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Resource Overview

Conducting an SRA in accordance with HIPAA policy is a complex task, especially for small to medium providers such as community health centers. The HIPAA Security Rule mandates security standards to safeguard electronic Protected Health Information (ePHI) maintained by electronic health record (EHR) technology, with detailed attention to how ePHI is stored, accessed, transmitted, and audited. This rule is different from the HIPAA Privacy Rule, which requires safeguards to protect the privacy of PHI and sets limits and conditions on it use and disclosure. Meaningful Use supports the HIPAA Security Rule. In order to successfully attest to Meaningful Use, providers must conduct a security risk assessment (SRA), implement updates as needed, and correctly identify security deficiencies. By conducting an SRA regularly, providers can identify and document potential threats and vulnerabilities related to data security, and develop a plan of action to mitigate them.

Security vulnerabilities must be addressed before the SRA can be considered complete. Providers must document the process and steps taken to mitigate risks in three main areas: administration, physical environment, and technical hardware and software. The following set of resources provide education, strategies and tools for conducting SRA.

Security Risk Analysis Resources
Maui Ransomware to Target the Healthcare and Public Health Sector

Maui Ransomware to Target the Healthcare and Public Health Sector

An alert from the FBI, CISA, and the Department of the Treasury

Introduction

Ransomware is a type of malware that takes control over a computer or computer system by encrypting all the data on the drive. The data is then held at ransom until a predetermined cost is paid. Due to the use of cryptocurrencies (e.g., bitcoins) for payment it is difficult to track those demanding the ransom making it tough to prosecute.

Problem Statement

The Federal Bureau of Investigation (FBI), Cybersecurity and Infrastructure Security Agency (CISA), and the Department of the Treasury (Treasury) are releasing this joint Cybersecurity Advisory (CSA) to provide information on Maui ransomware, which has been used by North Korean state-sponsored cyber actors since at least May 2021 to target Healthcare and Public Health (HPH) Sector organizations.

Mitigations

The FBI, CISA, and Treasury urge HPH Sector organizations to:

  • Limit access to data by deploying public key infrastructure and digital certificates to authenticate connections with the network, Internet of Things (IoT) medical devices, and the electronic health record system, as well as to ensure data packages are not manipulated while in transit from man-in-the-middle attacks. 
  • Use standard user accounts on internal systems instead of administrative accounts, which allow for overarching administrative system privileges and do not ensure least privilege.  
  • Turn off network device management interfaces such as Telnet, SSH, Winbox, and HTTP for wide area networks (WANs) and secure with strong passwords and encryption when enabled. 
  • Secure personal identifiable information (PII)/patient health information (PHI) at collection points and encrypt the data at rest and in transit by using technologies such as Transport Layer Security (TPS). Only store personal patient data on internal systems that are protected by firewalls, and ensure extensive backups are available if data is ever compromised. 
  • Protect stored data by masking the permanent account number (PAN) when it is displayed and rendering it unreadable when it is stored—through cryptography, for example. 
  • Secure the collection, storage, and processing practices for PII and PHI, per regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Implementing HIPAA security measures can prevent the introduction of malware on the system. 
  • Implement and enforce multi-layer network segmentation with the most critical communications and data resting on the most secure and reliable layer. 
  • Use monitoring tools to observe whether IoT devices are behaving erratically due to a compromise. 
  • Create and regularly review internal policies that regulate the collection, storage, access, and monitoring of PII/PHI.

Ransomware & HIPAA Implications

OCR states that whether or not the presence of ransomware would be a breach under the HIPAA Rules is a fact-specific determination. A breach under the HIPAA Rules is defined as, “…the acquisition, access, use, or disclosure of PHI in a manner not permitted under the [HIPAA Privacy Rule] which compromises the security or privacy of the PHI.” See 45 C.F.R. 164.402.6

When electronic protected health information (ePHI) is encrypted as the result of a ransomware attack, a breach has occurred because the ePHI encrypted by the ransomware was acquired (i.e., unauthorized individuals have taken possession or control of the information), and thus is a “disclosure” not permitted under the HIPAA Privacy Rule.

Unless the covered entity or business associate can demonstrate that there is a “…low probability that the PHI has been compromised,” based on the factors set forth in the Breach Notification Rule, a breach of PHI is presumed to have occurred. The entity must then comply with the applicable breach notification provisions, including notification to affected individuals without unreasonable delay, to the Secretary of HHS, and to the media (for breaches affecting over 500 individuals) in accordance with HIPAA breach notification requirements. See 45 C.F.R. 164.400-414.

 

Find links and further documentation below...

 

Documents to download

Previous Article Ransomware Alert and Guidance for Health Centers
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Intended Audiencehealth center IT staff, CIO, Health Center Staff, Health Center Leadership, threat intelligence

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Acknowledgements

This resource collection was cultivated and developed by the HITEQ team with valuable suggestions and contributions from HITEQ Project collaborators.

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