If you needed yet one more example of the risks of PHI in employee email accounts
I’m not sure what it might take to get a real shift in how entities approach security of employee email accounts. Despite known risks of phishing and hacks, a tremendous amount of personally identifiable information (PII) and protected health information (PHI) resides in emails or email attachments in employee accounts.
Read the following chronology provided by Choice Health Management Services in North Carolina. They are a business associate that provides IT, payroll, billing, and compliance functions for numerous independent living, assisted living, and skilled nursing facilities. In “late 2019,” they reportedly discovered suspicious activity in certain employee email accounts. From discovery to notification should take no longer than 60 days under HIPAA and HITECH, right? But it doesn’t always go so quickly:
With the assistance of third-party forensic investigators, Choice Health Management Services launched an investigation into the nature and scope of this incident. On January 17, 2020, Choice Health Management Services confirmed that certain employee email accounts were subject to unauthorized access, but was unable to determine what, if any, individual emails or attachments within the accounts were subject to unauthorized access. With the assistance of a third-party firm, Choice Health Management Services then began a comprehensive and time-intensive review process of the email accounts subject to unauthorized access to determine what, if any, sensitive information they contained. On March 27, 2020, the review concluded, and Choice Health Management Services learned that personal health information was contained in certain email accounts. However, since the vendor was unable to link a large number of the individuals to the facility where the individuals sought treatment, Choice Health Management Services began a review of its internal records to determine this information so notice could be provided to the appropriate facility. On May 12, 2020, Choice Health Management Services completed its internal review and determined which individuals received care from a facility associated with Choice Health Management Services. On April 16, 2020 and again on May 22, 2020, Choice Health Management Services notified facilities about the event and requested permission to provide patients and residents with notice, which was subsequently granted.
On June 23, Choice Health Management Services began mailing notices to an unspecified number of individuals. They did not offer them any complimentary monitoring or restoration services, claiming that they had no evidence of any actual misuse of the data and were providing the notice “in an abundance of caution.”
So what did this incident cost them, all told? They said they have implemented additional safeguards to prevent a future incident, although they are (understandably) not specific about the nature of the additional safeguards. Did they implement 2FA? Do they require password resets every few months with no re-use of passwords permitted? Are they reducing the storage of emails in employee accounts to move it to more secure storage more quickly?
It took them more than 6 months to make notifications on this one incident. Could they go through this all again tomorrow? What prevents that? And will HHS ever do anything about all the entities that take more than 60 days from when they first detect a problem to actually notifying patients? Or should we all just redefine or clarify the point from which the 60-day clock starts ticking?