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What’s the Biggest Threat to Your Medical Practice? Your Staff!

What’s the Biggest Threat to Your Medical Practice? Your Staff!

Many of us are aware of recent attacks impacting health care entities large and small. As ransomware and other cybersecurity-related crimes are being reported daily, there is a tremendous focus on the “dark web” and how to decrease the likelihood your entity will be impacted by hackers. But as we put systems in place to deal with those security issues, we must not forget about the threat of other malicious actors. These individuals are not strangers who only interact with our computer systems remotely. This threat is much closer. We’re referring to your staff members who may inappropriately access and utilize patient data for personal gain.

Employers generally believe they hire the best candidates. In most instances that is correct. After combing over résumés and doing countless interviews, it is determined the selected individual is a person you can trust and respect. As these individuals prove themselves to be competent and dependable, many of us will place a high level of confidence not only in that person’s ability to perform the job, but also in their character.

As time passes we learn a lot about our colleagues. We learn about each other’s families, interests and life goals. We become invested in our co-workers, and we share in moments of success and disappointment. These events endear us to one another and become the fabric of our working relationships. However, just as this bonding is reflective of our human desire to find commonalities, these relationships can also blind us to a very serious threat. This threat is the impact that these very individuals can have on our entities if they intentionally or inadvertently compromise a patient’s protected health information (PHI). We must constantly remind ourselves good people can do bad things depending on that individual’s circumstances at the time they make a compromising decision.

“Insider threat” is a term used to describe the threat to an entity’s systems or data that originates from within the entity. These “insiders” can be current or former employees, contractors, or business associates who have or has had authorized access to an entity’s systems or data and misuse that access.

Red Flag Behavioral Indicators

When entities endure a significant data breach, they are often in disbelief the incident occurred. Then as they begin the investigation phase, they realize there were behaviors exhibited by the bad actor that should have drawn suspicion.

Here are some behaviors entities should be watchful of:1

  • Works odd hours without authorization; notable enthusiasm for overtime work, weekend work, or unusual schedules which may result in them being able to carry out their illicit activities privately.
  • Remotely accesses the computer network while on vacation, sick leave, or at other odd times.
  • Interest in matters outside the scope of their duties, particularly where patient data may be stored and how that information may be accessed.
  • Unexplained affluence; buys things they cannot afford on their household income.
  • Without need or authorization, takes proprietary or other material like patient information home, via paper records, thumb drives or by emailing information to their personal email accounts.
  • Overwhelmed by life crisis or career disappointments.
  • Paranoia about being investigated; believes there are listening devices or cameras in their homes or workplaces.
  • Disregarding computer policies on installing personal software or hardware, accessing restricted websites, conducting unauthorized searches, or downloading confidential information.

How to Reduce Your Risk

  • Appropriately manage your employees. Entities should pay particular attention to individuals who are disgruntled or who may be undergoing financial hardship. Also, be watchful of employees who show up to work very early or leave very late with no work product to show for the extra time they’ve worked. Additionally, background checks can be very telling. This is especially true for employees whose records identify financial issues like issuing bad checks.
  • Be mindful of security access privilege designations. Only provide employees with the security access privileges they need to perform their job functions. The less access they have to patient data that does not involve them, the less likely they will be able to create large data breaches.
  • Proactively audit user access. Perform audits of user actions to determine who has been remoting into your entity’s computer network or who has been accessing your systems after normal business hours. Review reports of failed log-in attempts to determine whether employees are trying to log into systems they have not been officially granted access to view.
  • Develop and adhere to effective termination procedures. Once you become aware an employee will need to be terminated, make plans to disable their physical and system access such that the terminated employee does not have the opportunity to negatively impact your entity or systems. During the exit interview, make it clear to the terminated employee your entity will not tolerate inappropriate data access and will seek criminal prosecution if it discovers any employees are engaging in such activity.
  • Effective training programs. Ensure your employees are aware of your entity’s privacy and security policies and procedures. Reiterate these principals in training and inform them of the consequences of not adhering to these requirements. Additionally, train employees to be particularly watchful of co-workers who exhibit the behavioral indicators described above. Ensure they know the warning signs and to whom to report their concerns.
  • All insiders are not necessarily in your building. Be mindful that Business Associates and contractors may also have access to your systems
    and data. The activities of these users should be monitored as well. Individuals within those entities should be signing confidentiality agreements at a minimum and Business Associate Agreements, when applicable.


Your entity’s designated Security Officer can play a key role in monitoring the electronic behavior of staff members, Business Associates and contractors. Ensure this individual is knowledgeable about your entity’s HIPAA security policies and procedures, and they are following up on audits that identify behaviors that may be placing your patient data at risk. If your entity does not have updated HIPAA security policies and procedures, consider hiring a health care compliance professional to ensure regulatory compliance.

Article contributed by Samarria Dunson, J.D., CHC, CHPC, attorney/principal of Dunson Group, LLC, a health care compliance consulting and law firm in Montgomery, Ala.

1 “The Insider Threat”, U.S. Department of Justice Federal Bureau of Investigation;
2 “Insider Threats: What every government agency should know and do,” Deloitte Dbriefs, March 2016.

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Breach Notification…Who, How, When?

Breach Notification…Who, How, When?

February is typically a very busy month for health care compliance professionals because the majority of breaches are required to be reported to the Department of Health and Human Services (HHS) within the first 60 days of the calendar year following the breach. However, the type of breach determines the applicable deadline so it is very important to know what needs to be reported to whom and when.

Entities regulated by HIPAA, including healthcare providers, health plans and business associates, must identify breaches in an adequate and timely manner and respond to breaches accordingly. This response includes identifying the occurrence, thoroughly investigating the incident, completing a thorough Breach Assessment of the incident and timely reporting conclusions to the appropriate parties.

A “breach” is an impermissible use or disclosure that compromises the privacy or security of protected health information. When a breach occurs in a health care setting, the entity may be required to provide notice of the breach to affected parties, including the patient or client, HHS and in some instances media outlets.


Health care entities are required to assess all breaches by considering the likelihood that patient or client protected health information was compromised. This is different than the previous harm standard, which required a determination of whether the breach caused a significant risk of financial, reputational or other harm. Under the compromise standard, consideration is given to the identity of the individual to whom the information was wrongfully provided and the possibility of that individual being able to retain and/or utilize the information.

Entities rely on their Breach Assessment tool to assist them with developing conclusions about the status of a breach. Unless an entity can substantiate and document that the breach was low-risk, it must be reported to appropriate parties as a breach. Pursuant to federal regulation, specific elements must be considered before an entity can determine a breach to be low-risk. Those elements include:

  • The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification;
  • The unauthorized person who used the protected health information or to whom the disclosure was made;
  • Whether the protected health information was actually acquired or viewed; and
  • The extent to which the risk to the protected health information has been mitigated.[1]

These elements, in addition to other documented analysis, must be included on the entity’s Breach Assessment. This document should be customized to the entity and identify criteria that would lead to an objective determination about the nature of the breach.

The adequacy of an entity’s Breach Assessment tool is vital to that entity reaching an appropriate conclusion. The Breach Assessment should document the type of breach and the source of the breach. It should reflect whether it was an oral breach or whether documentation was shared. It should consider whether the individual with whom the information was shared is also a workforce member of a HIPAA-covered entity or whether that individual had any duty to keep the information confidential. After considering these questions, in addition to other factors, the entity should be able to make a reasonable determination about whether the protected health information was compromised.

Content of Notice

If an entity determines that a breach occurred and that breach notification is necessary, they must provide notice of the breach, which at a minimum includes the following:

  • A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known;
  • A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, social security number, date of birth, home address, account number, diagnosis, disability code, or other types of information were involved);
  • Any steps individuals should take to protect themselves from potential harm resulting from the breach;
  • A brief description of what the covered entity involved is doing to investigate the breach, to mitigate harm to individuals, and to protect against any further breaches; and
  • Contact procedures for individuals to ask questions or learn additional information, which shall include a toll-free telephone number, an e-mail address, website, or postal address.[2]

Timeliness Requirements

Entities must adhere to specific deadlines for breach reporting. The timeline is considered to have started on the date that the entity “knew or should have known of the breach.” Meaning that the entity either had direct knowledge of the breach or in the exercise of due diligence the entity should have been aware that the breach took place. This should have known element is important because it holds entities responsible for breaches based on an objective standard which discourages entities from pretending to be unaware of breach incidents.

Notification deadlines are directly related to the size of the breach. Breaches fewer than 500 individuals require notification to the patient within 60 days of discovery of the breach, also known as Individual Notice. Additionally, for breaches fewer than 500, notification must be provided to HHS within the first 60 days of the following calendar year.

Breaches involving 500 individuals or greater require entities to meet the Individual Notice standard described above, but it also requires simultaneous notice to HHS and media notice. Media notice is required to take place both in the place where the entity does business and in the location where the individuals affected by the breach reside. For example, a practice is located in Montgomery, Ala., and they provide services to patients in Montgomery and in Huntsville, Ala. The entity will be responsible for contacting media outlets in both Montgomery and Huntsville to ensure that consumers are informed of the breach. Additionally, if the entity has a website the notice must also be placed on the entity website.

Wall of Shame (for breaches of 500 individuals or greater)

The HHS Office of Civil Rights (OCR) notifies the public of large breaches in an effort to strengthen consumer trust and transparency. These breaches can be found on the HHS website and are known in the health care industry as the “Wall of Shame.” This Wall of Shame identifies entities that are currently under investigation, as well as entities who have already settled their cases with HHS or otherwise resolved their cases through administrative proceedings. It documents the name of the entity, the exact number of people involved in the incident and the type of breach. While the Wall of Shame generally reports incidents that occurred within the last two years, there is also an archive section that allows consumers to review cases occurring before that cut off period. You can view the HHS Wall of Shame by utilizing the following link:

Understanding the Breach Notification Rule can be tricky. This area of the regulations has many aspects that require professionals to perform specific analysis as they navigate each incident. Your entity compliance professional should be trained on the requirements and ensure that your policies and procedures are updated regularly. Your entity can report breaches to HHS by utilizing the following link:

Should your entity have questions regarding the Breach Notification Rule, they should contact a healthcare compliance professional for guidance.

[1] 45 CFR 164.402(a)(2)

[2] 45 CFR 164.404 (c)

Article contributed by Samarria Dunson, J.D., CHC, CHPCattorney/principal of The Dunson Group, LLC, a health care compliance consulting and law firm in Montgomery, Ala. The Dunson Group, LLC, is an official partner with the Medical Association.

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HIPAA and the Holidays

HIPAA and the Holidays

As the holiday season builds momentum we are faced with numerous distractions like holiday decorations, taking advantage of online sales and soaking in the traditions that we look forward to each year. But this season of joy and giving should also be met with a heightened sense of awareness and adherence to HIPAA policies and procedures. You’re likely thinking to yourself, “How can Christmas, Hanukkah, Kwanza or the New Year impact HIPAA?” Well, those holidays can’t, but your employees’ behavior sure can.

Electronic Protected Health Information (ePHI)

This busy season will cause some employees to take advantage of online shopping while at work. While that seems relatively harmless, and in most cases it is, this also invites the possibility of introducing viruses into your system from unprotected and/or unapproved sites. It is important to have a clear policy and procedure regarding internet access on your entity’s equipment and it is equally important to ensure that your entity is enforcing compliance. Likewise, the threats of ransomware are ever increasing. A distracted employee is more likely to click a suspicious link or open a questionable email that could introduce ransomware into your computer system or electronic medical records. This is a great time to remind staff of their responsibilities to protect ePHI.

Physical Security

Unfortunately, the season of “giving” for some means a season of “taking” for others. Generally, criminal activity like property theft and break-ins rise during the shopping season. This makes it extremely important for your entity to adhere to mandatory HIPAA Physical Safeguards. The HIPAA Security Rule requires entities to have a documented Facility Security Plan, which memorializes the use of physical access controls. Specifically, entities are required to “implement policies and procedures to safeguard the facility and the equipment therein from unauthorized physical access, tampering, and theft.”[1] The entity’s designated HIPAA Security Officer should be reminding employees of the policy of not providing keys or swipe access to individuals who are not employees or staff members of the entity. Additionally, HIPAA Security Officers should review and document the use of cameras, alarm systems, keys and swipe cards to assess whether any changes need to be made to address any areas of vulnerability.

This is also particularly important for employees and staff who travel with PHI or ePHI. Whether it is paper records or a laptop, employees and staff should ensure they are not leaving these items in their vehicles in plain view. We advise our clients to have a policy that requires employees to leave any PHI or ePHI in the trunk of their vehicle where it is not visible or inviting for a would-be-thief. This can significantly reduce the entity’s risk of HIPAA breaches, as well as property loss.

Workstation Security

Many health care providers will experience an increase in patient activity as people clamber to make their end of the year appointments to take advantage of any cost savings before the new year begins. Combine that with flu-season and the prevalence of winter illnesses and all of a sudden the waiting room just became standing room only. The euphoric nature of the season, coupled with a dramatic increase in patient activity can be a recipe for HIPAA violations. While employees struggle to keep up with the demand, they are more likely to be careless about workstation security. They become less likely to lock their computers when they walk away from their station and more likely to share usernames and passwords in order to accomplish certain tasks more quickly. While these activities seem relatively harmless, these are violations that can cost the entity greatly if it leads to breaches of PHI or ePHI.

Visitors and Guests

The holidays aren’t nearly as fun without office holiday parties. These parties generally include catered meals, outside delivery services and even invited guests. Entities should ensure that they have a documented visitor/guest policy and procedure and that their employees follow that procedure. This includes a visitor/guest sign-in. Depending on the layout of the facility, these visitor/guests should be escorted to their destination so that they don’t have an opportunity to view documents or lab reports that may be left unattended in the facility.

Delivery personnel and vendors are not the only individuals subject to that policy. Family members and friends who present to the facility to visit with staff members and employees must also adhere to the entities visitation policies. Just because the person may be a relative or close friend does not earn them the right to overhear conversations about patient PHI or the right to view PHI that may be on someone’s desk or workstation.

Tone of Voice

One of the biggest complaints that our office receives regarding patient privacy is the tone of voice used by employees and staff as they discuss their health conditions. During the holiday season, many entities play festive music in their waiting areas which automatically cause employees and staff to raise their voices as they converse with patients or other providers. Entities should pay particular attention to the location of their waiting rooms and the position of their reception desk. Employees and staff should be advised of this concern and reminded of the importance of using a professional tone that would not give rise to unauthorized or inappropriate disclosures of PHI.

This is without argument “the most wonderful time of the year.” It’s a time to enjoy family, get reacquainted with friends, and provide for the health and well-being of patients. As the activity of the season builds, it is important to make every effort to ensure that your entity is in compliance with HIPAA regulations. Adhering to appropriate policies and procedures will not only ensure that you provide appropriate patient care, it will also reduce the likelihood of liability for violations which is a great way to start the New Year.

[1] § 164.310(a)(2)(ii)

Samarria Dunson, J.D., CHC, CHPC is attorney/principal of Dunson Group, LLC, a health care compliance consulting and law firm in Montgomery, Alabama.  Read other articles from Dunson Group here.

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