and Human Services (HHS) any privacy or security breach affecting 500 or more individuals within 60 days of discovery of the breach by the covered entity or its business associate.  The HHS Office for Civil Rights (OCR), which is responsible for privacy and security enforcement under the Health Insurance Portability and Accountability Act (HIPAA) and HITECH Act provisions that strengthened privacy and security enforcement, is required to post those breaches on…

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