Over the last 20 years, the healthcare industry has shifted towards embracing a more holistic adoption of digital data exchange. However, this increased utilization of digital data sharing has also given more opportunities for cyberhackers to steal personal medical information—healthcare has seen an 256% rise in significant hacking-related breaches over the last five years as reported to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR). For this reason, any organizations that have access to or store health data must prioritize satisfying HIPAA compliance to help reduce the number of exploitable attack vectors within their organization. This is because adhering to HIPAA compliance not only fulfills regulatory requirements but also significantly improves your organization’s data protection. By implementing HIPAA guidelines, you put essential safeguards in place that fortify your security measures, making it harder for cybercriminals to exploit vulnerabilities and access sensitive patient information.
In light of the growing threats to patient data, we’ll cover the typical data governance missteps that often result in HIPAA non-compliance. By understanding these pitfalls, your organization can better structure its data governance framework to maximize its efficacy and mitigate its chances of succumbing to a data breach.
Common HIPAA Violations
Familiarizing yourself with common HIPAA violations is crucial for any healthcare organization that handles sensitive patient data. HIPAA regulations are designed to protect the privacy and security of patient information, but even small oversights can lead to significant breaches and costly penalties.
Lack of Employee Training
Healthcare employees must be trained to protect physical and electronic patient information (PHI and ePHI) and to recognize and avoid areas of noncompliance with HIPAA regulations. Common violations resulting from lack of training include:
- Emailing ePHI to personal email accounts
- Removing PHI from a healthcare facility
- Leaving portable electronic devices and paperwork unattended
- Releasing patient information to an unauthorized individual
- Disclosing PHI to third parties after the expiration of an authorization
- Impermissibly accessing patient health records
Tip: Provide training to all employees who handle ePHI, including new hires and temporary staff. Incorporate HIPAA training into employee onboarding and ongoing professional development programs.
Failure to Issue Breach Notifications Within 60 Days
The HIPAA Breach Notification Rule mandates that a covered entity must promptly notify relevant parties, including individuals, the U.S. Department of Health and Human Services (HHS), and the media (if over 500 patient records are involved), once it knows or could have known by exercising reasonable diligence that a breach has occurred. This notification must be made without undue delay or within 60 calendar days of the date of discovery.
Tip: Develop a comprehensive Breach Response Plan to address breaches holistically. Establish clear communication channels among key personnel involved in the response process. Document all data breaches, including the cause, response, and corrective actions taken. Conduct a post-incident review to identify areas for improvement.
Omission of Business Associate Agreements
A “business associate” refers to an individual or entity that performs functions or services on behalf of a covered entity, or provides services that require access to PHI. The HIPAA Rules require covered entities and business associates to sign contracts with their business associates to ensure the appropriate safeguarding of PHI. However, these agreements may not meet HIPAA requirements, especially if they haven’t been updated since the Omnibus Final Rule.
Tip: Regularly review and update your business associate agreements to ensure they comply with current HIPAA requirements.
Failure to Provide Patients with Access to Their PHI
Under the HIPAA Privacy Rule, patients have the right to access their medical records and obtain copies upon request. Denying access, charging excessive fees, or not providing records within 30 days violates HIPAA regulations.
Tip: Establish a plan for reviewing and addressing access requests, and ensure that staff members are educated on the legal grounds for rejecting requests.
Neglecting to Conduct Regular Risk Assessments
Performing regular risk analyses is crucial for identifying and implementing protective measures that meet the Security Rule’s standards. Without regular assessments, organizations may not detect threats to the confidentiality, integrity, and availability of PHI, leading to unaddressed risks.
Tip: HIPAA Gap Assessments and Penetration Tests are effective methods to analyze and address risks.
Having reviewed the common forms of HIPAA non-compliance, it’s now essential to understand the consequences that can result from these violations.
Consequences of HIPAA Non-Compliance
Understanding the consequences of HIPAA non-compliance is crucial for any healthcare organization. By recognizing the full scope of these consequences, healthcare providers can better understand the importance of maintaining strict adherence to HIPAA standards, ultimately safeguarding both their operations and the privacy of their patients.
Increased Vulnerability to Ransomware Attacks
In 2019, a Maryland-based behavioral healthcare provider’s network was hit by a ransomware attack that encrypted their electronic health records and company files, affecting the data of more than 14,000 individuals. The OCR’s investigation revealed multiple HIPAA violations before and during the attack. This case underscores the growing correlation between cyberattacks and HIPAA non-compliance. The top five worst data breaches in healthcare have all led to HIPAA violations for failing to meet the required standards.
Organizations that don’t prioritize HIPAA compliance risk falling victim to cyberattacks and failing to implement the necessary security practices to defend against common ransomware strategies. Beyond weakening security posture, non-compliance can exacerbate the financial and legal repercussions of recovering from a cyberattack, extending the road to recovery.
The Financial Cost of Non-Compliance
Once a ransomware attack is reported to the OCR, the ensuing HIPAA violations can result in significant financial penalties. Fines for non-compliance can range from thousands to millions of dollars, depending on the severity and duration of the violation. Additionally, the impacted organization may incur costs related to breach notification, legal fees, and other regulatory fines. These expenses can quickly accumulate, straining financial resources and operational capabilities.
Moreover, the provider may face lawsuits from affected individuals or class-action lawsuits representing multiple patients, further increasing the financial burden.
The Long Road to Reputation Restoration
Rebuilding trust after a data breach is a challenging task that requires transparent communication with patients and stakeholders, acknowledgment of the breach, and actions to prevent future incidents. However, regaining a tarnished reputation is often a long and arduous process with no guarantees of success.
The impact of a HIPAA violation can have far-reaching consequences on an organization’s long-term success. Patients are increasingly discerning when choosing healthcare providers, and a damaged reputation can deter them from seeking care from a compromised organization. In today’s competitive healthcare sector, maintaining a positive reputation is crucial for attracting and retaining patients.
Conclusion
It’s crucial to remain vigilant and stay up to date with the latest HIPAA requirements to protect patient privacy and maintain compliance. By taking a proactive approach, conducting regular risk assessments, and preparing adequate response plans, organizations can minimize the risk of violations and potentially save hundreds of thousands of dollars and their reputation. Ransomware attacks are far too common and underscore the dire need for security fortification in the healthcare sector. Prioritizing HIPAA compliance is a critical step in achieving this security, helping your organization maintain its efficacy over time while mitigating the financial, legal, and reputational damage associated with cyberattacks.