Not all monetary penalties are for breaches affecting large numbers of patients. In this case, HHS imposed a penalty on an entity that had breaches in both 2017 and 2020. PogoWasRight notes that the 2017 incident affected 3,370 patients, and the 2020 incident affected 2,553 patients — as reported to HHS at the time. Today, we are first learning that the 2020 incident affected 10,840 patients.
Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a $548,265 civil monetary penalty against Children’s Hospital Colorado, concerning violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules following receipt of breach reports in 2017 and 2020, relating to email phishing and cyberattacks . OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules, which set forth the requirements that covered entities (health plans, health care clearinghouses, and most health care providers), and business associates must follow to protect the privacy and security of protected health information (PHI). The HIPAA Security Rule establishes national standards to protect and secure our health care system by requiring administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of electronic PHI (ePHI).
“Email continues to be a very common way for cyberattackers to enter health information systems and jeopardized privacy and security,” said OCR Director Melanie Fontes Rainer. “Health care entities should identify potential risks and vulnerabilities to email accounts and train their workforce to protect health information in those accounts.”
OCR investigated Children’s Hospital Colorado following breaches which reported a phishing attack that compromised an email account containing 3,370 individuals’ PHI and another after three email accounts were breached, containing 10,840 individuals’ PHI. OCR’s investigation determined that the first reported breach occurred because multi-factor authentication was disabled on an email account. The second breaches occurred, in part, when workforce members gave permission to unknown third parties to access their email accounts. OCR also found violations of the HIPAA Privacy Rule for failure to train workforce members on the HIPAA Privacy Rule, and the HIPAA Security Rule requirement to conduct a compliant risk analysis to determine the potential risks and vulnerabilities to ePHI in its systems.
In June 2024, OCR issued a Notice of Proposed Determination seeking to impose a civil money penalty. Children’s Hospital Colorado waived its right to a hearing and did not contest OCR’s findings. Accordingly, OCR imposed a civil money penalty of $548,265.
The Notice of Proposed Determination can be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/childrens-hospital-colorado-npd/index.html.
The Notice of Final Determination can be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/childrens-hospital-colorado-nfd/index.html.
OCR recommends that health care providers, health plans, health care clearinghouses, and business associates that are covered by HIPAA take the following steps to mitigate or prevent cyber-threats:
- Review all vendor and contractor relationships to ensure business associate agreements are in place as appropriate and address breach/security incident obligations.
- Integrate risk analysis and risk management into business processes; conducted regularly and when new technologies and business operations are planned.
- Ensure audit controls are in place to record and examine information system activity.
- Implement regular review of information system activity.
- Utilize multi-factor authentication to ensure only authorized users are accessing ePHI.
- Encrypt ePHI to guard against unauthorized access to ePHI.
- Incorporate lessons learned from incidents into the overall security management process.
- Provide training specific to organization and job responsibilities and on regular basis; reinforce workforce members’ critical role in protecting privacy and security.
Source: HHS OCR