At the close of National Cybersecurity Awareness Month, a number of cybersecurity tips were published by OCR (the office within HHS that enforces HIPAA). These are timely and important reminders, relevant to everyone in the regulated community of covered entities and business associates, particularly in light of OCR’s recent settlement agreement with Anthem in connection with its major breach of a couple years ago, as well as OCR’s release of a new and improved security risk assessment tool. Without further ado, here they are:
- Encryption: Encryption is the conversion of electronic data into an unreadable or coded form that is unreadable without a decryption key. The proper use of encryption can prevent unauthorized users from viewing encrypted data in a usable form and may substantially reduce the risk of compromising ePHI. HIPAA covered entities and business associates are required to assess whether encryption is a reasonable and appropriate safeguard as a means of protecting ePHI at rest (i.e., ePHI that is stored such as on a computer’s hard drive or on electronic media) and ePHI that is electronically transmitted. See 45 CFR §§164.312(a)(2)(iv), 164.312(e)(2)(ii).
- Social Engineering: Phishing remains one of the most common and effective social engineering tactics for stealing user credentials and other sensitive information. Malicious actors send deceptive emails to users, enticing them to disclose login credentials or click links that may install malware (malicious software). The effectiveness of phishing attacks can be greatly reduced with proper training to keep information system users aware of the threats of phishing attacks and helps users identify suspicious emails. The Security Rule requires covered entities and business associates to implement security awareness and training programs for all workforce members including management. See 45 CFR § 164.308(a)(5)(i).
- Audit Logs: Network and system activity can be recorded and monitored with logs, which are a record of events and information pertaining to whatever device, system, or software they are monitoring. Audit logs are an important security tool that allows organizations to detect suspicious activities as they are occurring and can be used to reconstruct events that happened in the past. In order to be effective, the information contained in logs should be reviewed on a regular basis. The HIPAA Security Rule requires the implementation of audit controls, i.e., safeguards to record and examine activity on information systems that contain or use ePHI (see 45 CFR § 164.312(b)) and to regularly review records of information system activity, such as audit logs. See 45 CFR § 164.308(a)(1)(ii)(D).
- Secure Configurations: Proper configuration of network devices and software will reduce the attack surface for bad actors and greatly improve an organization’s cybersecurity defenses. The aforementioned tools – encryption, anti-malware, and audit logs – require appropriate settings in order to function as intended. If encryption safeguards are not implemented correctly and do not use the latest versions, the encryption solution may be compromised or bypassed. Anti-malware software settings determine what files or devices are scanned and how often. Maintenance and updating of malware definitions will ensure that the software is providing maximum protection. Proper log configuration is also essential to effective network defense. If logs do not collect and retain the correct data, suspicious activity may go unnoticed. Furthermore, logs should be protected against unauthorized manipulation or deletion, which is a common tactic malicious actors use to cover their tracks. These are just a few examples of network components that require proper configuration to provide effective cybersecurity defense. The configuration of firewalls, workstations, routers, servers, and other components all play an important role in minimizing the chance of security incidents. See 45 CFR §§ 164.306(e), 164.308(a)(8), 164.312(a)(1), 164.312(a)(2)(iv), 164.312(b), 164.312(c), and 164.312(e)(2)(ii).
You shouldn’t wait until you experience a breach to start thinking about cybersecurity. If or when you do, however, I recommend that you take the opportunity to do a serious root cause analysis and to communicate with everyone in your organization – from the c-suite to front-line staff – openly and productively about the results of that analysis and plans for implementing administrative, physical and technical fixes to the layers of security protection in your data infrastructure and operations. We often hear about organizations that try to sweep security incidents under the rug (the most recent example that comes to mind rhymes with Google), and the reputational costs are often greater than those that might be associated with “coming clean” in the first place. Remember: cybersecurity is a process, not a one-time deliverable, and unless and until this is accepted at all levels of every affected organization, and is funded and otherwise supported appropriately, preventable breaches will continue to occur.