Of the safeguards required by the HIPAA Security Rule, which of the following is NOT at issue due to HealthCo’s actions?

SCENARIO

Please use the following to answer the next QUESTION:

You are the chief privacy officer at HealthCo, a major hospital in a large U.S. city in state

A. HealthCo is a HIPAA-covered entity that provides healthcare services to more than 100,000 patients. A third-party cloud computing service provider, CloudHealth, stores and manages the electronic protected health information (ePHI) of these individuals on behalf of HealthCo.

CloudHealth stores the data in state

B. As part of HealthCo’s business associate agreement (BAA) with CloudHealth, HealthCo requires CloudHealth to implement security measures, including industry standard encryption practices, to adequately protect the data. However, HealthCo did not perform due diligence on CloudHealth before entering the contract, and has not conducted audits of CloudHealth’s security measures.

A CloudHealth employee has recently become the victim of a phishing attack. When the employee unintentionally clicked on a link from a suspicious email, the PHI of more than 10,000 HealthCo patients was compromised. It has since been published online. The HealthCo cybersecurity team quickly identifies the perpetrator as a known hacker who has launched similar attacks on other hospitals C ones that exposed the PHI of public figures including celebrities and politicians.

During the course of its investigation, HealthCo discovers that CloudHealth has not encrypted the PHI in accordance with the terms of its contract. In addition, CloudHealth has not provided privacy or security training to its employees. Law enforcement has requested that HealthCo provide its investigative report of the breach and a copy of the PHI of the individuals affected.

A patient affected by the breach then sues HealthCo, claiming that the company did not adequately protect the individual’s ePHI, and that he has suffered substantial harm as a result of the exposed data. The patient’s attorney has submitted a discovery request for the ePHI exposed in the breach.

Of the safeguards required by the HIPAA Security Rule, which of the following is NOT at issue due to HealthCo’s actions?

A. Administrative Safeguards

B. Technical Safeguards

C. Physical Safeguards

D. Security Safeguards

View Answer

Answer: D

Explanation:

The HIPAA Security Rule requires covered entities and their business associates to implement three types of safeguards to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI): administrative, physical, and technical1. Security safeguards is not a separate category of safeguards, but rather a general term that encompasses all three types. Therefore, it is not a correct answer to the question.

Administrative safeguards are the policies and procedures that govern the conduct of the workforce and the security measures put in place to protect ePHI. They include risk analysis and management, training, contingency planning, incident response, and evaluation12.

Physical safeguards are the locks, doors, cameras, and other physical measures that prevent unauthorized access to ePHI. They include workstation and device security, locks and keys, and disposal of media12.

Technical safeguards are the software and hardware tools that protect ePHI from unauthorized access, alteration, or destruction. They include access control, encryption, audit controls, integrity controls, and transmission security12.

In the scenario, HealthCo’s actions have potentially violated all three types of safeguards.

For example:

HealthCo did not perform due diligence on CloudHealth before entering the contract, and has not conducted audits of CloudHealth’s security measures. This could be a breach of the administrative safeguard of risk analysis and management12.

HealthCo discovers that CloudHealth has not encrypted the PHI in accordance with the terms of its contract. This could be a breach of the technical safeguard of encryption12.

HealthCo provides its investigative report of the breach and a copy of the PHI of the individuals affected to law enforcement. This could be a breach of the physical safeguard of disposal of media, if HealthCo did not ensure that the media was properly erased or destroyed after the transfer12.

Reference: 1: Summary of the HIPAA Security Rule, HHS.gov. 2: What is the HIPAA Security Rule? Safeguards … – Secureframe, Secureframe.com.