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HIPAA and PHI Cybersecurity Best Practices in the COVID-19 Era

Steven M. Harris, Esq.  |  Issue: September 2021  |  September 14, 2021

  • What if a healthcare professional providing telehealth services has their device stolen or compromised?
  • How will a healthcare organization respond to a data breach when its cybersecurity employees are working remotely?
  • Is there an emergency plan in place that contemplated both a remote and in-person workforce and has a functional security incident response team and security incident response plan been implemented?
  • If a healthcare professional is providing telehealth services from a location outside the office, is the wireless internet connection being used secure and is the healthcare professional in a non-public location?
  • If a healthcare professional needs to step away from their device during a telehealth visit or while working remotely, will the device log off automatically within a reasonable period of time?
  • Are healthcare professionals and support staff properly trained to identify correspondence threats, such as email phishing and ransomware?

These scenarios are meant to identify potential breach vulnerabilities, but they should not necessarily be cause for concern. In the COVID-19 era, healthcare providers should take time to reevaluate their policies, protocols and procedures to ensure they address the types of scenarios described above.

It stands to reason that cybersecurity risks are here to stay, but organizations that have contemplated and formally established policies related to threat management will be best prepared to address and resolve breaches. The best practice is to make sure the scenarios above, as well as other scenarios that an organization’s executive team can reasonably expect to face, are addressed prior to their occurrence.

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Healthcare organizations may also choose to reevaluate their third-party vendors and internally audit their cybersecurity capabilities. In the COVID-19 era, the following outside vendors should be scrutinized for effectiveness:

  • Internet, data and cellular services;
  • Firewall and malware protection;
  • Cloud storage;
  • Password protection services;
  • Email and communications services; and
  • Document management software.

The above services may already be adequate, but the best practice is to have a refreshed and informed view of the scope of cybersecurity services being performed and how those services both independently, and as a part of an overarching security plan, fit into a company’s operations.

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Further, internal audits of policies and procedures related to the procurement and ongoing maintenance of third-party services can assist in ensuring an organization is taking adequate measures to effectively leverage third-party expertise alongside internal expertise in its cybersecurity efforts.

In January 2021, the Health Infor­mation Technology for Economic and Clinical Health (HITECH) Act was amended to require the U.S. Department of Health and Human Services (HHS) to incentivize utilization of cybersecurity best practices. Specifically, the legislation requires HHS to take into consideration a covered entity’s or business associate’s use of industry-standard security practices (i.e., recognized security practices) within the past year, when investigating allega­tions of non-compliance with HIPAA rules and undertaking enforcement actions.

When calculating fines related to a breach, HHS is required to take cybersecurity into consideration and also reduce the extent and length of an audit if the entity being investigated has met industry-standard best practices security requirements. However, HHS is not permitted to increase fines or the length of an audit when an entity is found to be out of compliance with recognized security practices.

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Filed under:Legal Updates Tagged with:HIPAAprotected health information

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