The U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) announced a settlement with Heritage Valley Health System (Heritage Valley), which provides care in Pennsylvania, Ohio and West Virginia, concerning potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Security Rule, following a ransomware attack. Ransomware and hacking are the primary cyber-threats in healthcare. Since 2018, there has been a 264% increase in large breaches reported to OCR involving ransomware attacks.
OCR’s investigation revealed multiple potential violations of the HIPAA Security Rule, including failures by Heritage Valley to: conduct a compliant risk analysis to determine the potential risks and vulnerabilities to electronic protected health information in its systems; implement a contingency plan to respond to emergencies, like a ransomware attack, that damage systems that contain electronic protected health information; and implement policies and procedures to allow only authorized users access to electronic protected health information.
Under the terms of the resolution agreement, Heritage Valley agreed to pay $950,000 and implement a corrective action plan that will be monitored by OCR for three years. Under the plan Heritage Valley will take a number of steps to resolve potential violations of the HIPAA Security Rule and protect the security of electronic protected health information, including:
- Conduct an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to the confidentiality, integrity, and availability of its electronic protected health information;
- Implement a risk management plan to address and mitigate security risks and vulnerabilities identified in their risk analysis;
- Review and develop, maintain, and revise, as necessary its written policies and procedures to comply with the HIPAA Rules; and
- Train their workforce on their HIPAA policies and procedures.
OCR recommends healthcare providers, health plans, clearinghouses, and business associates that are covered by HIPAA take the following steps to mitigate or prevent cyber-threats:
- Review all vendor and contractor relationships to ensure business associate agreements are in place as appropriate and address breach/security incident obligations.
- Integrate risk analysis and risk management into business processes; conducted regularly and when new technologies and business operations are planned.
- Ensure audit controls are in place to record and examine information system activity.
- Implement regular review of information system activity.
- Utilize multi-factor authentication to ensure only authorized users are accessing electronic protected health information (ePHI).
- Encrypt ePHI to guard against unauthorized access to ePHI.
- Incorporate lessons learned from incidents into the overall security management process.
- Provide training specific to organization and job responsibilities and on regular basis; reinforce workforce members’ critical role in protecting privacy and security.
