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Building a Framework for HIPAA and HITECH Compliance

Posted by on Monday, 27 August, 2012

HITECH laws were enacted to up the ante on healthcare organizations to meet HIPAA legal compliance for data security and privacy, which, of course puts an additional burden on IT to make sure all bases are covered.  But regardless of the rigors of enacted laws, compliance doesn’t happen overnight. It takes diligence and continued effort to understand and address all necessary requirements. To avoid the potential penalties of breaking HIPAA and HITECH laws, losing the confidence of patients and partners, and incurring hefty penalties, a focused, deliberate, measured plan is essential.

In addition to becoming familiar with HIPAA and HITECH regulations (a good place to start is the HHS.gov website), it’s critical to meet with your security and management team and make decisions as to how your organization can best protect sensitive healthcare information. One of the first places to start this process is to fully document your department’s own security policy and procedures.  This provides the foundation from which to train internal users in understanding and complying with the HIPAA and HITECH rules. In fact, having a security policies and procedures document is a requirement by HIPAA and HITECH.

If you don’t currently have your security policies and procedures documented, one option for finding a good template is to Google the term, “IT Security Policies and Procedures.” You will find free downloadable templates that give you a basic outline to follow.

If you already have this document in place, keep in mind it needs to be treated as a living document, to be changed and updated often as circumstances and requirements change.  Make a point to do a yearly, if not a bi-yearly, review.

Of course, documentation of security policies is only a start. You need to procure and implement proven security tools across your enterprise to protect your data — whether the data resides on a server or is being transmitted across a network or the Internet.  A less-than exhaustive list of necessary IT security tools for ensuring compliance:

 

  • Firewall – This security measure prevents intrusion into the private network from unauthorized outside viewers.
  • Email encryption  – To meet privacy requirements, email communications that contain private data must be encrypted.
  • Malware protection – This step keeps spyware/malware from infecting PCs and servers containing private data.
  • FTP communications – Managed file transfer solutions are designed specifically to provide encryption, logging and automation tools that make sure the sensitive data is secured and tracked while in motion, while reducing the time to manage all incoming and outgoing transactions
  • Backup protection – Backup files and tapes need to be encrypted and otherwise secured to make sure sensitive data can’t fall into the wrong hands
  • Data shielding – Sensitive fields need to be encrypted or hidden to ensure that it can’t be viewed or extracted by unauthorized viewers. A good data encryption product can also encrypt data on backup tapes as well sensitive data that might be shown in on-screen applications.
  • Physical facility protection – Server rooms, fax/copy/printer rooms, workstations all must be  considered when protecting sensitive data that is printed on paper or residing on servers or PCs.
  • Telephone and online communications – Anyone involved in telephone, online chat or discussion groups needs to be trained to be sensitive to privacy regulations and exposing sensitive information.

 

As you can see, there are several aspects of compliance to HITECH and other laws that need to be considered and addressed.  Healthcare professionals and organizations need to take their patients’ privacy seriously, whether in the hospital, physician office or in electronic format on servers and digital communications with others.

Daniel Cheney

Daniel has been the IT Director at a healthcare company for the last 12 years and a longtime beneficiary of GoAnywhere Director and the IBM i platform. He is also a technical analyst and writer for various technical and social media projects with Humanized Communications.

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HITECH Compliance Offers Challenges for IT

Posted by on Tuesday, 19 June, 2012

Outside of the finance industry, healthcare is one of the most regulated industries in the U.S.  As the healthcare policy debates rage on, one issue on which most Americans can agree is the need to keep personal healthcare information confidential and secure.

Major regulations such as HIPAA and HITECH have been passed into law to increase the security of our personal health information.  For better or worse, a major portion of the burden to comply with the regulations and all of their revisions falls upon the IT professionals.

HIPAA and HITECH: a brief overviewHITECH, data security, compliance

While HIPAA (Health Insurance Portability Accountability Act), passed in 1996, has received the most attention (see our blog), the more recently implemented HITECH law is quickly having an impact.

HITECH (Health Information Technology for Economic and Clinical Health Act) was passed into law in 2009. The goal for the  HITECH is to strengthen the civil and criminal enforcement of already existing HIPAA regulations that require health organizations and their business partners to report data breaches.  HITECH also increases the penalties for security violations, and implements new rules for tracking and disclosing patient information breaches.

Data breach notification

Under HITECH rules, all data breaches of PHI (protected health information) must be reported to the individuals whose data was compromised. This includes reporting files that may have been hacked, stolen, lost or even transmitted in an unencrypted fashion.  If such a breach — or potential breach — affects 500 people or more, the media must also be notified.   Breaches of all sizes must always be reported to the Secretary of Health and Human Services (HHS), but if fewer than 500 individuals’ records are affected, healthcare organizations can report the breach via the HHS website on an annual basis.  Larger breaches must be reported to HHS within 60 days.

Penalties for data breach

The HITECH Act implements a four tier system of financial penalties assessed based on the level of “willful neglect” a healthcare organization demonstrated resulting in the breach. Fines range from  $100 per breached record for unintended violations all the way up to $50,000 per record (with an annual cap of $1.5 million) when “willful neglect” is demonstrated.

Access to electronic health records (EHRs)

HITECH requires that the software that a health organization uses to manage its EHRs must make a person’s electronic PHI records available to the patient and yet remain protected from data breach by encrypting the data and securing the connection.  Not surprisingly, email is not considered a secure method of data transmission.

Business associates

Before HITECH,  business associates of healthcare organizations were not held directly liable for privacy and security under the HIPAA rules, even though they had access to PHI.  HITECH now requires that all business associates with access to PHI are subject to the HIPAA rules and must maintain Business Associate Agreements with the healthcare organization that provides the PHI.  Business associates are also required to report any data breaches and are subject to the same penalties as their healthcare business partners.

Daniel Cheney

Daniel has been the IT Director at a healthcare company for the last 12 years and a longtime beneficiary of GoAnywhere Director and the IBM i platform. He is also a technical analyst and writer for various technical and social media projects with Humanized Communications.

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Are Insurance Companies Managing Their Risk of Data Breach?

Posted by on Wednesday, 9 May, 2012

An injury that doesn’t happen needs no treatment. An emergency that doesn’t occur requires no response. An illness that doesn’t develop demands no remedy. The best way to stay safe … is to avoid getting into trouble in the first place. That requires planning, training, leadership, good judgment, and accepting responsibility—in short, risk management.  

– Boy Scout Field Book

Insurance companies are the experts at analyzing and managing risk. They identify, quantify and set pricing based on the calculated costs of risk. Naturally, the higher the perceived risk, the higher the cost to mitigate the potential losses.

Yet here is the irony.  While those in the insurance industry excel at evaluating risk management for their clients, they often neglect risk mitigation within their own operation.

Exposed data is serious risk

The insurance industry collects and analyzes overwhelming amounts of data. This often sensitive and confidential information becomes the basis upon which many critical decisions are made, and which produces the competitive advantage to provide better policies, prices, and solutions to the market.

All of this data, both historical and cutting-edge, is truly the lifeblood of the insurance industry. Therefore, the astute management and protection of this data is the infrastructure of arteries and veins delivering this lifeblood to all of the appendages of the company that need the results of this data compilation.

In addition, this sensitive and private information is disseminated to various internal and external associates, customers, partners and collaborators usually via the Internet, which exposes this data to compromise.

And yet, despite their expertise in risk analysis, many in the insurance industry fail to ask these questions:

  • Given how much data we’re exchanging with clients, partners, financial institutions, healthcare organizations, etc., what is our risk of a data breach?
  • What is our liability if we suffer a data breach?
  • What can be done to mitigate potential losses?

When examined this way, any underwriter would agree that failure to adequately protect the sensitive data continually in transit in an insurance company’s daily workflow presents an extremely high risk.

Insurance industry, heal thyself

If data really is the lifeblood of the insurance business, and the data center is at the heart of the company, then the arteries and veins are the methods of moving that data to and from your departments, clients, business partners, and others.

While adding layers of physical security to the data center is a top priority for insurance IT professionals, securing the pathways in and out of that data center tends to be overlooked, despite media coverage of data breaches at companies worldwide.   This lack of action underestimates the extent of the public’s concern that their private data may be compromised, and state and federal efforts to more strictly regulate data storage and transfer policies.

Effectively managing FTP transactions is essential to mitigating the risks of data loss.  The costs of implementing managed file transfer solutions are minimal and provide tremendous flexibility when striving to meet the requirements of trading partners and compliance regulations.

As the insurance industry knows better than anyone, the best approach is to mitigate risk with a cost efficient solution.  In this case, taking direct action to protect data transfers is the obvious prescription for any organization — especially one based on risk management.

Daniel Cheney

Daniel has been the IT Director at a healthcare company for the last 12 years and a longtime beneficiary of GoAnywhere Director and the IBM i platform. He is also a technical analyst and writer for various technical and social media projects with Humanized Communications.

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FTP May Be Easy, But That May Be the Problem

Posted by on Monday, 23 April, 2012

It happens in your office every day:  someone on your team hits a roadblock when they realize that email just won’t handle the huge file they need to send – immediately. Or another coworker starts to send an account number or password via email and realizes that perhaps, email isn’t all that secure.

FTP alternative, managed file transferThat’s when the tech savvy gal in the corner suggests the obvious solution: just send that file or sensitive personal information via FTP!  She lists a variety of “free” tools that can be downloaded easily, as well as a couple cloud solutions, and in desperation (and often ignorance), your coworker takes her advice and a new FTPer is born.

FTP, or “file transfer protocol,” is a solution that’s been available for more than 30 years.  Within the last decade, so many free or inexpensive FTP tools have become available that many of us assume that FTP must be a reliable solution, or why would so many people be using it?

As we know with many of society’s ills, just because something is easy to find and popular to use doesn’t mean it’s a smart or effective idea.

The downside of FTP

While FTP may be able to send large files, standard FTP – like email — is not secure, and is therefore vulnerable to hackers.

Rogue FTP tools, like those free tools sprinkled on employees’ PCs, start to become a liability to the company, both financially and to its reputation and credibility.

To begin with, multiple employees with multiple FTP tools mean that no one has a master view of the flow of data in and out of your company. It’s impossible to know who is sending what to whom, and who is receiving files from where.

State and Federal laws require that data which contains personally identifiable information must be encrypted and secured. This also applies to most of the financial data that we collect and create. How can you keep tabs on all of this with a lot of FTP processes running on various PCs throughout the office?

Second, because FTP is not secure, the company increases its risk for a data breach.  Costs to notify those affected when a data breach occurs, combined with the fines that can be assessed, can be in the millions of dollars, not to mention the damage to the company’s brand.

If not FTP, then what?

One approach to control FTP traffic is to set up restrictions on the corporate firewall, essentially prohibiting access for all but specifically authorized personnel to the ports required for FTP processes to work.

Chances are, though, that the same tech savvy employee who suggested FTP in the first place also knows how to bypass this restriction by finding different ports or switching to online FTP services. For determined FTPers, even our cell phones are equipped to send and receive files.

So, if it’s hard to stop it, the next best option is to educate your employees, and to develop and promote clear expectations and consequences regarding sending files and sensitive data from work. Many employees want to do the right thing, but don’t understand the implications of sending sensitive data through the easiest – though not necessarily the safest – means.

Another option that is rapidly growing in popularity is the implementation of a managed FTP solution that can be configured to allow users to send and receive large files  and sensitive information within their daily workflow, but with the addition of administrative control and much greater security.

A managed file transfer solution such as Linoma Software’s GoAnywhere Suite, in combination with setting up appropriate firewall rules and educating all employees of corporate policy and procedures,  will keep your employees – tech savvy or not – productive and happy, and give your IT department peace of mind knowing that the company data is secure.

Daniel Cheney

Daniel has been the IT Director at a healthcare company for the last 12 years and a longtime beneficiary of GoAnywhere Director and the IBM i platform. He is also a technical analyst and writer for various technical and social media projects with Humanized Communications.

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Is Your Company Letting Data Slipping Through the Cracks?

Posted by on Monday, 16 April, 2012

Many Americans have spent the last few days frantically searching for receipts and other documentation to finish their taxes before Tuesday, April 17.  No doubt some of those people thought they knew exactly where to find what they needed, and were dismayed to discover that their confidence — as well as their data — had been misplaced.data breach, managed file transfer

How about your confidence regarding your organization’s sensitive data? As managers, are you aware of all of the transactions going in and out of the company network? Who is sending and pulling files, and why? What’s the best way to manage all of these data exchanges? Isn’t there a more user-friendly solution than prohibiting all FTP communications except from specified computers or user profiles?

Efficient workflow requires efficient data flow

No doubt data security is critical.  So is the ability to exchange information to accomplish daily business goals.  Almost every department needs to exchange files with trading partners, customers, vendors, remote employees, and more.

Here are just a few examples of data your company may be exchanging every day:

Finance/Accounting/HR

  • Tax documents
  • Annual, quarterly monthly reports to shareholders, investors, banks, financial partners
  • Personnel reporting

Marketing/Sales

  • Art files to/from artists, printers, marketing partners
  • Video and other content for web, publishers, printers
  • PDF brochures, proposals, whitepapers to prospects, partners, customers

Information Technologies

  • Data files to/from system integration partners
  • Database exchanges with business networks
  • System updates
  • EDI file transaction exchanges
  • Update to HA and offsite systems

Customer Service

  • Customer update documents
  • Client reporting documents
  • Receipt of supporting documents

Production/Warehousing

  • Supplier data exchange
  • Customer data exchange
  • Inventory reporting

Research & Development

  • Product specifications to/from manufacturing partners
  • Large CAD/engineering data to/from development partners

How do you control the data flow?

Educate your employees

Each organization has developed rules and codes of conduct to maintain productivity, positive morale, and customer confidence.  Ideally, these policies are documented and part of employee training. It’s imperative that the rules governing data management are also included in the documented policies, and all employees regardless of their roles need to demonstrate their understanding of the data management policies. Clear directives regarding management’s expectations is the first line of defense against data breach.

Implement the appropriate technology solution

The right technology tools can also be a valuable part of the data control approach.  Most data exchanges can be performed through secure email, FTP and network communications. A combined implementation of firewall and managed FTP solutions will help secure and distribute the resource requirements as appropriate for every department’s needs.

Firewalls not only protect the company network from outside intruders, but can also help manage internal traffic.  A managed file transfer (MFT) system allows specific types of transfers based on users’ permissions or specified events so the inbound/outbound flow of data can be better managed and monitored. With an MFT system, audit logs are automatically kept of each data exchange, and files and emails can be encrypted and secured to ease worries that they might be sent to the wrong people.

The bottom line

Given the multitude of data files that need to be moved in and out of your organization, and the need to create efficient workflows that allow employees to do their jobs while maintaining strict vigilance about data security, few facets of your business are more important than controlling your data flow.  Getting information in the right hands and keeping sensitive data shielded from non-authorized access is an ongoing challenge, but education and the right tools are the keys to success.

Daniel Cheney

Daniel has been the IT Director at a healthcare company for the last 12 years and a longtime beneficiary of GoAnywhere Director and the IBM i platform. He is also a technical analyst and writer for various technical and social media projects with Humanized Communications.

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