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Dialogue on HIPAA/HITECH
Compliance
Director Leon Rodriguez
U.S. Department of Health and Human Services
Office for Civil Rights
OCR/NIST 6th Annual Conference
Safeguarding Health Information: Building Assurance through HIPAA
Security
May 22, 2013
Resolution Agreement with Idaho
State University
• ePHI of approximately 17,500 individuals was accessible
from August 2010 to May 20, 2011 because an ISU server
firewall was disabled;
• ISU’s risk analyses and assessments of its clinics were
incomplete and inadequate to thoroughly identify potential
risks or vulnerabilities to ePHI as well as an assessment on
the likelihood of whether potential risks would occur;
• OCR further concluded that ISU did not apply proper
security measures and policies to address risks to ePHI and
that it did not have in place procedures for routine review
of information system activity which could have detected
the breach in the firewall much sooner;
• Overall, ISU failed to ensure the uniform implementation of
required Security Rule protections at each of its covered
clinics;
• ISU agreed to a corrective action plan and paid OCR a
settlement of $400,000.
U.S. Department of Health and Human Services, Office for Civil Rights May 22, 2013 | page 2
Total of $14,883,345 in Resolution
Agreements and CMPs Since 2008
U.S. Department of Health and Human Services, Office for Civil Rights May 22. 2013 | page 3
Covered Entity Amount Date
Hospice of North Idaho $50,000 December 28, 2012
Massachusetts Eye and Ear Institute $1.5 Million September 17, 2012
Alaska DHSS $1.7 Million June 26, 2012
Phoenix Cardiac Surgery $100,000 April 13, 2012
BCBS Tennessee $1.5 Million March 13, 2012
University of California at
Los Angeles Health System
$865,500 July 6, 2011
Massachusetts General Hospital $1 Million February 14, 2011
Cignet Health of
Prince George's County, MD (CMP)
$4.3 Million
(Summary Judgment by U.S. District Court
for $4,782,845.43)
February 4, 2011
(August 28, 2012)
Management Services Organization of
Washington, Inc.
$35,000 December 13, 2010
Rite Aid Corporation $1 Million July 27, 2010
CVS Pharmacy, Inc. $2.25 Million January 16, 2009
Providence Health & Services $100,000 July 16, 2008
Total Complaints filed (since 2003): 74,554 Total Cases Investigated: 26,513 Total Cases with Corrective Action: 17,767
Be Smart and Implement Best Practices
Risk analysis, ongoing risk management, and routine
information system reviews are the cornerstones of an
effective HIPAA security compliance program.
U.S. Department of Health and Human Services, Office for Civil Rights May 22, 2013 | page 4
Together, proper security measures and policies help mitigate
potential risk to patient information.
Questions?
OCR website www.HHS.gov/OCR
U.S. Department of Health and Human Services, Office for Civil Rights May 22. 2013 | page 5

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HIPAA Compliance Dialogue with OCR Director

  • 1. Dialogue on HIPAA/HITECH Compliance Director Leon Rodriguez U.S. Department of Health and Human Services Office for Civil Rights OCR/NIST 6th Annual Conference Safeguarding Health Information: Building Assurance through HIPAA Security May 22, 2013
  • 2. Resolution Agreement with Idaho State University • ePHI of approximately 17,500 individuals was accessible from August 2010 to May 20, 2011 because an ISU server firewall was disabled; • ISU’s risk analyses and assessments of its clinics were incomplete and inadequate to thoroughly identify potential risks or vulnerabilities to ePHI as well as an assessment on the likelihood of whether potential risks would occur; • OCR further concluded that ISU did not apply proper security measures and policies to address risks to ePHI and that it did not have in place procedures for routine review of information system activity which could have detected the breach in the firewall much sooner; • Overall, ISU failed to ensure the uniform implementation of required Security Rule protections at each of its covered clinics; • ISU agreed to a corrective action plan and paid OCR a settlement of $400,000. U.S. Department of Health and Human Services, Office for Civil Rights May 22, 2013 | page 2
  • 3. Total of $14,883,345 in Resolution Agreements and CMPs Since 2008 U.S. Department of Health and Human Services, Office for Civil Rights May 22. 2013 | page 3 Covered Entity Amount Date Hospice of North Idaho $50,000 December 28, 2012 Massachusetts Eye and Ear Institute $1.5 Million September 17, 2012 Alaska DHSS $1.7 Million June 26, 2012 Phoenix Cardiac Surgery $100,000 April 13, 2012 BCBS Tennessee $1.5 Million March 13, 2012 University of California at Los Angeles Health System $865,500 July 6, 2011 Massachusetts General Hospital $1 Million February 14, 2011 Cignet Health of Prince George's County, MD (CMP) $4.3 Million (Summary Judgment by U.S. District Court for $4,782,845.43) February 4, 2011 (August 28, 2012) Management Services Organization of Washington, Inc. $35,000 December 13, 2010 Rite Aid Corporation $1 Million July 27, 2010 CVS Pharmacy, Inc. $2.25 Million January 16, 2009 Providence Health & Services $100,000 July 16, 2008 Total Complaints filed (since 2003): 74,554 Total Cases Investigated: 26,513 Total Cases with Corrective Action: 17,767
  • 4. Be Smart and Implement Best Practices Risk analysis, ongoing risk management, and routine information system reviews are the cornerstones of an effective HIPAA security compliance program. U.S. Department of Health and Human Services, Office for Civil Rights May 22, 2013 | page 4 Together, proper security measures and policies help mitigate potential risk to patient information.
  • 5. Questions? OCR website www.HHS.gov/OCR U.S. Department of Health and Human Services, Office for Civil Rights May 22. 2013 | page 5