Workplace Privacy, Data Management & Security Report : Privacy Lawyers & Attorneys : Jackson Lewis Law Firm : Data Security, HIPAA & Confidentiality Issues

On August 18, 2010, the Connecticut Insurance Commissioner issued Bulletin IC-25 which mandates that entities within its jurisdiction notify the Department of Insurance of any "information security incident." This post provides a brief summary of this new requirement.

Who must provide the notice?

The Bulletin applies to all licensees and registrants of the Department. This generally means all entities regulated by the Insurance Department, including, insurance producers, public adjusters, bail bond agents, appraisers, certified insurance consultants, casualty claim adjusters, property and casualty insurers, life and health insurers, health care centers, fraternal benefit societies, captive insurers, utilization review companies, risk retention groups, surplus line companies, life settlement companies, preferred provider networks, pharmacy benefit managers, and medical discount plans.

Additionally, in cases where the information security incident happens at a vendor or business associate, the Department expects to be notified of the incident as well as how the

licensee or registrant is managing the vendor's/business associate's activities and what protections and remedies are being put in place by the vendor/business associate for the Connecticut consumers.

What is an "information security incident"? 

Under this Bulletin, an information security incident is:

any unauthorized acquisition or transfer of, or access to, personal health, financial, or personal information, whether or not encrypted, of a Connecticut insured, member, subscriber, policyholder or provider, in whatever form the information is collected, used or stored, which is obtained or maintained by a licensee or registrant of the Insurance Department, the loss of which could compromise or put at risk the personal, financial, or physical well being of the affected insureds, members, subscribers, policyholders or providers.

Thus, unlike the general Connecticut data breach notification statute which requires notification only with respect to computerized personal information, this mandate applies to paper documents which includes personal health, financial or personal information. Also, encrypted data is not exempt from this notification requirement.

What is personal health, financial, or personal information?

The Bulletin does not define this term and, therefore, is unclear in this regard. However, in discussing its authority to impose the requirement, the Department cites to Conn. Gen. Stat. §42-471, which defines "personal information" to mean:

information capable of being associated with a particular individual through one or more identifiers, including, but not limited to, a Social Security number, a driver's license number, a state identification card number, an account number, a credit or debit card number, a passport number, an alien registration number or a health insurance identification number, and does not include publicly available information that is lawfully made available to the general public from federal, state or local government records or widely distributed media.

This definition, however, may not be as broad as how the Department views the term "personal health, financial or personal information." Licensees and registrants should be careful here and err on the side of being more inclusive when deciding whether an incident needs to be handled in accordance with this Bulletin.

When must notification be provided?

The Bulletin requires licensees and registrants of the Department to notify it of the incident as soon as the incident is identified, but no later than five (5) calendar days after the incident is identified.

Where should notice be sent?

Notification should be sent to the Insurance Commissioner in writing via first class mail, overnight delivery service or electronic mail.

What must the notice include?

Notification should include as much information as is known concerning the incident. The Bulletin provides the following list of items of information to be reported to the Department:

• Date of the incident
• Description of incident (how information was lost, stolen, breached)
• How discovered
• Has lost, stolen, or breached information been recovered and if so, how
• Have individuals involved in the incident (both internal and external) been identified
• Has a police report been filed
• Type of information lost, stolen, or breached (equipment, paper, electronic, claims, applications, underwriting forms, medical records etc)
• Was information encrypted
• Lost, stolen or breached information covers what period of time
• How many Connecticut residents affected
• Results of any internal review identifying either a lapse in internal procedures or confirmation that all procedures were followed
• Identification of remedial efforts being undertaken to cure the situation which permitted the information security incident to occur.
• Copies of the licensee/registrants Privacy Policies and Data Breach Policy.
• Regulated entity contact person for the Department to contact regarding the incident. (This should be someone who is both familiar with the details and able to authorize actions for the licensee or registrant)
• Other regulatory or law enforcement agencies notified (who, when)

One of the items on this list to note is a Data Breach Policy which all entities should consider adopting even if not subject to this Bulletin.

Does the Department require that credit monitoring be offered in the event of an information security incident?

It looks like the Department may require credit monitoring in some circumstances. The Bulletin states that:

Depending on the type of incident and information involved, the Department will also want to have discussions regarding the level of credit monitoring and insurance protection which the Department will require to be offered to affected consumers and for what period of time. 

In addition, the Department wants to review the draft letters informing individuals of the information security incident.

Will the Department impose penalties?

The Bulletin states that the Department will evaluate each incident independently based on the applicable circumstances, and notes that some situations may warrant imposition of administrative penalties. The Department urges licenses and registrants to follow these procedures in order to minimize the possibility for penalties.

Licenses and registrants surely will need to review this guidance and incorporate it into their information security programs. Other entities should take note of this development and recognize the increasing efforts by federal and state agencies to safeguard personal information.

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California led the way in 2002 when it enacted the nation’s first data breach notification law. Last week, the State’s lawmakers sent Governor Arnold Schwarzenegger S.B. 1166 (pdf), which would mandate that data breach notification communications include more detailed information about the breach and that businesses experiencing data breaches affecting more than 500 Californians notify the State’s Attorney General.

Since California enacted its data breach notification law, lawmakers have been trying to make changes to it, with mixed results. Assembly Bill 1298 ("A.B. 1298"), which became effective January 1, 2008, expanded the application of the existing law to include medical and health information. However, to date, attempts to add content requirements to the notice and require notification to the State’s Attorney General have failed, despite similar requirements in the laws of a number of other states, such as Massachusetts, New York, North Carolina.

S.B. 1166 marks the third attempt by Senator Joe Simitian to amend the law in this manner. Both prior attempts were vetoed by the Governor Schwarzenegger. In addition to requiring notice to the State’s Attorney General for certain breaches, his current effort would require notices stating:

• a general description of the breach incident;
• the type of information breached;
• the date and time of the breach;
• whether the notification was delayed because of a law enforcement investigation; and
• a toll-free number of major credit reporting agencies if the breach exposed Social Security numbers, driver's license numbers, or state identification card numbers.

Because many states have similar content requirements and there are a number of websites that report on data breaches, passage of S.B. 1166 should not impose a significant burden in breaches involving individuals in multiple states. Nonetheless, companies should be alert to developments in California and be prepared to update their California data breach notification policies should the measure pass.
 

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On August 5, 2010, U.S. Senators Mark Pryor (D-AR) and John D. (Jay) Rockefeller IV (D-WV)  introduced legislation to require businesses and nonprofit organizations that store consumers’ personal information to put in place strong security features to safeguard sensitive data, alert consumers when this data has been breached, and provide affected individuals with the tools they need to protect their credit and finances, including credit monitoring services.

More specifically, the "Data Security and Breach Notification Act of 2010" would require entities that own or possess data containing personal information to establish reasonable security policies and procedures to protect that data. If a security breach occurs, entities would have to notify each individual whose information was acquired or accessed as a result of the breach within 60 days. Affected consumers would be entitled to receive consumer credit reports or credit monitoring services for two years, as well as instructions on how to request these services.

In support of the new law, the press release issued by the Senate Committee on Commerce, Science, and Transportation notes that data security breaches and identity theft are a growing problem in the United States. In 2009, the business industry experienced the greatest number of data breaches (41.8%), followed by government/military (18.1%) and education sectors (15.7%).

Of course, passage of this measure is possible, but, given the number of prior efforts to pass a national data breach notification law, passage seems unlikely. This outcome is made more likely by the inclusion of the credit monitoring mandate, the cost of which could be considerable to businesses affected by a data breach. Businesses should stay tuned . . .

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Rite Aid Corporation and its affiliates have agreed to pay $1 million to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule, the U.S. Department of Health and Human Services (HHS) announced today. At the same time, Rite Aid signed a consent order with the Federal Trade Commission (FTC) to settle potential violations of the FTC Act.

The lesson to be learned from this case:

Disposing of individuals’ health information in an industrial trash container accessible to unauthorized persons is not compliant with several requirements of the HIPAA Privacy Rule and exposes the individuals’ information to the risk of identity theft and other crimes.

The Office of Civil Rights, which enforces the HIPAA Privacy and Security Rules, opened its investigation of Rite Aid after television media videotaped incidents in which pharmacies were shown to have disposed of prescriptions and labeled pill bottles containing individuals’ identifiable information in industrial trash containers that were accessible to the public. These incidents were reported as occurring in a variety of cities across the United States. Rite Aid pharmacy stores in several of the cities were highlighted in media reports.

The investigation also indicated other potential concerns about Rite Aid's policies related to safeguarding patient information during the disposal process, training employees, and a related sanction policy.

The Director of OCR noted:

It is critical that companies, large and small, build a culture of compliance to protect consumers’ right to privacy and safeguard health information. OCR is committed to strong enforcement of HIPAA.

The corrective action Rite Aid has agreed to includes improving policies and procedures to safeguard the privacy of its customers' health information, and applies to all of its nearly 4,800 retail pharmacies. More specifically, the settlement requires Rite Aid to take a number of steps including

• Revising and distributing its policies and procedures regarding disposal of protected health information and sanctioning workers who do not follow them;
• Training workforce members on these new requirements;
• Conducting internal monitoring; and
• Engaging a qualified, independent third-party assessor to conduct compliance reviews and render reports to HHS and FTC.

The HHS corrective action plan will be in place for three years; the FTC order will be in place for 20 years. The length and scope of these plans show the seriousness these agencies are taking concerning compliance with requirements to safeguard personal information.  

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U.S. Department of Health and Human Services Secretary Kathleen Sebelius has announced final rules for eligible health care professionals and hospitals to qualify for a portion of the $27 billion or so in Medicare and Medicaid incentive payments for implementation and meaningful use of certified electronic health records (EHR). Many are concerned these incentives will increase the risks for data privacy and security that will come with more health data being maintained, used and disclosed in electronic format. Under the rules, eligible professionals may receive as much as $44,000 under Medicare and $63,750 under Medicaid, and hospitals may receive millions of dollars under both Medicare and Medicaid.
 

"We will make the immediate investments necessary to ensure that within five years, all of America's medical records are computerized."

President Barack H. Obama, January 8, 2009 

HHS’s July 13 action is consistent with the agenda of President Obama and some of his predecessors to help improve Americans’ health, increase safety and reduce health care costs through expanding use of EHRs and simplifying the administrative costs of healthcare. The enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 significantly advanced this agenda by establishing the statutory structure for eligible health care professionals and hospitals to receive government subsidies to adopt certified EHR technology. The HITECH Act, however, also expanded and tightened the HIPAA privacy and security regulations to address, in part, concerns about improper access and use of EHRs.

HHS’s regulations (consisting of more than 1,000 pages) define the minimum requirements and “meaningful use” objectives to qualify for the bonus payments (pdf) and identify the technical capabilities required for certified EHR technology (pdf). At the same time, providers and hospitals will need to focus on the evolving privacy and security mandates under HITECH, as well as under state law, to minimize the risks to protected health information and other personal information. So, as providers and hospitals look to Medicare and Medicaid funds to jumpstart their move to EHR systems, it will be important for them to be sure to have in place the appropriate policies, procedures and agreements to safeguard those records, which should include the careful handling and/or disposition of the mountains of paper records they currently maintain.

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Further to our discussions of the proposed regulations to implement statutory amendments under the Health Information Technology for Economic and Clinical Health Act (the “HITECH Act”), we summarize here a proposed changed to the definition of “business associate.” A significant part of the “HIPAA community” (covered entities, business associates and their agents and subcontractors) already is aware of the expanded application of HIPAA to business associates under HITECH. This expansion went into effect February 18, 2010, and, in fact, many business associate agreements currently are being modified in an attempt to reflect the statutory provisions. The HIPAA community, however, may not yet be aware of the proposal to further expand the direct application of the privacy and security rules under HIPAA to subcontractors performing functions for business associates.

A New Class of Business Associate

Prior to the HITECH Act changes, business associates and their agents and subcontractors were not directly subject to HIPAA. Instead, HIPAA required covered entities to obtain certain written assurances from their business associates. One of those written assurances was that business associates would ensure that their agents and subcontractors would agree to be subject to the same conditions and restrictions contained in the business associate agreement entered into with the covered entity.

The proposed regulations would include subcontractors in the group of “business associates” to the extent that they require access to protected health information. Such subcontractors are those persons who are not members of the business associate’s workforce, but perform functions for or provide services to a business associate. This would be the case even if the business associate has failed to enter into a business associate contract with the subcontractor. The regulator’s goal is to ensure the privacy and security protections will not lapse merely because a function is performed by an entity with no direct relationship with a covered entity, although the regulations seek public comments on the definition of subcontractor.

The proposed regulations state (emphasis added):

[W]e propose that downstream entities that work at the direction of or on behalf of a business associate and handle protected health information would also be required to comply with the applicable Privacy and Security Rule provisions in the same manner as the primary business associate, and likewise would incur liability for acts of noncompliance. We note, and further explain below, that this proposed modification would not require the covered entity to have a contract with the subcontractor; rather, the obligation would remain on each business associate to obtain satisfactory assurances in the form of a written contract or other arrangement that a subcontractor will appropriately safeguard protected health information. For example, under this proposal, if a business associate, such as a third party administrator, hires a company to handle document and media shredding to
securely dispose of paper and electronic protected health information, then the shredding company would be directly required to comply with the applicable requirements of the HIPAA Security Rule (e.g., with respect to proper disposal of electronic media) and the Privacy Rule (e.g., with respect to limiting its uses and disclosures of the protected health information in accordance with its contract with the business associate).

As the example above shows, if made final, the proposed regulation would further HIPAA’s reach and affect many businesses that may not currently view themselves as directly subject to the requirements or penalties under HIPAA. Many companies, including those that service the healthcare industry, such as health plans, likely will need to revisit their HIPAA-compliance measures.

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We recently reported here that the Department of Health and Human Services (HHS) is issuing proposed regulations to implement statutory amendments under the Health Information Technology for Economic and Clinical Health Act (the “HITECH Act”). These proposed regulations contain a number of important points to think about for HIPAA covered entities (and business associates), even though these rules are in proposed form. One is avoiding HIPAA violations involving “willful neglect," which under the HITECH Act will require a formal investigation and civil penalties.

To date, the Secretary of HHS has attempted to resolve complaints and certain violations by informal means, as required by § 160.312 of the current regulations. A significant change to the HIPAA enforcement scheme in the HITECH Act requires that if a preliminary investigation of the facts of a complaint indicates a possible violation due to willful neglect, the Secretary is required to commence a formal investigation. If the formal investigation finds a HIPAA violation involving willful neglect, the Secretary must impose a civil money penalty.

What is “willful neglect”?

Willful neglect is defined at § 160.401 as the “conscious, intentional failure or reckless indifference to the obligation to comply with the administrative simplification provision violated.” The term not only presumes actual or constructive knowledge on the part of the covered entity that a violation is virtually certain to occur, but also encompasses a conscious intent or degree of recklessness with regard to the entity’s compliance obligations.

So what does that mean, what are some examples? The proposed regulations provide the following examples:

1. A covered entity disposed of several hard drives containing electronic protected health information in an unsecured dumpster, in violation of § 164.530(c) and § 164.310(d)(2)(i). HHS’s investigation reveals that the covered entity had failed to implement any policies and procedures to reasonably and appropriately safeguard protected health information during the disposal process.
2. A covered entity failed to respond to an individual’s request that it restrict its uses and disclosures of protected health information about the individual. HHS’s investigation reveals that the covered entity does not have any policies and procedures in place for consideration of the restriction requests it receives and refuses to accept any requests for restrictions from individual patients who inquire.
3. A covered entity’s employee lost an unencrypted laptop that contained unsecured protected health information. HHS’s investigation reveals the covered entity feared its reputation would be harmed if information about the incident became public and, therefore, decided not to provide notification as required by § 164.400 et seq.

In addition to having actual or constructive knowledge of one or more violations, the covered entities in the examples above, particularly Example 1, failed to develop or implement compliant policies and procedures and, thus, demonstrated either conscious intent or reckless disregard with respect to the compliance obligations under HIPAA.

Based on the proposed regulations, covered entities can no longer expect the velvet hand of the regulators to resolve a violation informally in all cases. Covered entities that fail to have policies and procedure and make a good faith compliance effort likely will find themselves subject to mandatory formal investigations and penalties.

Covered entities like the one in example 1 above might want to consider certain precautions, including:

• maintaining a record retention policy,
• maintaining media re-use policy,
• maintaining a data destruction policy,
• maintaining an e-discovery policy, and
• and engaging a good data destruction/shredding company.
 

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Effective May 1, 2010, Alberta amended its Personal Information Protection Act (PIPA) to require breach reporting and notification requirements. U.S. businesses with a presence in Alberta should take note of the new law as it is a bit different than most of the state data breach notification laws in the United States. 

PIPA governs the collection, use and disclosure of personal information by businesses. Under the amendment to PIPA that adds the mandatory breach notification requirement, organizations that experience a breach will be required to report the incident to the Privacy Commissioner where there exists “a real risk of significant harm” to an individual. The Commissioner can, in turn, require the organization to notify the affected individuals.

Alberta's Privacy Commissioner Frank Work commented on the new law:

Now an organization has to report significant losses to my Office. I can then require notification of affected individuals. Our experience has been that most businesses already notify people affected by losses and we encourage this. This is not necessarily a matter of making businesses liable for losses of information; it is about warning people so that they can take precautions. Hopefully it will make businesses more aware of the need for reasonable security measures.”

Of course, the challenge for multi-national companies will be to consider and coordinate the laws in various jurisdictions.

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As companies struggle with the risks and exposures related to data breaches, insurance can be an important part of an overall risk management strategy – so long as it is the right insurance.

Insurance carriers are offering products that purport to address this type of risk. Such insurance can be particularly important to businesses for which the handling of personal information or protected health information, such as some HIPAA “business associates,” is their lifeblood. However, as an ongoing litigation in a Utah federal district court makes clear, it is critical for businesses to be cautious and thorough when assessing insurance coverage, if only to avoid litigation about the scope of the coverage.

Court filings show that Perpetual Storage, a data storage company, had purchased certain insurance coverage through Colorado Casualty Insurance. One of Perpetual’s clients, University of Utah Hospitals and Clinics, stores significant amounts of its data with Perpetual, including personal information and protected health information. The University experienced a data breach on June 1, 2008, when storage disks were stolen from the car of a Perpetual employee who had picked up the disks from the University. The University claims the breach affected 1.7 million people. Claims expenses totaling approximately $3,354,753 were incurred in the course of responding to the breach. The specific costs alleged are $2,483,057 for credit monitoring expenses, $646,149 in printing and mailing costs, $81,389 in phone bank costs, and $144,158 in additional miscellaneous costs.

Naturally, the University is looking to Perpetual to reimburse it for these costs. In turn, Perpetual is looking to its insurance carrier, Colorado Casualty, to back it up. The insurer, however, has denied coverage. Colorado Casualty seems to be asserting that the claims do not constitute certain “bodily damages” or “property damages” as those terms are defined in the applicable policy. The insurer also claims that a number of policy exclusions support its decision to deny coverage.
At the same time, the University is seeking in its lawsuit to bring its insurance broker and adviser into the litigation, alleging they were "careless, negligent, and made various negligent misrepresentations about Perpetual's insurance coverage from Colorado Casualty."

A ruling in favor of Colorado Casualty likely would make it more difficult to seek reimbursement under commercial liability policies in connection with data breaches. Such a ruling also should be a wake-up call to businesses relying on their current commercial liability policies to deal with data breach issues.

The moral of the story for businesses - review your coverage with your insurance brokers or other insurance advisers to ensure appropriate coverage.

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On June 10, 2010, the California Department of Public Health (CDPH) announced  issuing administrative penalties and fines totaling $675,000 against five hospitals in the state. CDPH cites the facilities’ failure to prevent unauthorized access to confidential patient medical information as required under new legislation (Section 1280.15 of California’s Health and Safety Code) (pdf) as the basis for the penalties and fines.

Relevant portions of Section 1280.15 of California’s Health and Safety Code provide:

A clinic, health facility, home health agency, or hospice . . . shall prevent unlawful or unauthorized access to, and use or disclosure of, patients' medical information . . . The department, after investigation, may assess an administrative penalty for a violation of this section of up to twenty-five thousand dollars ($25,000) per patient whose medical information was unlawfully or without authorization accessed, used, or disclosed, and up to seventeen thousand five hundred dollars ($17,500) per subsequent occurrence of unlawful or unauthorized access, use, or disclosure of that patients' medical information. For purposes of the investigation, the department shall consider the clinic's, health facility's, agency's, or hospice's history of compliance with this section and other related state and federal statutes and regulations, the extent to which the facility detected violations and took preventative action to immediately correct and prevent past violations from recurring, and factors outside its control that restricted the facility's ability to comply with this section. The department shall have full discretion to consider all factors when determining the amount of an administrative penalty pursuant to this section.

CDPH Director Dr. Mark Horton commented, “medical privacy is a fundamental right and a critical component of quality medical care in California.” His position and the actions taken by the agency highlight the need for health care providers to do more to safeguard patient records. In most of these cases, according to the CDPH announcement, multiple hospital employees accessed confidential patient medical information without authority to do so.

However, California hospitals should not be the only entities concerned about exposure relating to unauthorized access to confidential personal information, nor is California’s Health and Safety Code the only statutory obligation to safeguard such information. Mandates to protect personal information are growing and apply to industries beyond healthcare and persons other than patients. In short, businesses in all states and industries should be reviewing, at a minimum:

1. how they safeguard personal information, whether it be that of customers, patients, employees, or their dependents,
2. who they permit to access personal information, and
3. what their plan is in the event of unauthorized access or acquisition.

We’ve written about a number of these areas of concern:

• Pending Federal Legislation
• State Attorneys General enforcing (i) HIPAA, (ii) Deceptive and Unfair Trade Practices Laws, (iii) record destruction laws.
• Risks if You Are a Business Associate
• Criminal Penalties Under HIPAA
• State Laws Mandating Protections for Personal Information, not just medical information.
• HHS Enforcing HIPAA Following Data Breach
• Developing a Plan

Like most things, "an ounce of prevention is worth a pound of cure."

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Connecticut Attorney General Richard Blumenthal has commenced an investigation in a second case involving potential HIPAA violations by a worker at Griffin Hospital. This follows the suit commenced against Health Net for HIPAA violations following a data breach. As reported by George Gombossy of ctwatchdog.com, this would be the second time a state attorney general has used the enforcement authority granted under the Health Information Technology for Economic and Clinical Health Act (HITECH).

The Attorney General’s press release states:

My office is investigating allegations that a radiologist formerly affiliated with Griffin Hospital improperly accessed the medical information of almost 1,000 of the hospital’s patients.

These charges, if true, are deeply disturbing. Patients rightly expect and demand that their medical information remain secure and confidential, viewed only by authorized individuals.

Unauthorized accessing of patient information is a violation of the federal HIPAA law that my office is empowered to enforce. I will seek strong and significant sanctions, if warranted by the facts.

Griffin Hospital rightly informed my office of this alleged data breach and is cooperating with our investigation.

Efforts are underway to help state Attorneys General become more actively involved in HIPAA enforcement. For example, the Department of Health and Human Services (HHS) has awarded a $1.7 million contract to train attorneys general on enforcing HIPAA and, specifically, to assist the Office of Civil Rights (an arm of HHS) “in conceptualizing and implementing a training curriculum for state attorneys general staff and others affected by the HIPAA Privacy and Security Rules.”

It is important that HIPAA-covered entities and business associates focus on compliance so when there is a data breach, they will be better positioned to respond to a state attorney general inquiry.

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Have you noticed that negotiating that business associate agreement has gotten a lot more difficult? Many companies that serve health care providers and health plans, generally known as business associates, have noticed. These companies include software vendors, benefits brokers, cloud computing providers, data storage/destruction companies, and accountants, among others.

The clients of these companies are citing HIPAA, ARRA, HITECH, data breach notification requirements, and state law mandates as they demand stricter contract language and additional rights and protections, such as the right to audit the business associate and to be held harmless in the event of any data mishap. Business associates that took HIPAA lightly in 2003 and 2004, when the HIPAA regulations first became effective (2005 and 2006 for the security regulations), are playing catch-up.

When President Obama signed the American Recovery and Reinvestment Act of 2009 (ARRA), “business associates” may not have expected the significant effects that law would have on their businesses. Chief among those effects are mainly due to four sentences in The Health Information Technology for Economic and Clinical Health (HITECH) Act (pdf), passed as part of ARRA, and which generally became effective on February 17, 2010 (the breach notification mandate became effective on September 23, 2009), one year after enactment:

• “Sections 164.308, 164.310, 164.312, and 164.316 of title 45, Code of Federal Regulations, shall apply to a business associate of a covered entity in the same manner that such sections apply to the covered entity. The additional requirements of this title that relate to security and that are made applicable with respect to covered entities shall also be applicable to such a business associate and shall be incorporate[d] into the business associate agreement between the business associate and the covered entity.” ARRA Sec. 13401(a). This statement makes business associates directly subject to nearly all of the HIPAA security regulations, the HIPAA rules relating to electronic protected health information. Prior to the change, these obligations existed for business associates only as a matter of contract.
• “A business associate of a covered entity that accesses, maintains, retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses unsecured protected health information shall, following the discovery of a breach of such information, notify the covered entity of such breach.” ARRA Sec. 13402(b). This statement creates a new obligation for business associates – report to covered entities breaches of unsecured protected health information.
• “The additional requirements of this subtitle that relate to privacy and that are made applicable with respect to covered entities shall also be applicable to such a business associate and shall be incorporated into the business associate agreement between the business associate and the covered entity.” ARRA Sec. 13404(a). This statement makes business associates directly subject to nearly all of the HIPAA privacy regulations. Prior to the change, as with the security regulations, these obligations existed for business associates only as a matter of contract.

In response to these law changes, and in the absence of regulatory guidance, covered entities have been demanding modifications to existing business associate agreements or requesting new agreements. In both cases, covered entities are seeking greater assurances from their business associates concerning the handling of the covered entities’ protected health information.

On top of that, covered entities are weaving into business associate agreements and other agreements requirements under newly enacted state laws requiring protections for “personal information” in the hands of vendors (e.g., business associates) to curb identity theft. Given the cost and reputational harm that could come from a data breach, as well a growing enforcement activity, many covered entities are becoming more forceful in their negotiations, citing legal mandates and established company policies for their unwillingness to budge on many provisions, even those that go beyond statutory mandates.

What is a business associate to do? Here are some thoughts:

1. Confirm your company is a business associate. (go to HHS HIPAA frequently asked questions and insert "business associate" for helpful guidance). In some cases, covered entities are blanketing all of their vendors with these agreements. If believe your company is not a business associate, raise it with your client. Of course, even if you avoid being considered a business associate, your customer/client still may demand written assurances under state law for the personal information you handle on its behalf.
2. Become compliant. As noted above, the HIPAA privacy and security requirements are now directly applicable to business associates. While additional guidance is expected as to what this means precisely, there is enough existing guidance concerning covered entities for business associates to use to achieve compliance. Among other things, compliance means conducting a risk assessment, adopting a written set of policies and procedures concerning the safeguarding of protected health information, and training staff. Being compliant not only reduces risk, but in an environment of increasing attention to data privacy and security, compliance can be a competitive advantage.
3. Review agreements carefully. Covered entities increasingly include contract provisions that provide the covered entity with greater protections than the law requires. To the extent possible, try to remove those provisions. In any event, it is important to know your obligations under these agreements; they can vary dramatically from covered entity to covered entity.
4. Develop strategies for reviewing/complying with multiple contracts. Some business associates have many clients and, therefore, business associate agreements. Managing unique provisions multiple agreements can be daunting, although the ability to negotiate a uniform agreement across a client basis is increasingly unlikely. So, where possible, try to use similar provisions in all agreements and know ahead of time your approach to certain key provisions, such as handling data breaches.
5. Understand the law. Even if you’ve mastered the determination of whether you are a business associate, the rules outlining your business' obligations likely will be evolving under HIPAA over the next few years, particularly with the expected growth of electronic health records and the expansion of health care. The same is true of state laws concerning personal information. In many cases these laws might coexist peacefully, in other cases there will be conflict. You need to be aware of the conflicts and be prepared to act accordingly.

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The Federal Trade Commission announced it is further delaying its enforcement of the “Red Flags” Rule through December 31, 2010. This move comes at the request of several Members of Congress who want to further consider legislation that would clarify who is subject to the Rule.

The delay follows the lawsuit (pdf) filed by the American Medical Association and others arguing that the Red Flags Rule should not apply to physicians.  As reported by amednews.com, the plaintiffs bolster their case by pointing to a 2009 federal court ruling (pdf) (American Bar Assn. v. Federal Trade Commission) exempting lawyers from the Rule. That ruling is now on appeal to the U.S. Court of Appeals for the D.C. Circuit

Legislation is pending in the United States House of Representatives that would exempt certain professions, including physicians, from the Red Flags Rule. H.R. 3763 passed the House unanimously in October 2009, but there has been no further movement in Congress on this issue.

The Rule was developed under the Fair and Accurate Credit Transactions Act, in which Congress directed the FTC and other agencies to develop regulations requiring “creditors” and “financial institutions” to address the risk of identity theft. The resulting Red Flags Rule requires all such entities that have “covered accounts” to develop and implement written identity theft prevention programs to help identify, detect, and respond to patterns, practices, or specific activities – known as “red flags” – that could indicate identity theft.

In its announcement, the FTC notes that as was the case with prior enforcement delays, this enforcement delay is limited to the Red Flags Rule and does not extend to the rule regarding address discrepancies applicable to users of consumer reports, or to the rule regarding changes of address applicable to card issuers.

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Health care providers beware – curiosity about patients can put you in jail.

According to NBC News, Huping Zhou, a licensed cardiothoracic surgeon in China, who worked at the UCLA School of Medicine as a researcher, will serve four months in prison for snooping into medical records back in 2003. This follows Mr. Zhou’s guilty pleas earlier this year to criminal charges under the Health Insurance Portability and Accountability Act (HIPAA).

In many cases, the snooping incidents involved celebrities. According to the NBC story, investigators claim Zhou “accessed UCLA patient records at least 323 times during one three-week period in 2003.”

This case together with recent amendments to HIPAA highlight the need for HIPAA covered entities to be more thorough and recurrent in their training of employees and other workforce members, as well as in their monitoring of access to confidential information. While safeguards and policies cannot prevent all breaches, they can go a long way toward reducing these kinds of incidents and the reputational harm that follows. 

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We are honored that the National Association of Professional Employer Organizations (NAPEO), the largest national trade association for professional employer organizations (PEOs), recently published our article in its May 2010 edition of its PEO Insider publication, an important resource for any PEO.  

PEOs no doubt provide valuable services for businesses across the country. However, in doing so, they generally have access to and maintain vast amounts of personal information. Our article, "Key Data Privacy and Security Issues for PEOs," summarizes emerging data privacy and security laws and their effects on PEOs.

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On April 16, 2010, Florida Attorney General Bill McCollum announced a settlement (pdf) with Certegy Check Services, Inc. over how the company secures consumer records. The Attorney General’s enforcement action stems from a massive data breach by a former Certegy employee who stole personal identification information from approximately 5.9 million consumer files.

According to the Attorney General’s press release, Certegy promptly notified the Attorney General and consumers of the data thefts, and cooperated with the Attorney General’s investigation. In addition to agreeing to maintain a comprehensive information security program, under the settlement, Certegy will contribute $125,000 to the Attorney General’s “Seniors vs. Crime Program” for educational, investigative and crime prevention programs for the benefit of senior citizens and the community. Further, it will pay $850,000 for the state’s investigative costs and attorney’s fees.

Massachusetts and some other states have specific statutory provisions requiring the safeguarding of personal information. No similar law exists in Florida. The Attorney General commenced its action against Certegy under the State’s deceptive and unfair trade practices statutes. Businesses with data security safeguards that can be viewed as subpar, therefore, cannot depend on the absence of specific state statutes to shield them from state action in case of a data breach or allegations that personal information is not being adequately safeguarded.

In addition to the nearly one million dollars Certegy will pay the State of Florida, the company agreed to

maintain a comprehensive “Information Security Program” that assesses internal and external risks to consumers’ personal information, implements safeguards to protect that consumer information, and regularly monitors and tests the effectiveness of those safeguards. Certegy and its related entities will also adhere to payment card industry data security standards as those standards continue to evolve.

Significantly, the settlement requires Certegy to conduct initial and annual assessments of its policies and procedure.

The settlement with the Attorney General followed a class action settlement in U.S. District Court in Tampa. Under that settlement, Certegy made certain monitoring services available to affected consumers, who also were able to seek reimbursement of certain out-of-pocket costs incurred or identity theft expenses. 

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With Mississippi enacting its own data breach notification law on April 7, Alabama, Kentucky, New Mexico, and South Dakota remain the only states without such a law. Mississippi Gov. Haley Barbour signed H.B. 583 making his state the 46th to enact a breach notification law. The law becomes effective July 1, 2011.

Like many breach notification statutes:

• the notification obligation falls on any business in the state which owns or licenses personal information,
• personal information generally includes name plus either Social Security number, drivers license number, or financial account number,
• encrypted personal information is not subject to the breach notification requirement, and
• the notification obligation applies only when there is a risk of harm to affected state resident in connection with a breach of security.

The law will be enforced by Mississippi’s Attorney General, however, the law prohibits individuals from commencing a privacy lawsuit under the new law.

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Under a measure passed overwhelmingly by the U.S. House of Representatives (408-13), federal contractors would be required to adopt measures established by the Office of Management and Budget to limit open network peer-to-peer file sharing software (P2P Software). Likely a response to the leakage of House and Senate ethics investigations, if the “Secure Federal File Sharing Act” (H.R. 4098) (pdf) becomes law it would be the first widespread federal statute regulating P2P Software.

Under the law, federal government employees and contractors would be prohibited from downloading, installing, or using P2P Software on federal computers without government approval. Federal agencies would be required to take steps to find and remove P2P Software from such computers, including those government computers operated by contractors. In particular, the Act requires OMB guidelines to:

to address the download, installation, or use by Government employees and contractors of such software on home or personal computers as it relates to telework and remotely accessing Federal computers, computer systems, and networks, including those operated by contractors on the Government’s behalf.

Within 90 days of enactment, OMB will need to set up a procedure for approving the use of P2P Software. Within 180 days of enactment, with respect to contractors, agencies will need to

1. require any contract awarded by the agency to include a requirement that the contractor comply with OMB guidance in the performance of the contract;
2. update their information technology security or ethics training policies to ensure that all employees working for contractors on the government’s behalf are aware of the requirements of OMB guidance and the consequences of engaging in prohibited conduct; and
3. ensure that proper security controls are in place to prevent, detect, and remove file sharing software that is prohibited by the OMB guidance from all federal computers, computer systems, and networks operated by contractors on the government’s behalf.

Numerous examples of data leaks caused by irresponsible use of P2P Software should push all businesses to take steps to use this potentially valuable technology more carefully. 

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Co-authored by Jason Gavejian

Employees’ increasing sensitivity to data privacy and security, and widely accepted public policy to protect personal data maintained by businesses, require employers to respond meaningfully to employee data privacy and security complaints or risk whistle blower claims of retaliation.

The U.S. District Court for the District of New Jersey recently held that an employee who voiced concerns regarding his employer’s handling of data security before he was fired may proceed to trial under the New Jersey Conscientious Employee Protection Act (“CEPA”) on the ground that he was engaged in protected whistle blowing activity under CEPA. This is one of the first decisions linking a NJ CEPA or similar claim and data security concerns, and is in line with increased efforts by both the federal and state governments to protect employee data. 

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Over the past few months, many businesses, particularly in the Northeast Region, have been focusing on creating a written information security program (WISP) to comply with Massachusetts identity theft regulations that went into effect March 1, 2010. For many, this has been a significant effort, reaching most, if not all, parts of their organizations. However, it is important to remember that although Massachusetts may be the state with the most comprehensive set of rules for securing personal data, other states have enacted similar protections, and compliance with Massachusetts does NOT necessarily mean compliance with other states.

Consider the following examples:

California. The Civil Code in California states a business that owns or licenses personal information about a California resident must:

implement and maintain reasonable security procedures and practices appropriate to the nature of the information, to protect the personal information from unauthorized access, destruction, use, modification, or disclosure.

For purposes of this requirement, “personal information" means:

an individual's first name or first initial and his or her last name in combination with any one or more of the following data elements, when either the name or the data elements are not encrypted or redacted:
(A) Social security number.
(B) Driver's license number or California identification card number.
(C) Account number, credit or debit card number, in combination with any required security code, access code, or password that would permit access to an individual's financial account.
(D) Medical information.

Similar pretections for medical information exist in Arkansas, but that information is not covered by the rules in Massachusetts. Illinois requires safeguards for certain biometric information, a classification of data also not covered by the Massachusetts regulations.

Oregon. Oregon’s Consumer Identity Theft Protection Act lays out safeguards similar to those in Massachusetts, with some relief for small businesses (those manufacturing businesses with 200 employees or fewer and all other forms of business having 50 employees or fewer). Key is the requirement to implement an “information security program” that contains administrative, technical and physical safeguards.

Administrative safeguards include, for example: 

1. designating one or more employees to coordinate the program;
2. identifying reasonably foreseeable internal and external risks;
3. assessing the sufficiency of data safeguards;
4. training employees in the program’s practices and procedures;
5. limiting outside service providers to those maintaining adequate data security safeguards; and
6. adjusting the program according to business changes or new circumstances.

In New Jersey, regulations are pending that would create similar obligations.

Connecticut. Without specifying the kinds of safeguards, Connecticut requires any person in possession of personal information of another person to:

safeguard the data, computer files and documents containing the information from misuse by third parties, and [ ] destroy, erase or make unreadable such data, computer files and documents prior to disposal.

For purposes of this law, “personal information” includes:

information capable of being associated with a particular individual through one or more identifiers, including, but not limited to, a Social Security number, a driver's license number, a state identification card number, an account number, a credit or debit card number, a passport number, an alien registration number or a health insurance identification number.

Similar requirements were enacted in other states, including Arkansas, North Carolina, Rhode Island, Texas, and Utah. But note the definition in Connecticut goes beyond the elements of data protected under the Massachusetts regulations.

Service contracts. Some states go a step further, requiring certain provisions be included in contracts between entities and their service providers when the contracts involve the disclosure of a state resident’s personal information from the owner of the information to the service provider. For example, such contracts in Nevada and Maryland must include a provision requiring the person to whom the information is disclosed to implement safeguards to protect that information.

The emergence of state mandates fueled by the continued rapid advancement and increased use of technology suggest a trend that is sure to become a fact of life for businesses operating anywhere in the U.S. Whether the technology is “cloud computing” or “peer-to-peer” software, businesses need to take appropriate steps to protect personal information maintained throughout their organizations.

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It’s been around for a while, but could new products in the “cyber-insurance” market help companies focus on this emerging threat known as “information risk”?

The National Journal reports that for many companies online security is not a priority. Tom Risen’s article cites to a Verizon study conducted between 2004 and 2008 (pdf) that determined

75 percent of breaches were not discovered by the victimized organization, and that 87 percent could have been prevented with reasonable online protection.

Mr. Risen reports that historically cyber-insurance covered “hazards such as unauthorized Web site access, online libel, data privacy loss and repairs to company databases after system failures.” However, with the explosion of data breaches over the last 10 years or so, new, broader policies have emerged, covering costs related to responding to a data breach, such as sending notices, providing credit monitoring services, engaging legal counsel, employing a call center, and defense of claims by affected individuals and federal and state officials. Some companies in this space include Beazley, Chartis, Travelers, Chubb and others.

It may be, as Robert Parisi of Marsh suggested to Mr. Risen, that federal legislation might encourage more awareness of these issues, something we raised as well. Certainly, we are beginning to see greater attention to these issues as businesses are beginning to focus on the Massachusetts data security/identity theft regulations, which become effective March 1, 2010.

Whatever the driving force, businesses need to drill down on their data security needs and address their information risk. Preventive measures – in the form of a written information security program – are certainly necessary and appropriate. But it may not be enough. As anyone who drives knows, for example, it is not enough to drive carefully and wear a seat belt. Insurance can play a critical role in addressing risks that even the best safeguards can’t. For this reason, cyber-insurance should be considered as a part of any business’ comprehensive approach to information risk. 

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