Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), announced a settlement with Montefiore Medical Center, a non-profit hospital system based in New York City for several potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. OCR is responsible for administering and enforcing health information privacy, including enforcement of the HIPAA Privacy, Security, and Breach Notification Rules for the health care sector. OCR plays a unique role in serving as the agency at HHS that enforces federal civil rights, privacy and security laws in health care. HIPAA requires that health care providers, insurers and others take steps to protect the privacy and security of patients’ protected health information. The $4.75 million monetary settlement and corrective action resolves multiple potential failures by Montefiore Medical Center relating to data security failures by Montefiore that led to an employee stealing and selling patients’ protected health information over a six-month period.
“Unfortunately, we are living in a time where cyber-attacks from malicious insiders are not uncommon. Now more than ever, the risks to patient protected health information cannot be overlooked and must be addressed swiftly and diligently,” said OCR Director Melanie Fontes Rainer. “This investigation and settlement with Montefiore are an example of how the health care sector can be severely targeted by cyber criminals and thieves—even within their own walls.
Cyber-attacks do not discriminate based on organization size or stature, and it’s incumbent that our health care system follow the law to protect patient records.”
The action is the latest step by HHS who released a Department-wide Cybersecurity strategy for the health care sector in December of 2023, and released voluntary performance goals to enhance cybersecurity across the health sector just last week.
“Cyber-attacks that are carried out by insiders are one of the many ways that can lead to a security breach, leaving patients vulnerable,” said HHS Deputy Secretary Andrea Palm. “Our priority is and always has been improving the quality of health care patients receive. Part of this health care is establishing a trust that medical records will not be exposed. HHS will continue to remind health care systems of their responsibility as providers, which is to have policies and procedures in place to keep patients’ medical information secure.”
In May 2015, the New York Police Department informed Montefiore Medical Center that there was evidence of theft of a specific patient’s medical information. The incident prompted Montefiore Medical Center to conduct an internal investigation. It discovered that two years prior, one of their employees stole the electronic protected health information of 12,517 patients and sold the information to an identity theft ring. Montefiore Medical Center filed a breach report with OCR.
OCR’s investigation revealed multiple potential violations of the HIPAA Security Rule, including failures by Montefiore Medical Center to analyze and identify potential risks and vulnerabilities to protected health information, to monitor and safeguard its health information systems’ activity, and to implement policies and procedures that record and examine activity in information systems containing or using protected health information. Without these safeguards in place, Montefiore Medical Center was unable to prevent the cyberattack or even detect the attack had happened until years later.
Under the terms of the settlement, Montefiore Medical Center will pay $4,750,000 to OCR and implement a corrective action plan that identifies certain steps toward protecting and securing the security of protected health information. These actions include:
- Conducting an accurate and thorough assessment of the potential security risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information;
- Developing a written risk management plan to address and mitigate security risks and vulnerabilities identified in the Risk Analysis;
- Developing a plan to implement hardware, software, and/or other procedural mechanisms that record and examine activity in all information systems that contain or use electronic protected health information;
- Reviewing and revising, if necessary, written policies and procedures to comply with the HIPAA Privacy and Security Rules; and
- Providing training to its workforce on HIPAA policies and procedures.
OCR will monitor Montefiore Medical Center for two years to ensure compliance with the law.
In OCR’s breach reports, over 118 million individuals have been affected by large breaches in 2023, whereas 55 million were affected in 2022. OCR recommends that health care providers, health plans, clearinghouses, and business associates that are covered by HIPAA must implement safeguards to mitigate or prevent cyber threats. These include:
- Reviewing all vendor and contractor relationships to ensure business associate agreements are in place as appropriate and address breach/security incident reporting obligations.
- Integrating risk analysis and risk management into business processes; and ensuring that they are conducted regularly, especially when new technologies and business operations are planned. Ensuring audit controls are in place to record and examine information system activity.
- Implementing regular review of information system activity.
- Utilizing multi-factor authentication to ensure only authorized users are accessing protected health information.
- Encrypting protected health information to guard against unauthorized access.
- Incorporating lessons learned from previous incidents into the overall security management process.
- Providing training specific to organization and job responsibilities and on regular basis; and reinforcing workforce members’ critical role in protecting privacy and security.
OCR regularly provides guidance and information to the health care industry to support data privacy and security. As part of this ongoing initiative, this Fall,OCR provided the following resources:
- Telehealth Privacy and Security Tips for Patients
- Resource for Health Care Providers on Educating Patients about Privacy and Security Risks to Protected Health Information when Using Remote Communication Technologies for Telehealth
- Cybersecurity Newsletter on Security Rule Sanctions
- Videos on “How the HIPAA Security Rule Can Help Defend Against Cyber-Attacks” in English and Spanish .
- OCR Webinar on The HIPAA Security Rule Risk Analysis Requirement
- OCR’s eight regional offices conducted cybersecurity training for large hospitals, small medical providers, business associates, state health departments, and state social service agencies to assist them in complying with their cybersecurity obligations in the face of changing hostile threats.
The resolution agreement and corrective action plan may be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/montiefore/index.html
For more information on managing malicious insider threats you can view OCR’s Summer 2019 Cybersecurity Newsletter at: https://www.hhs.gov/hipaa/for-professionals/security/guidance/cybersecurity-newsletter-summer-2019/index.html.
OCR is committed to enforcing the privacy and security of peoples’ health information that is protected under HIPAA. If you believe that your or another person’s health information privacy or civil rights have been violated, you can file a complaint with OCR at:
NOTE: Montefiore had a number of incidents involving insider-wrongdoing/theft of patient information as a search of DataBreaches.net will reveal.