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

In recognition of Data Privacy Day (January 28, 2012) and to facilitate a more interactive experience for our readers and subscribers, we want to extend to you the opportunity to tell us what is on your mind in the world of data privacy, social media and information management.

For the last two years, we have brought you developments on a wide range of issues concerning these topics. We realize many of you might like us to report on or provide information concerning certain issues/topics that we have not covered before. If so, please tell us!

To submit a topic, you can email us at informationrisk@jacksonlewis.com, or reach out to us through our Workplace Privacy Report on Facebook and Twitter. Feel free to “Like” our Facebook page and “Follow” us on Twitter by clicking on the corresponding buttons on the right below. If we select your topic, we will reach out to you privately to see if you would like us to identify you in the responsive post.

Of course, what would any communication from a lawyer be without a DISCLAIMER?

We look forward to hearing from you!

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The ECRI Institute recently published an excellent summary of key issues for hospitals concerning social media (registration required), a valuable read for any hospital administrator, risk manager or human resources director. ECRI reports that approximately 4,000 U.S. hospitals own social media sites and that number is sure to grow significantly. One of the reasons for this growth will likely be due in significant part to the increasing number of people looking to social media to research health decisions. According to a National Research Corporation survey cited in the summary, 41% of nearly 23,000 respondents said that they used social media for this purpose.

The summary discusses critical areas for healthcare organizations to consider concerning social media, which can be applied to most other industries:

• Understand the medium - what is social media, what are the different venues (Facebook, LinkedIn, FourSquare etc.), what is the competition doing, what new media is coming.
• Determine desired uses - promotion of services/sales, recruiting, reputation management, community involvement, education, and so on. 
• Assess risks - privacy, network security, employment, reputation, regulatory, malpractice, and protecting the brand.
• Develop policies and procedures - control company message and regulate employee activity.
• Implement and train and reevaluate - limit the number of employees who can speak for the organization, train employees on legal risks (such as with HR looking up applicant/employee background information on line), determine whether social media plan is producing desired results

Businesses in all industries are "going social," and should be developing a comprehensive plan before doing so. The ECRI summary provides a good starting point for thinking through some of the issues, particularly for those in healthcare.   

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In addition to concerns about social media, school districts across the country need to address a growing interest in the personal data of the students they educate. No, this interest does not stem from a desire to see if kids are reading at the desired level, or if the children have the resources they need to receive an adequate education. Data thieves want this information to commit identity theft. 

As reported by the Huffington Post:

Identity theft in schools is more than theoretical. Last July, Sheyla Diaz, 44, a former Broward County, Florida high school teacher, was sentenced to six months of house arrest for stealing the identities of former students. In 2009, Jonathan E. Kelly, who worked as a police officer for the Palm Beach County School District, was sentenced to eight years in prison for stealing the identities of former students and teachers.

The thieves know that children have pristine credit and that school districts, hampered by substantial budget cuts, may not be doing all they could to safeguard this information. Parents and school districts need to take steps to address this growing risk.

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While we do not know the exact nature and scope of the imminent HIPAA audits, we do know that HIPAA compliance and the verification of compliance (the audit) can be a very daunting process that mandates a great deal of preparation and organization. Beyond getting legally compliant, HIPAA covered entities and business associates need to consider how to practically and efficiently track and illustrate this compliance should they find an OCR investigator knocking at the door.

We have asked Alan Heyman, Managing Director of Cyber Security Auditors & Administrators LLC (CSA2) to discuss how certain applications can facilitate the response to a HIPAA audit, including minimizing the time staff needs to be involved. The following is an excerpt from Alan's discussion of this issue:

For many health care providers and other covered entities, compliance with HIPAA and other data privacy and security requirements is a multifaceted and ongoing process of assessing changing risks, policy development and implementation across various departments, conducting and tracking training of workforce members, monitoring compliance, managing vendors and vendor agreements, responding the customer complaints and so on. When an OCR auditor is on the doorstep, pulling evidence of all of these efforts together would likely sap an already thin workforce of most covered entities. When various segments of the covered entity are not coordinated, the files are incomplete, and the persons leading the effort are in disarray, the auditor is likely to suspect there are substantial deficiencies and adjust the audit accordingly.

It is not difficult to imagine the Privacy Officer having to go from department to department asking, among other things:

• Where are the current policies and procedures for your department concerning privacy and security?

• Would you please send me the training sign-in sheets for your group? Why was that group not trained?

• Where are the signed copies of the business associate agreements? Is this all of them?

• Where can I find a copy of the risk assessment for your department? Is it updated?

• How was that complaint resolved? Were there any others?

• Do you have all of the documents for the data breach that affected the radiology department?

• Can you send me your evaluation logs and what changes you have made based upon those efforts?

It is also not difficult to imagine how much easier this process would be if the covered entity's compliance efforts were tracked, maintained and documented in a single environment. An environment that would, for example

• Allow different departments/groups to log on an update their compliance efforts,

• Secure email notification/reminders for maintenance to update all required analysis, training, network architecture diagrams, etc.,

• Digital repository for all required employee affidavits, training sign-in sheets and managed with email notification for maintenance and updating,

• Maintain and track policy changes via secure email notification/reminders to all departments and employees from Privacy Officer or legal counsel,

• Track and document responses to patient complaints,

• Digitize interactive system for updating and obtaining required commentary from all required departments and Business Associates to establish and audit trail for creating “defensible position” to regulators.

• Centralize administration for permissions to all employees, advisors or Business Associates access to read only, print, edit, etc., with watermark capabilities on all printed and viewed documents.

• Centralize reporting dashboard status of all projects as well as the ability to digitally feed approved 3rd party software analytic results for centralized viewing to permission based participants with email notification of updates.

• Prepare for post-breach requirements in a pre-breach environment allowing reduction in costs of time sensitive response.

Such a tool also could be designed to permit the auditor limited access to conduct the audit with less effort on the part of the privacy officer or his or her staff. While certainly not required under HIPAA, organizing compliance in this way would simplify the compliance process and put the covered entity in a much better position to survive an OCR audit with minimal effort.

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Today, the Office for Civil Rights formally announced it is implementing the audit requirement under the American Recovery and Reinvestment Act of 2009, in Section 13411 of the HITECH Act. The agency confirmed that it is piloting a program to perform up to 150 audits of covered entities to assess privacy and security compliance, and that the pilot phase will begin November 2011 and conclude by December 2012.

A new page on OCR's website answers some helpful questions for covered entities and business associates... 

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As previously discussed, the federal appeals court in San Francisco had reinstated an indictment charging a former employee of Korn/Ferry International, Inc., with violations of the Computer Fraud and Abuse Act, 18 U.S.C. § 1030 (the “CFAA”) for trying to start a business that would compete with his former employer. Now, however, at the urging of the former employee’s counsel, by order dated October 27, the same court has agreed to rehear, en banc, its previous indictment reinstatement order.

The Ninth Circuit Court of Appeals reinstated the indictment on April 28 against former employee David Nosal on the basis of its interpretation that “an employee exceeds authorization under [the CFAA] when the employee uses that authorized access to obtain or alter information in the computer that the accesser is not entitled in that manner to obtain or alter.” The Court had reaffirmed that employers determine what access or authorization an employee has to an employer’s computer. It also pointed to specific examples of what the employer did to limit access to and authorized uses of information, including using unique usernames and passwords, requiring employees to enter into agreements that explained the limitations on the use of certain company information, and causing a notice concerning data security and confidentiality to pop up on each employee’s computer screen whenever the employee logs onto the company’s system.

The Ninth Circuit’s pending rehearing by the full court of the issue of unauthorized employee access to information under the CFAA puts its previous interpretation in doubt. It is clear, however, is that employers that wish to rely on the CFAA as a means of recovery against employees who steal data or take other actions to harm company computers must plan ahead. That is, employers must clearly define access rights and limitations to their information and information systems, and effectively communicate those rights and limitations to employees.
 

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The Securities and Exchange Commission's Division of Corporate Finance provided guidance to public companies on October 13, 2011, about their disclosure obligations concerning cybersecurity risks and cyber incidents. The Division is careful to point out that federal securities laws, in part, are designed to elicit disclosure of timely, comprehensive, and accurate information about risks and events that a reasonable investor would consider important to an investment decision. So, while this guidance does establish new obligations for registrants, it seeks to help them understand their existing disclosure obligation as they relate to increasing cyber risks.

The guidance summarizes the kinds of attacks that may raise concerns:

• unauthorized access to digital systems for purposes of misappropriating assets or sensitive information, corrupting data, or causing operational disruption;
• causing denial-of-service attacks on websites; or
• third parties or insiders using techniques that range from highly sophisticated efforts to electronically circumvent network security or overwhelm websites to more traditional intelligence gathering and social engineering aimed at obtaining information necessary to gain access.

Concerning the disclosure obligation, the Division observes:

Although no existing disclosure requirement explicitly refers to cybersecurity risks and cyber incidents, a number of disclosure requirements may impose an obligation on registrants to disclose such risks and incidents. In addition, material information regarding cybersecurity risks and cyber incidents is required to be disclosed when necessary in order to make other required disclosures, in light of the circumstances under which they are made, not misleading. Therefore, as with other operational and financial risks, registrants should review, on an ongoing basis, the adequacy of their disclosure relating to cybersecurity risks and cyber incidents.

In determining whether risk factor disclosure is required, including whether to include cybersecurity risks and cyber incidents in the Management’s Discussion and Analysis of Financial Condition and Results of Operations (MD&A), registrants will need to consider all of the facts and circumstances, such as:

• prior cyber incidents;
• severity and frequency of those incidents;
• the probability of cyber incidents occurring;
• the quantitative and qualitative magnitude of those risks, including the potential costs and other consequences resulting from misappropriation of assets or sensitive information, corruption of data or operational disruption;
• the adequacy of preventative actions taken to reduce cybersecurity risks in the context of the industry in which they operate and risks to that security, including threatened attacks of which they are aware; and
• the costs or other consequences associated with one or more known incidents or the risk of potential incidents represent a material event, trend, or uncertainty that is reasonably likely to have a material effect on the registrant’s results of operations, liquidity, or financial condition or would cause reported financial information not to be necessarily indicative of future operating results or financial condition.

At the same time, the Division does not expect a registrant will make a disclosure that itself would compromise the registrant’s cybersecurity.

As cybersecurity risks continue to grow and cyber incidents become more widespread, all companies need to assess and address these risks. For public companies, this is even more critical given their reporting requirements. 

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A Federal Acquisition Regulation proposed on October 14, 2011 (76 Fed. Reg. 63896, 10/14/11), would require federal contractors to conduct privacy training before being given access to government records or handling personally identifiable information. For many entities, training may already be called for under a federal or state law, or contract provision. However, this regulation raises the bar by effectively halting a contractor's work until the training is performed. Contractors will need to watch this regulation closely as it may affect their businesses. The public may submit comments on this regulation until Dec. 13, 2011.

Key features of the proposed regulations:

• Contractors would be required to provide initial training and annual training for employees who either —(1) require access to a government system of records; (2) Handle personally identifiable information; or (3) Design, develop, maintain, or operate a system of records on behalf of the federal government.
• Federal agencies are required to provide contractors the training materials unless, on
  an exception basis, the contracting officer authorizes a contractor to provide its own privacy training materials.
• The contractor is responsible to ensure the training is completed, and must maintain documentation of the training.
• Certain privacy clauses will need to be added to the contract between the contractor and  the government.

Training must cover at least the following seven areas:

1. The protection of privacy, in accordance with the Privacy Act (5 U.S.C. 552a);
2. The handling and safeguarding of personally identifiable information;
3. The authorized and official use of government system of records;
4. Restrictions on the use of personally-owned equipment to process, access, or store personally identifiable information;
5. The prohibition against access by unauthorized users, and unauthorized use by authorized users, of personally identifiable information or systems of records on behalf of the Federal
   Government;
6. Breach notification procedures i.e., procedures for notifying appropriate individuals when privacy information is lost, stolen, or compromised) and
7. Any agency-specific privacy training requirements.

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CLICK HERE FOR UPDATED INFORMATION CONCERNING THE AUDIT PROGRAM

The Health Information Technology for Economic and Clinical Health law (“HITECH”) made a number of changes for HIPAA covered entities and business associates. One key change stems from Section 13411 of HITECH, which gives the Secretary of the Department of Health and Human Services authority to conduct “periodic audits to ensure that covered entities and business associates” comply with the privacy and security mandates under HIPAA. Susan McAndrew, the Deputy Director for Health Information Privacy at the Office of Civil Rights ("OCR"), has been speaking out about the nature, scope and timing of these audits, which are expected to begin in February 2012. A summary of reports about the audit program follows below.  

Covered entities and business associates need to be prepared and take stock of their HIPAA compliance. One hundred percent compliance can be an elusive goal, particularly in a short time frame. So, perhaps a more efficient way to prepare for the coming wave of audits it to look, at a minimum, for the low hanging fruit, such as: (i) having clear policies and procedures on topics such as access management, breach notification, discipline, passwords, managing portable data storage devices, distributing notices of privacy practices, and similar items, (ii) conducting and documenting training of workforce members, and (iii) ensuring appropriate agreements are in place with business associates and subcontractors.   

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In November 2010, the Department of Health and Human Services established the Department-wide Text4Health Task Force to among other things identify ongoing initiatives and proposals for feasible new projects which would deliver health information and resources to users' fingertips via their mobile phones. The Task Force announced recommendations on September 19 to support health text messaging and mobile health programs, which include addressing the privacy and security concerns inherent in texting.

The Task Force acknowledged in its recommendations some critical facts driving the need for guidance in this area:

• Approximately 2.2 trillion text messages were sent in the U.S. in 2010.
• Text messaging is particularly prevalent among teenagers, with nearly 90% of teenagers who have cell phones reporting that they use text messaging.
• A growing body of empirical studies suggests that the use of mobile phone text messaging can be effective in improving health behaviors and health outcomes.

The recommendations note that text messaging programs may be subject to numerous privacy and security laws, including the privacy and security regulations under Health Insurance Portability and Accountability Act of 1996 (HIPAA). Additional guidance in this area would be welcomed as many health care providers look to use developing technologies, including texting, to deliver their services.

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The Office of Civil Rights of the U.S. Department of Health and Human Services (“HHS”) has published its first round of annual reports to Congress under the HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 to Congress. The first report concerns HHS’s HIPAA (Health Insurance Portability and Accountability Act of 1996) enforcement activity for 2009 and 2010 and the second report focuses on reported or recorded data breaches occurring in 2009 and 2010.  

The HITECH Act contains multiple breach notification requirements for HIPAA-covered entities and their business associates. Covered entities and business associates that create unreadable or indecipherable protected health information, however, are exempt from such requirements. Covered entities must notify individuals and the Secretary of HHS of any breach of unsecured protected health information within 60 days following the discovery of the breach. For breaches involving more than 500 residents of a state, a covered entity must also notify the media in addition to the individuals and the Secretary of HHS. Business associates of covered entities under HIPAA must notify the covered entity of any breach of unsecured protected health information so the covered entity can notify affected individuals. 

As reported by HHS, between September 23, 2009 and December 31, 2010, the HHS Office of Civil Rights received 45 reports of breaches affecting 500 individuals or more in 2009 and 207 reports in 2010, resulting in notification of 7.8 million affected individuals. 

The general causes of breaches of unsecured protected health information included, first and foremost, theft.  27 of the 45 large 2009 incidents involved theft and 17 of those incidents occurred on the premises of a covered entity or its business associates. Likewise, 99 of the 207 incidents in 2010 involved theft, primarily of electronic or paper records, affecting some 2,979,121 people. Types of theft noted by HHS included theft of back-up tapes transported by a vendor of a medical facility, of laptops or desk-top computers at covered entity sites, and of smart phones or flash drives. Other causes of breaches generally involved loss of electronic media or paper records containing protected health information, unauthorized access to, use of or disclosure of protected health information, human error, and improper disposal. Notably, loss of portable electronic devices is a major factor in the loss of electronic media.

With respect to complaints and compliance with HIPAA’s Privacy Rule, HHS reports that from April 14, 2003, the date HIPAA-covered entities were to comply with the Privacy Rule, through December 31, 2010, it received 57,375 complaints and resolved 91% of them.   Through the same time period, HHS investigated 19,161 complaints, achieved corrective action in 66% of them and found no violation in 34%. 

HHS further reports that between April 20, 2005, and December 31, 2010, it investigated 289 complaints of the 803 it received related to HIPAA’s Security Rule, resolving 77% of them and finding no violation in 48%. 

The compliance issues related to the Privacy Rule most investigated included impermissible uses and disclosures of protected health information, lack of safeguards, and denial of individual access. HHS Security Rule investigations focused on a covered entity’s failures to demonstrate adequate policies and procedures to address response or reporting of security incidents, security training, access controls and workstation security.  

The two HHS reports to Congress show a marked improvement in compliance with HIPAA’s Privacy Rule. However, the reports also highlight a continuing vulnerability for covered entities that rely on electronic devices and employee accountability for elements of their privacy and security compliance programs under HIPAA (as we have touched on in previous posts). As noted by HHS, remedial actions for violations include revising policies and procedures; improving physical security; training or retraining workforce members; adopting encryption technologies; changing passwords; performing new risk assessments; and revising business associate agreements to specify required confidentiality protections. The HHS reports remind covered entities and their business associates to review and place appropriate limits on employee access to protected health information and incorporate HHS’s remedial measures into their best practices.

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Connecticut Attorney General George Jepsen announced on September 14, 2011, the creation of a Privacy Task Force to help educate the public about data protection requirements and to focus his Office’s response to Internet privacy concerns and data breaches that affect consumers. According to Attorney General Jepsen's press release, “Internet and data privacy have been among the biggest issues affecting the broad public interest during my first eight months in office” and nearly a dozen investigations have been initiated or pursued regarding security breaches that resulted in the loss of medical and insurance records or personal customer information.

Like nearly all states across the country, Connecticut has a data breach notification law. The State's Insurance Commissioner has also adopted rules concerning data breach notification requirements for its licensees. Among other laws, the Nutmeg state has also enacted specific protections for Social Security Numbers, employment applications, and personal information, which 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.  

The Task Force will be responsible for all investigations of consumer privacy breaches, which we are assuming will apply to breaches of any personal information for which notification is required, including patients and employees. The Task Force will also help to educate the public and business community about their responsibilities, which include protecting personally sensitive data and promptly notifying affected individuals when breaches do occur.

Clearly a sign of increased attention to and enforcement of the state's data security and consumer protection mandates, Connecticut businesses and businesses maintaining personal information of Connecticut residents should revisit their information security programs and data breach response plans to ensure they could withstand the scrutiny of an inquiry by the Attorney General's office.  

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As we suspected, California's current governor, Edmund G. “Jerry” Brown, Jr. (D), signed into law S.B. 24, which adds some additional protections to the state's current data breach notification requirements. The champion of this law and its recent enhancements, State Sen. Joe Simitian (D-Palo Alto), has finally succeeded after a number of prior attempts to pass this measure were vetoed by then-Gov. Arnold Schwarzenegger (R).

Summary of Changes

Under S.B. 24, breaches occurring on and after January 1, 2012, that require notification to California residents will have to meet the following additional requirements:

• The notifications themselves will need to satisfy specific content requirements, such as including a description of the type of information breached, time of breach, and toll-free telephone numbers and addresses of the major credit reporting agencies;
• If more than 500 California residents are affected by a single breach, an electronic copy of the breach notification must be send to the California Attorney General;
• If the law's "substitute notice" provisions are used, notice also must be provided to the Office of Information Security or the Office of Privacy Protection. Substitute notice is permitted when the person or business required to provide the notice demonstrates that (I)(i) the cost of providing notice would exceed two hundred fifty thousand dollars ($250,000), or (ii) that the affected class of subject persons to be notified exceeds 500,000, or (II) the person or business does not have sufficient contact information. Prior to the change, substitute notice consisted of only email notification, conspicuous posting of the notice on the person or business' website, and notification to statewide media.

Companies responding to multi-state breaches face significant challenges trying to harmonize the various state law requirements. See, for example, the recent changes to the Illinois statute. Presently, a number of bills are being considered in Congress that would preempt all of the state laws in this area, however, passage of one of these laws does not appear to be imminent. As data breaches go global, similar concerns exist as countries are enacting their own breach notification mandates.

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Illinois Governor Pat Quinn approved a measure on August 22, 2011, amending his state's data breach notification law. The changes, which become effective January 1, 2012, are designed to increase protections for Illinois residents in the following ways:

New information that must be included in breach notifications:

• the toll-free numbers and addresses for consumer reporting agencies,
• the toll-free number, address, and website address for the Federal Trade Commission, and
• a statement that the individual can obtain information from these sources about fraud alerts and security freezes.

Information that may not be included in breach notifications:

• information concerning the number of Illinois residents affected by the breach.

New requirements for "data collectors" that maintain or store, but do not own or license, computerized data:

As with most breach notification statutes, entities that maintain or store certain personal information on behalf of the owner or licensee of that data also have obligations in the event of a breach of the security of that data. Generally, the obligation is to notify the owner of the breach. So, for example, a third party claims administrator or an accounting firm might perform services for ABC Corp. (the owner) requiring the administrator or accounting firm to maintain or store the personal information. If an employee of the administrator or accounting firm loses a laptop containing ABC Corp.'s personal information, or the employee or some third party impermissibly accesses or acquires the information, the administrator or accounting firm would be required to notify ABC Corp. which, in turn, would need to notify the affected individuals.  

As amended, Illinois' breach notification law requires companies that maintain or store personal information to cooperate with the owner or licensee in matters relating to the breach, by notifying the owner or licensee of: 

• the date or approximate date of the breach and the nature of the breach, and
• any steps the entity has taken or plans to take relating to the breach.

However, this cooperation shall not require either (i) the disclosure of confidential business information or trade secrets of the company that maintains or stores the information, or (ii) the notification of an Illinois resident who may have been affected by the breach.

New Mandates for Disposing of Materials Containing Personal Information 

The amended law requires "persons" (including natural persons, corporations, partnerships, associations, or other legal entities, including governmental entities) to dispose of the materials containing personal information "in a manner that renders the personal information unreadable, unusable, and undecipherable." The law provides examples of proper disposal methods: 

• Paper documents containing personal information may be either redacted, burned, pulverized, or shredded so that personal information cannot practicably be read or reconstructed.
• Electronic media and other non-paper media containing personal information may be destroyed or erased so that personal information cannot practicably be read or reconstructed.

Companies may engage third parties to carry out the disposal of personal information, provided that third parties performing these services must implement and monitor compliance with policies and procedures that prohibit unauthorized access to or acquisition of or use of personal information during the collection, transportation, and disposal of materials containing personal information. It is recommended that service contracts be carefully drafted to address these issues and appropriate steps be taken to monitor compliance.

Penalties for violations of the disposal requirements can be up to $100 for each individual with respect to whom personal information is disposed, subject to a maximum penalty of $50,000 for each instance of improper disposal.

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Connecticut joins five other states (Hawaii, Illinois, Oregon, Washington, and Maryland) in limiting what credit report information employers may use in making hiring or employment decisions. Other states have considered similar measures.

Under the new law, effective October 1, 2011, employers (including their agents, representatives or designees) may not demand that an employee or prospective employee consent to a credit report as a condition of employment unless:

1. the employer is a financial institution, 
2. the credit report is required by law,
3. the employer reasonably believes that the employee has engaged in specific activity that constitutes a violation of the law related to the employee's employment, or
4. such report is "substantially related to the employee's current or potential job" or the employer has a bona fide purpose for requesting or using information in the credit report that is substantially job-related and is disclosed in writing to the employee or applicant.

For purposes of this law, a credit report is a report that contains information about the employee's or prospective employee's credit score, credit account balances, payment history, savings or checking account balances or savings or checking account numbers. The report will be treated as being "substantially related to the employee's current or potential job," where the position:

• is a managerial position which involves setting the direction or control of a business, division, unit or an agency of a business,
• involves access to customers', employees' or the employer's personal or financial information other than information customarily provided in a retail transaction,
• involves a fiduciary responsibility to the employer, including, but not limited to, the authority to issue payments, collect debts, transfer money or enter into contracts,
• provides an expense account or corporate debit or credit card,
• provides access to certain confidential or proprietary business information, including trade secret information under certain circumstances; or
• involves access to the employer's nonfinancial assets valued at $2,005 or more, including, but not limited to, museum and library collections and to prescription drugs and other pharmaceuticals.

Employees or prospective employees who believe the law has been violated may file a complaint. Employers could be liable for $300 in civil penalties for each inquiry that violates the law.

In addition to affecting the traditional employee-employer relationship, this law (and those cited above) may affect the practice of requiring employees of a company's vendors to jump through certain hoops before coming on-site. Increasingly, company A, when it utilizes the services of employees of company B (such as for back office processing or health care staffing needs) will require company B to ensure its employees undergo certain background checks and other certification procedures and tests. Those arrangements need to consider these limitations on the kinds of inquiries that can be made by employers.

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. . . A Potential Headache for Employers of Younger Workers

Written by Lillian Moon

Retail, entertainment, hospitality and other industries that traditionally employ large numbers of younger workers may soon get dragged into criminal proceedings because of “sexting” by their younger workers. Florida has joined 20 other states — Alaska, Arkansas, California, Hawaii, Indiana, Iowa, Kansas, Mississippi, Nevada, New Jersey, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, and Guam — which have all enacted similar legislation addressing teen sexting. Because employees frequently transmit these materials using their employer’s networks, criminal prosecutions under these laws may require employers to respond to discovery requests and subpoenas, or permit searches pursuant to warrants obtained by law enforcement authorities, which, in turn, may unexpectedly trigger disciplinary proceedings.

On June 21, 2011, Florida Governor Rick Scott signed into law H.B.75/S.B. 888. Under this law, which will take effect beginning October 1, 2011, a minor (anyone under the age of 18) commits the criminal act of “sexting” if he or she knowingly uses a computer, cell phone, or other transmission device (1) to transmit or distribute to another minor a photograph or video of any person which depicts nudity; or (2) possesses such photograph or video which was transmitted or distributed by another minor, unless the photograph was unsolicited, the minor took reasonable steps to report the photograph or video to their legal guardian, school official, or law enforcement, and the minor did not transmit or distribute the video or photograph to a third party. A minor’s first offense is considered noncriminal and is punishable by 8 hours or community service or a $60 fine. The minor’s second offense is a misdemeanor in the first degree, punishable with imprisonment not to exceed one year or a $1,000 fine; and the minor’s third offense is a felony of third degree, punishable with up to five years’ imprisonment or a $5,000 fine.

Of course, sexting is not only an issue for minors. It is fast becoming an easy and well-utilized mechanism for sexual and other workplace harassment. Accordingly, employers should review and update their anti-harassment policies to include a prohibition of harassment via e-mail, text messaging, or use of social networking sites; and they should review their electronic communications policies to include a prohibition against using any employer-provided electronic device to transmit or retain any sexually suggestive or explicit pictures, texts, videos or any other derogatory material regarding race, ethnicity, age, disability, religion, or any other protected category. Employers should also educate and train employees on the revised policies and continue to enforce all policies in a fair and consistent manner. At the same time, employers should remain mindful of any limitations on such policies (as written or as applied) that may be imposed under the National Labor Relations Act.
 

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Disclosure to management by the company’s in-house physician of an employee’s alleged “lie” (or at least significant omission) made months earlier on a post-job offer medical questionnaire violated the Americans with Disabilities Act’s confidentiality provisions, a federal District Court in Maine held last week. Blanco v. Bath Iron Works Corp., D. Me., No. 2:10-cv-00429.

Medical professionals are becoming a fixture at many workplaces, whether they be occupational nurses or full scale on-site health clinics. As reported by the L.A. Times on July 3, 2011, 15% of U.S. companies with 500 or more employees had health centers last year, up from 11% the year before, and companies with 20,000 or more employees were even more likely to have clinics. However, having these resources on site can raise a range of workplace law risks, not the least of which concerns confidentiality.

In the Maine case, following his job offer, Mr. Blanco completed a pre-placement medical screening, which included filling out and signing a “Medical Surveillance History Questionnaire,” administered by the employer’s in-house physician. He did not reveal on that form that he had Attention Deficit Hyperactivity Disorder (ADHD). Mr. Blanco received good reviews for the first few months of his employment, but when he was moved to a different position, his performance began to wane. During a meeting with his manager, he attributed his poor performance to his ADHD and not long after requested a reasonable accommodation.

Mr. Blanco was referred to the same in-house physician who administered the Medical Surveillance History Questionnaire. Rather than explore the substance of his request, the physician interrogated Mr. Blanco concerning the ADHD omission on the Questionnaire. He explained that he did not understand the questions to ask about mental or emotional issues, such as ADHD. The physician refused to provide an accommodation, or even address the issue, and shortly after the physician informed management of Mr. Blanco’s omission from the Questionnaire, he was fired.

In refusing to dismiss Mr. Blanco’s complaint under the Americans With Disabilities Act and the state anti-discrimination law, the Court rejected two interesting arguments raised by the employer:

1. Employees that lie should not be able to get protection under the ADA’s medical information confidentiality protections; and,
2. As a policy matter, these kind of misstatements put in-house physicians “in a pickle.” The court allowed, “If the revealed condition places the employee and his co-workers at risk, the doctor’s conflicting loyalty would become a safety issue."

In each case, however, the Court said it didn’t matter to its decision that the employee may have lied on the medical questionnaire. The Court simply pointed to the statutory language, which it found clear and controlling. The court stated:

The Court agrees that whether he lied is not dispositive since the confidentiality provision does not apply only to truthful information. But this does not assist the Defendants. The ADA clearly protects the confidentiality of Mr. Blancos’ response if truthful and the ADA still protects its confidentiality if not. In other words, there is no prevarication exception to the ADA’s confidentiality mandate for employment entrance examinations, much less for information the company doctor perceives is inaccurate. It is the information, accurate or not, that the statute protects.

In response to the conflicting loyalty argument, the Court reasoned:

The brief answer, however, is that these policy arguments do not trump the statutory language. Congress, not this Court, is a policy-making body, and the Court is duty-bound to follow the law as enacted by Congress. Congress may or may not have considered whether to carve out a disclosure exception for instances where the employer concludes that the employee lied or misrepresented his pre- employment medical or mental condition. In any event, there is no such exception in the statute.

More than ever, businesses are realizing that comprehensive approaches to disability and leave management not only can mitigate compliance and litigation concerns, but also can enhance employee productivity and, therefore, profit margins. For these companies, on-site health clinics, occupational health clinics, and in-house physicians can be attractive options. However, as this case makes clear, employers need to be mindful of the workplace law risks. The ADA may be one source of such risks.

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Reuters and other news outlets are reporting that Representative Mary Bono Mack has circulated draft legislation in response to the steady stream of data breaches that have occurred this year. According to the report, Senate Majority leader Harry Reid also has asked four Senate committees to pull together a comprehensive cybersecurity bill, hoping it will be brought to the floor by late summer. After years of failed attempts at data breach legislation, the federal government could be poised to enact broadly applicable requirements for safeguarding data and responding to data breaches. 

Some key provisions of the draft legislation would require covered entities (basically, any person engaged in interstate commerce) to:

• establish and implement policies and procedures to protect personal information (defined in a manner similar to most current state breach notification laws) to include, without limitation, designating a point person to manage information security, and having a process for identifying and assessing foreseeable vulnerabilities;
• erase personal data that is no longer needed and otherwise take steps to minimize the amount of personal information maintained;
• notify law enforcement within 48 hours of a data breach, and if data could be used to steal a customer's identity, notify the Federal Trade Commission within 48 hours and begin contacting the affected persons; and
• provide 2 years of credit reporting services or credit monitoring services to individuals affected by a covered data breach.

The law would be enforceable by state attorneys general and the Federal Trade Commission with maximum penalties running into the millions of dollars. The law would generally preempt similar state laws, but would not permit private lawsuits. 

Of course, companies should not be waiting to see if any action is taken at the federal level. There are a number of states with similar laws already on the books. In addition, exposure from a data breach, particularly when there were no safeguards in place to prevent the breach, should be sufficient motivation to take steps to safeguard personal data.

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An article in Bloomberg tells a harrowing story of computers that have secretly come under the control of hackers. This can happen to company and personal computers alike that download certain embedded malware - such as when downloading an email attachment. These computers become known as "bots," and part of a "botnet." The consequences can be crippling.

Accordingly to the article:

The enslaved “bots,” as the infected computers are known, have become so pervasive they now threaten the security of the Internet, said Gunter Ollmann, head of research at Atlanta-based Damballa Inc., which tracks botnet activity. At least 18 percent of home computers are now under remote command of cyber-thieves without their owners’ knowledge, according to Damballa’s research. 

For corporate computers, which are usually protected by expensive security measures, around seven percent are controlled by such malware, which is hidden from the user and controlled via the Internet, Ollmann said.

When this happens, companies can find themselves in uncomfortable and potentially dangerous circumstances . . . consider the following exchange described in the Bloomberg article:

“I’m sure we can settle on control of bots,” a LulzSec hacker called Ninetales told Hijazi, according to a computer log of their interaction provided to Bloomberg News by Hijazi.

When Hijazi said he didn’t want to face extortion, another hacker named hamster_nipples replied: “Unfortunately, you have little choice at this point.”

Hijazi, who declined to identify his corporate clients, refused to comply with LulzSec’s demands and rejected a separate request for money. The hackers posted the company’s e-mails on the Internet June 3.

The harm that can result is significant. The Bloomberg article cites to one example of hackers controlling a botnet who sought to transfer nearly $1 million from one company. In other cases, hackers were successful in removing tens of thousands of dollars from bank accounts of affected companies.

Companies need to be more aware of these developments and take appropriate steps to protect their systems. While there are federal and state laws that require steps be taken to safeguard against these kinds of risks, the extent of damage that a botnet can cause to an entity's business can be far more damaging. 

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In a report issued earlier this week, the Office of Inspector General found that the Center for Medicare and Medicaid Services' (CMS) oversight and enforcement actions were not sufficient to ensure that covered entities, such as hospitals, effectively implemented the HIPAA Security Rule.

OIG's recommendation: Continue the compliance review process (audits) that began in 2009 and implement procedures for conducting compliance reviews to ensure that HIPAA Security Rule controls are in place and operating as intended to protect ePHI at covered entities.

To reach this conclusion, OIG audited 7 hospitals throughout the country (locations in California, Georgia, Illinois, Massachusetts, Missouri, New York, and Texas).  These audits focused primarily on:

1. wireless electronic communications network or security measures the security management staff implemented in its computerized information systems (technical safeguards);
2. the physical access to electronic information systems and the facilities in which they are housed (physical safeguards); and
3. the policies and procedures developed and implemented for the security measures to protect the confidentiality, integrity, and availability of ePHI (administrative safeguards).

Significant vulnerabilities identified. The audits identified 151 vulnerabilities in the systems and controls intended to protect ePHI, of which 124 were categorized as high impact. A high vulnerability refers to one that

may result in the highly costly loss of major tangible assets or resources; may significantly violate, harm, or impede an organization’s mission, reputation, or interest; or may result in human death or serious injury.

The report noted that outsiders or employees at some hospitals could have accessed, and at one hospital did access, systems and beneficiaries’ personal data and performed unauthorized acts without the hospitals’ knowledge. Although each of the seven hospitals had implemented some controls, policies, and procedures to protect ePHI from improper alteration or destruction, none had sufficiently implemented the administrative, technical, and physical safeguard provisions of the Security Rule. Clearly, mediocre compliance is not sufficient.  

Some of the more significant vulnerabilities found related to (i) wireless access; (ii) access controls, and (iii) integrity controls. In the case of wireless access problems, the report identified vulnerabilities including ineffective encryption, rogue wireless access points, no firewall separating wireless from internal wired networks, the inability to detect rogue devices intruding on the wireless network, and no procedures for continuously monitoring the wireless networks. Access control problems included inadequate password settings, computers that did not log users off after periods of inactivity, unencrypted laptops containing ePHI, and excessive access to root folders. According to the OIG, these conditions could have led to unauthorized individuals viewing or altering ePHI data on nonclinical workstations that were not automatically logged off after a period of inactivity; ePHI being compromised on lost or stolen unencrypted laptops; and unauthorized users circumventing system controls and harming system files.

The list goes on and on.

The Office of Civil Rights (OCR), the arm of HHS now charged with enforcing the HIPAA security regulations, may be listening. As reported here earlier, OCR appears to be taking steps to improve its enforcement efforts, which likely will include increasing the number of compliance reviews/audits at hospitals and health care providers around the country. These efforts include a request by the agency to increase its budget for 2012 by $5.6 million, or 13.6%, to be aimed at enforcement. 

Because HIPAA now applies to business associates, it would not be surprising to see business associates on an audit list. Accordingly, covered entities and business associates should be taking steps now to ensure compliance.

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NBC's Bob Sullivan reported on a rising trend of identity thieves targeting children. Why? Well, having no real credit history, most children’s credit is clean and good. Also, children, particularly younger children, are not going to be needing or looking at their credit for some time. These factors make children more attractive targets of identity theft.

Mr. Sullivan’s colleague Jeff Rossen and the "TODAY" show dig into this issue and provide some valuable information for parents about the problem and how to safeguard their children.

Businesses need to be in tune to this as well. All of the country’s data breach notification laws (46 states, plus other jurisdictions), as well as the laws requiring safeguards for personal information apply to “individuals,” not adults or persons over a certain age.

Some companies may believe they do not have personal information about children, but most companies do. For example, companies sponsoring medical, dental or vision coverage for employees, or health and dependent care flexible spending accounts maintain (or require vendors to maintain) personal information about children of covered employees. This kind of information also could be contained in retirement or life insurance plan beneficiary designation records, as well as records supporting leaves of absence and other matters.
 

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Bypassing the media attention that often accompany high-dollar penalties and settlements, the Department of Health and Human Services (HHS) has quitely reported a settlement concerning the HIPAA privacy and security rules that highlights the increasing cooperation of federal government agencies to enforce a steadily expanding and complex compliance environment. 

Late in 2009, HHS opened an investigation of Management Services Organization Washington, Inc. (MSO) following a referral from the HHS Office of Inspector General (OIG) and Department of Justice, Civil Division (DOJC), which had been investigating MSO and its owner for violations of the
federal False Claims Act (FCA). During the course of its investigation, OIG discovered that MSO's owner also owns Washington Practice Management, LLC (WPM) that earns commissions by marketing and selling Medicare Advantage plans.

According to the HHS Resolution Agreement with the company, the tip from OIG and DOJC led HHS to find that MSO:

• impermissibly disclosed electronic protected health information (ePHI) of numerous individuals to WPM without a valid authorization, for WPM'S purpose of marketing Medicare Advantage plans to those individuals; and
• did not have in place and did not implement appropriate and reasonable administrative, technical, and physical safeguards to protect the privacy of the ePHI.

Without acknowledging a HIPAA violation, MSO agreed to a resolution payment of $35,000 and to a two-year "Corrective Action Plan," which includes, among other things:

• adopting written policies and procedures to be reviewed and approved by HHS;
• obtaining a signed certification from all workers concerning the policies and procedures;
• changing its policies and procedures only with HHS approval; and
• conducting monitoring reviews every 180 days, which include performing unannounced interviews of workforce members.

It is not uncommon for companies considering compliance measures to assess the likelihood of a government audit or inquiry. Any illusion an organization may hold that it is operating “under the radar” of regulators should be shattered in the current compliance environment. Governmental agencies are increasingly able to efficiently coordinate with one another in matters of enforcement. Should HHS receive the additional $5.6 million it is seeking to enforce the HIPAA privacy and security regulations in its 2012 budget, flying under the radar will become more difficult.  

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Promising a company that you will safeguard its employees’ information and then failing to do it according to Federal Trade Commission (FTC) standards likely will be viewed by the FTC as an unfair and deceptive business practice and trigger an enforcement action.

This was the case for Lookout Services, Inc., a company that maintains large amounts of sensitive information about the employees of its business customers, including Social Security numbers. According to an FTC announcement on May 3, 2011, Lookout claimed it would take reasonable measures to secure the consumer data it maintained, including Social Security numbers, but failed to do so.

Lookout markets a product that allows employers to comply with federal immigration laws. It stores information such as names, addresses, dates of birth and Social Security Numbers. According to the FTC’s complaint, despite the company’s claims that its system kept data reasonably secure from unauthorized access, it did not in fact provide adequate security. (Note that an FTC complaint is not a finding or ruling that a respondent, such as Lookout , actually has violated the law.) For example, unauthorized access to sensitive employee information allegedly could be gained without the need to enter a username or password, simply by typing a relatively simple URL into a web browser, the complaint asserted. In addition, the complaint charged that Lookout failed to require strong user passwords, failed to require periodic changes of such passwords, and failed to provide adequate employee training. As a result of these and other failures, it was claimed, an employee of one of Lookout’s customers was able to access sensitive information maintained in the company’s database, including the Social Security numbers of about 37,000 consumers.

The settlement agreed to by Lookout to resolve these charges is comprehensive. Among other things, the settlement order requires Lookout (i) to conduct a risk assessment, (ii) to implement a comprehensive, written information security program, (iii) to cease making misrepresentations, including misleading claims about the privacy, confidentiality, or integrity of any personal information collected from or about consumers, (iv) to obtain independent third party security audits of the program every other year for 20 years, and (v) to make the settlement order available to its current and future employees having responsibilities relating to safeguarding customer data.

For companies that maintain personal information on other businesses’ employees in the course of providing services to those businesses, this development is an important reminder: Promises made to those businesses concerning the safeguarding of personal information must be supported by comprehensive policies and procedures. In addition to this kind of enforcement exposure, which also could arise at the state level from the states’ attorneys general, the employers that these businesses serve also could have causes of action for negligence and/or breach of contract. Increasingly, state laws require businesses to contractually obligate vendors to have appropriate safeguards to protect personal information provided to the vendor to perform its services. States having such laws include California, Maryland, Massachusetts, and Texas.

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Written by Nick Beerman

The federal appeals court in San Francisco has reinstated an indictment charging a former employee of Korn/Ferry International, Inc., with violations of the Computer Fraud and Abuse Act, 18 U.S.C. § 1030 (the “CFAA”) in trying to start a business that would compete with his former employer. .

The indictment in United States v. Nosal, which a lower court dismissed, alleged that the employee, David Nosal, “knowingly and with intent to defraud” exceeded his authorized access to his employer’s computer system for the purpose of setting up a competing business. Nosal was an executive at Korn/Ferry and subject to a non-competition agreement. After leaving the company, he started a competing business, soliciting the help of three Korn/Ferry employees to provide him with source lists, names, and contact information from a Korn/Ferry proprietary and confidential database. Employee access to the database was specifically restricted, except for legitimate Korn/Ferry business.

The Ninth Circuit Court of Appeals reinstated the indictment on April 28 against Nosal on the basis of its interpretation that “an employee exceeds authorization under [the CFAA] when the employee uses that authorized access to obtain or alter information in the computer that the accesser is not entitled in that manner to obtain or alter.” The Court reaffirmed that employers determine what access or authorization an employee has to an employer’s computer, and pointed to specific examples of steps the employer in this case took to limit access to and authorized uses of information. These examples include the use of unique usernames and passwords, requiring employees to enter into agreements that explained the limitations on the use of certain company information, and causing a notice concerning data security and confidentiality to pop-up on each employee's computer screen whenever the employee logged on to the company's system.  

Joining the Fifth and Eleventh Circuits, the Court ruled that as long as an employee has knowledge of an employer’s limitations on authorized use of a computer system, the employee will exceed authorized access under the CFAA whenever he or she violates those limitations or goes beyond his or her authorized access with an “intent to defraud” by an action that “furthers the intended fraud and obtains anything of value. It is as simple as that.”
 

The message to employers from this case is that if you want to be able to effectively use the CFAA as a means of recovery when employees steal data or take other actions to harm company computers or data, you will need to plan ahead. That is, employers will need to clearly define access rights and limitations to their information and information systems, and effectively communicate those rights and limitations to employees.

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Acknowledging the need "to help states combat the growing threat of business identity theft," the National Association of Secretaries of State (NASS) announced on April 18, 2011, the formation of a "Business Identity Theft Task Force." The focus of this task force is to assist states (not necessarily private business) with combating business identity theft in areas such as "the types of technology used by states in housing business documents, solutions for securing state business filing information and records, and key partnerships/liaisons for conducting outreach."

However, this action by the NASS highlights a growing problem for small and medium sized businesses: 

"With the downturn in the economy, the newest victims of identity theft are small and medium-sized businesses, including dormant or inactive companies," said NASS President Mark Ritchie of Minnesota, who serves on the task force. "As the state officials who oversee business registrations and corporate filings, secretaries of state have come together to educate business owners on how they can reduce their chances of falling prey to identity thieves and to explore safeguards for state filing systems." 

Identity thieves are not just attacking state filing systems, so businesses need to take steps of their own to safeguard not only personal information of customers, employees and others, but also the businesses' corporate and financial data. Many of the same principles that apply in the safeguarding of personal information also would apply to safeguarding the information of the business. Two critical steps in this process are conducting a risk assessment and developing a written information security program.

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Most would expect that when an entity experiences a data breach, that entity would take reasonable and appropriate steps to investigate the breach and mitigate harm. Making credit monitoring services available to affected persons is a typical way companies attempt to mitigate harm, and that is exactly what the Plymouth County Correctional Facility did when one of its prisoners hacked into its personnel records. Including these monitoring costs in a restitution award to the prison facility was proper, the U.S. Court of Appeals for the First Circuit ruled in United States v. Janosko.

Charged under the criminal provisions of the Computer Fraud and Abuse Act (CFAA), the inmate who hacked into the prison's records while incarcerated pleaded guilty

not only to causing such “damage” but also to causing “loss” by his damaging conduct, § 1030(a)(5)(B)(i).

The Court found that the "near juxtaposition of “loss” to “damage” inflicted on items or systems of equipment indicates some broader concept of forbidden effect and consequent scope of restitution" and that the definition of "loss" under the CFAA includes “any reasonable cost to any victim, including the cost of responding to an offense.” In this case, recovery by the prison facility was further enabled under the Mandatory Victims Restitution Act which mandates restitution for “expenses incurred during … the investigation or prosecution of the offense.”

Actually recovering these costs from this or any other hacker will likely be difficult. However, companies are increasingly experiencing breaches and are getting better at being able to identify those committing the breach, which often times are employees or former employees. This decision provides support for those companies seeking to recover the costs they incur when taking appropriate steps to investigate these data incidents and mitigate harm when a breach is found to have occurred. As this court noted:

It should go without saying that an employer whose personnel records have been exposed to potential identity thieves responds reasonably when it makes enquiry to see whether its employees have been defrauded. This act of responsibility is foreseeable to the same degree that indifference to employees’ potential victimization would be reproachable. It is true, of course, that once they were told of the security breach, the individual employees and former workers involved in this case could themselves have made credit enquiries to uncover any fraud, but this in no way diminishes the reasonableness of the Facility's investigation prompted by the risk that its security failure created. And quite aside from decency to its workers, any employer would reasonably wish to know the full extent of criminality when reporting the facts to law enforcement authorities.
 

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Written by Keturah Martin

Continuing the trend of significant enforcement of data privacy and security laws by federal and state agencies across the nation, the Office of the Massachusetts Attorney General (AG) has settled a lawsuit against Boston-based Briar Group LLC for $110,000, according to a press release issued by that AG’s office on March 28, 2011.

See complaint and final judgment.

As we reported in prior posts, the U.S. Department of Health and Human Services (HHS) recently imposed a $4.3 million fine on a Maryland health care provider for violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and days later entered into a $1 million settlement with a Massachusetts hospital that allegedly breached patient data. The recent enforcement activity of the HHS and the Massachusetts AG confirms that employers nationwide need to be as cognizant of the data privacy and security laws that apply to their operations as the government.

In its press release, the Massachusetts AG’s Office stated that the Briar Group, which owns and operates a number of bars and restaurants in the Boston area, “failed to take reasonable steps to protect its patrons’ personal information, thereby putting the payment card information of tens of thousands of consumers at risk.” The initial lawsuit filed by the AG’s Office stated that the Briar Group experienced a data breach in April 2009, in which hackers accessed customers’ credit and debit card information, but did not take steps to remove the software which allowed the hackers access to the company’s computer systems until December 2009, six months later. The lawsuit also outlined various other ways in which the company failed to properly safeguard its customers’ personal information, including:

• Failing to change default usernames and passwords on point-of-sale computer systems;
• Allowing multiple employees to share common usernames and passwords;
• Failing to properly secure its remote access utilities and wireless network; and
• Continuing to accept credit and debit card account information after knowing of the April 2009 data breach.

In addition to the monetary payment, the terms of the settlement require the company to “develop a security password management system and implement data security measures to comply with Payment Card Industry [PCI] Data Security Standards [and] state data security regulations, including implementation, maintenance, and adherence to a Written Information Security Program.”

This recent activity by the Massachusetts AG’s Office, along with HHS’s latest actions, should be motivation to employers to put in place the policies and procedures required by applicable data security and privacy laws. For those who have already taken steps toward conformity with the relevant laws, this should prompt a review of current policies and procedures to ensure the thoroughness of those policies and that they are being followed. For example, employers subject to HIPAA should have policies and procedures that address the management of protected health information of its constituents. Employers who employ Massachusetts residents or who maintain the personal information of Massachusetts residents are well advised to implement and follow a comprehensive WISP governing the storage, access, transmission and other forms of handling those individuals’ personal information.
 

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The confidentiality of medical records requirement under the Americans with Disability Act (ADA) is violated when an employer discloses a current or former employee's medical records in response to a state court subpoena absent the employee's release or some other exception under the ADA, the Equal Employment Opportunity Commission (EEOC) recently held in Bennett v. U.S. Postal Serv., 2011 WL 244217 (E.E.O.C.), Jan. 11, 2011.

Companies frequently receive requests for information about current and former employees. These requests often come in the form of an attorney's demand letter or a subpoena and apply to the individual's medical records. Those receiving such requests typically feel compelled to respond without taking the time to think through issues such as: 

• what kind of information in contained within the files being requested;
• what specific statutory or regulatory protections apply for some or all of the information being requested (see below);
• is a response appropriate without an authorization of the individual or giving an individual an opportunity to object;
• is a court order needed for some or all of the information being requested; and
• what safeguards should be taken to ensure the disclosure is secure.

As we have reported previously, failing to think through these issues can be a costly trap for the unwary.

EEOC Analysis

In the Bennett decision cited above, the EEOC sets out the basic ADA requirements concerning confidentiality of employee medical records:

Title I of the [ADA] requires that all information obtained regarding the medical condition or history of an applicant or employee must be maintained on separate forms and in separate files and must be treated as confidential medical records. [Citations omitted]. These requirements also extend to medical information that an
individual voluntarily discloses to an employer. [Citations omitted]. The confidentiality obligation imposed on an employer by the ADA remains regardless of whether an applicant is eventually hired or the employment relationship ends. [Citations omitted]. These requirements apply to confidential medical information from any applicant or employee and are not limited to individuals with disabilities. [Citations omitted].

The decision goes on to explain the general exceptions to these requirements:

• supervisors and managers may be informed regarding necessary restrictions on the work or duties of the employee and necessary accommodations;
• first aid and safety personnel may be informed, when appropriate, if the disability might require emergency treatment; 
• government officials investigating compliance with this part shall be provided relevant information on request;
• employers may disclose medical information to state workers' compensation offices, state second injury funds, workers' compensation insurance carriers, and to health care professionals when seeking advice in making reasonable accommodation determinations; and
• employers may use medical information for insurance purposes.

The EEOC found that the Postal Service's disclosure of Mr. Bennett's medical records in response to the subpoena issued by the Galveston County 405th District Court did not fall into one of these exceptions. The EEOC held that while the ADA allows an employer to comply with the requirements of another federal statute or rule, even if in conflict with the ADA, "it is not a valid defense to argue that the [Postal Service's] actions were required by state law," (emphasis added) unless one of the ADA exceptions applied.  The Commission also noted the subpoena in this case was signed and issued by the Deputy Clerk, and did not qualify as an “order” for purposes of the Privacy Act of 1974, on which the Agency attempted to rely to permit the disclosure.

Because of this violation of the ADA, the EEOC ordered the Postal Service (i) to start an investigation into compensatory and other damages that may be due to Mr. Bennett,  (ii) to conduct training concerning the ADA's confidentiality requirements, and (iii) to prepare a report regarding corrective action. The Postal Service also may be responsible for Mr. Bennett's attorneys' fees, among other things.

Is the ADA the only concern?

In short, no, the ADA is only one protection for medical and other personal information that could trigger exposure for a company that improperly discloses such information. There is an increasing array of federal and state laws that need to be examined, as appropriate, before responding to a request:

• GINA: Regulations issued under Title II (GINA's employment provisions) provide that  employers that possess genetic information must maintain the information in confidence and may not disclose that information except in limited circumstances, such as (i) at the request of the employee, (ii) in response to a court order, (iii) to respond to a request from a government official investigating GINA compliance, or (iv) in support of an employee’s FMLA certification. The preamble to the GINA regulations provides that the court order exception "does not allow disclosures in other circumstances during litigation, such as in response to discovery requests or subpoenas that are not governed by an order specifying that genetic information must be disclosed. Thus, a covered entity’s refusal to provide genetic information in response to a discovery order, subpoena, or court order that does not specify that genetic information must be disclosed is consistent with the requirements of GINA." Additionally, the individual whose genetic information is disclosed may need to be notified. 
• HIPAA: The privacy regulations under HIPAA likewise generally prohibit the disclosure of "protected health information" except in limited circumstances. HIPAA regulation 45 CFR 164.512(e), among other exceptions to the general rule, provides an exception for disclosures in connection with administrative and judicial proceedings. But one of the first questions to ask is whether the information being sought is "protected health information." Very often, employee medical information in a personnel or medical file is not, in the hands of the employer, protected health information subject to HIPAA. 
• 42 USC Part 2: Federal law provides very stringent protection for records relating to substance abuse treatment at certain federally funded facilities. 
• State law: Many states have laws protecting certain classes of medical records from disclosure without taking appropriate safeguards to address confidentiality. This includes application of the physician-patient privilege, as well as statutes and regulations dealing with specific types of information, such as mental health records. 

Because of these issues, businesses should develop a clear policy and procedure to direct employees on how to respond when they receive these requests. 

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Last month, the Federal Trade Commission's Bureau of Consumer Protection posted FAQs on its website to guide health care providers and health plans when their patients and subscribers are affected by medical identity theft. 

When most people hear about an identity theft or a data breach, they typically think about credit card data or Social Security numbers being stolen and used by unauthorized parties, and the damage to one's credit rating that sometimes follows. However, as reported by Businessweek, medical identity theft is one of the fastest growing types of identity theft. According to the article, the number of incidents of medical identity theft was approximately 275,000 in 2009; double the number in 2008. As the country implements the new health care reform law, assuming it gets past some significant obstacles, there likely will be periods of confusion and transition that may create the perfect conditions for even higher levels of medical identity theft.

The FTC's FAQs point out that health care providers and health plans may have some obligations when they learn about medical identity theft affecting their patients or subscribers. For example, depending on the circumstances, the provider or plan may have to revisit its privacy and security policies and procedures under HIPAA and other federal and state laws. The theft also may have resulted from a data breach that requires the provider or plan to notify other affected persons. Providers and plans also need to be prepared to help victims get the information they need and exercise their rights under HIPAA and other laws to help mitigate the adverse effects of this unfortunate crime.

Providers and plans should be taking steps to be prepared to address medical identify theft situations.

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Written by: Lillian Moon

As employees become more savvy with electronic communications and employers face increasing challenges with controlling vast amounts of data, the circumstances in this recent San Francisco Examiner story are likely being repeated all over the country – employee takes company information to support her wrongful termination case.

As reported by the Examiner, a Human Services Agency of San Francisco employee, after being terminated for performance issues, e-mailed caseload files, containing Medi-Cal beneficiaries’ names, Social Security numbers, and other personal identifying information belonging to 2400 individuals, to her personal computer, two attorneys and two union representatives.

While the facts are not entirely clear from the report, including why the former employee still had access to her former employer’s systems following termination, such a disclosure could have triggered the breach notification requirements under the HIPAA Privacy and Security Rules, and likely did trigger California’s own breach notification laws. With breach notification mandates in almost every state, few employers are immune from the risks of a data breach or the costs that are associated with responding to a breach when it occurs.

As this situation makes clear, employers need to implement written information security programs containing privacy and security policies. These policies should include data breach detection and response procedures and mandate training for all employees. While being mindful of applicable whistle blower protections, employers should remind employees that confidential company and personal information is not to be used or disseminated, except when consistent with the employee’s assigned job responsibilities. In this case, based on the information reported, the entire incident might have been avoided had the former employee's access to the Agency’s systems been terminated.

Employers must continually assess their risks (e.g., examining what information the company has, the nature of that information, how it moves through the organization and to/from its vendors, and the company's current set of safeguards), determine the best methods of protecting the sensitive information they possess, and create a culture of data security and privacy throughout their organizations. This can only be accomplished when data security and privacy are made a priority through clear policies with frequent training and attention. And, of course, when terminating or disciplining employees, employers should expect employees might begin using and disclosing information in a manner that is not permitted, and should take steps to prevent these kinds of disclosures.
 

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The demand for "data breach" insurance appears to be growing based on our experiences, as well as commentary such as a recent article by Pamela Lewis Dolan of American Medical News.

As we've reported, data breach coverage is something quite different than traditional "cyber-risk" coverage which tends to address "hazards such as unauthorized Web site access, online libel, data privacy loss and repairs to company databases after system failures.” According to Ms. Dolan's article, data breach policies tend to cover the cost of notification and credit monitoring for affected persons, public relations expenses to address reputational harm, breach investigation, legal fees and compensatory damages, judgments and settlements. Of course, as with any type of insurance, businesses should seek appropriate advice concerning the scope of coverage they are purchasing.

Ms. Dolan's focus on health care providers is well placed given the recent HIPAA breach notification mandate and the sensitive protected health information such businesses handle. This is particularly true for small health care practices which often do not have the resources to adequately respond to a data breach - for those, a data breach policy could be a wise investment.  It is also true for those businesses that service the health care industry - many of which are business associates that are also subject to HIPAA and its breach notification requirements. 

Beyond HIPAA, breach notification mandates exist in nearly all states in the U.S. and other jurisdictions. So, many businesses can benefit from addressing this risk through insurance as well as adopting policies and procedures to reduce the likelihood of a breach in the first place. In this connection, Ms. Dolan is also wise to report that data breach insurance doesn't absolve health care practices or any other business for that matter from implementing safeguards to protect personal information or protected health information. Various federal and state laws require to one degree or another businesses to adopt "written information security programs" to safeguard personal information.

This is much like protecting your building/office space from fire damage - you have fire insurance, but you also have a plan to safeguard critical assets and exit the building!

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As we reported here, the Senate passed legislation to clarify the application of the "red flag" rules to "creditors."  The law, the Red Flag Program Clarification Act of 2010, made its way through the House and, on December 18, 2010, was signed into law by President Barack Obama.

The Act makes clear that the red flag rules apply to a creditor that:

regularly and in the ordinary course of business - 

(i) obtains or uses consumer reports, directly or indirectly, in connection with a credit transaction;

(ii) furnishes information to consumer reporting agencies [defined elsewhere in the Fair Credit Reporting Ac] in connection with a credit transaction; or

(iii) advances funds to or on behalf of a person, based on an obligation of the person to repay the funds or repayable from specific property pledged by or on behalf of the person.

The definition of "creditor" under the Act goes on, however, to exclude those creditors that fall into item (iii) above, if the creditor advances funds for expenses incidental to a service provided by the creditor to the person. For many who believed that the red flag rules were never intended to apply to them, such as health care providers and attorneys, this language is expected to provide the relief they were seeking.

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Coauthored with Jason Gavejian

California hospitals and nursing homes take note - the California Department of Public Health (CDPH) takes data breaches seriously. Since June of this year, CDPH has imposed nearly $1.5 million in fines affecting 12 California health facilities. California Health and Safety Code 1280.15(a) requires covered health facilities to prevent unlawful or unauthorized access, use or disclosure of patient medical information.

Violations of this requirement can result in penalties of up to $25,000 per patient and up to $17,500 per subsequent occurrences of unlawful or unauthorized access, use or disclosure of that patients medical information. 

In its most recent wave of penalties, announced November 19, 2010, CDPH assessed fines totaling $792,500 against six hospitals and one nursing home that it determined failed to prevent unauthorized access to confidential patient medical information. In one case, a health facility was fined $310,000:

• $60,000 because the facility failed to prevent unauthorized access and disclosure of one patient’s medical information by two employees on three occasions.
• $250,000 because the facility failed to prevent the theft of 596 patients’ medical information

The larger penalty resulted in part when laboratory reports of 596 patients were lost. In its investigation, CDPH learned that the staff employee at the facility responsible for running and storing laboratory reports, and who had signed the facility's confidentiality statement, placed lab reports in an outside locker, but did not lock the locker because the lock was not working and the locker door was broken. This staff member told CDPH the locker had been broken for several months, although he did not report it. The lab reports that were lost included patient names, Social Security numbers and laboratory results, among other personal information. 

Beyond that, California health facilities should be reminded of Cal. Health and Safety Code § 1280.15, which requires covered facilities to notify CDPH and affected individuals of “unlawful or unauthorized access to” personal health data within five business days after discovery of a breach. Late notices can result in fines of $100 per day for each patient affected, up to maximum of $250,000. Of course, health care providers also need to take into account the interim final rules, promulgated under the Health Information Technology for Economic and Clinical Health (“HITECH”) Act and enforced by the Department of Health and Human Services (“HHS”), which require entities covered by the Health Insurance Portability and Accountability Act (“HIPAA”) to report similar incidents.  Under the HIPAA rules, notice must be provided without "unreasonable delay."

As the number of data security incidents in the health care industry continue to mount, CDPH's enforcement activity should urge covered health facilities in California to pay greater attention to data security. As the incident above makes clear, simply requiring an employee to sign an acknowledgment of complying with facility data security policy will not be enough. Health facilities, including hospitals and nursing homes, need to continually assess their risks in this area and create a culture of data privacy and security across their organizations. This can only be accomplished through clear policy and frequent training and attention to the issue. 

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We've written extensively here on the importance of safeguarding personal information. We've also made clear that the safeguarding of data should not stop with individually identifiable personal information. In fact, many times a company's most sensitive information, data critical to the survival of its business, is its corporate trade secrets, proprietary information, and its clients' information. My partner, Patricia Diulus-Myers, in our Pittsburgh office, drives this point home during a Q&A session with the Smart Business Network.

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As reported by the American Bar Association and PHIprivacy.net, lawyers, accountants, health care providers and others soon may get some clarity as to whether the "red flag" rules apply to them. The United States Senate voted unanimously to pass the Red Flag Program Clarification Act of 2010. Under the Act, according to statements from Sen. Christoper Dodd (D) of Connecticut:

lawyers, doctors, dentists, orthodontists, pharmacists, veterinarians, accountants, nurse practitioners, social workers, other types of health care providers and other service providers will no longer be classified as “creditors” for the purposes of the Red Flags Rule just because they do not receive payment in full from their clients at the time they provide their services, when they don’t offer or maintain accounts that pose a reasonably foreseeable risk of identity theft.

After the Red Flags Rule became final, many businesses indicated that they were not aware that they would be covered by this rule. Despite the Federal Trade Commission delaying enforcement of the rule several times to allow these entities time to come into compliance, a number of professional organizations, including the American Bar Association and the American Medical Association, sued the FTC for taking the position that professionals were “creditors” when they allowed consumers to pay later, and would have to comply with its Red Flags Rule. On May 28, 2010, the FTC announced that it would delay enforcing its Red Flags Rule through December 31, 2010 and asked Congress to pass legislation that would resolve any questions about which entities should be covered as “creditors” and to obviate the need for further enforcement delays.

Presently, only the Senate has acted on this request. The measure will need to be approved by the House of Representatives and signed by President Obama. Still, this is encouraging news for many concerned about compliance with this new mandate.  

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What had been the first use of the enforcement authority under the HIPAA privacy regulations granted to a State Attorney General, has ended in a settlement agreement between Connecticut's Insurance Department and Health Net of Connecticut. Under the agreement, Health Net will pay $375,000 in penalties, and it agreed to provide credit monitoring protection for 2 years to all affected persons in Connecticut and to take significant steps to improve data and equipment security in both its Shelton, CT locations.

One important item to note from the Insurance Department's press release is that the "most prominent failure stemmed from the untimely notification of the 2009 loss of a disk drive from the Shelton location resulting in the loss of personal health information of approximately 500,000 Connecticut members." This should be a reminder to any entity involved in a data breach of the importance of acting quickly to notify affected individuals.

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Welcome to the next advancement in the delivery of health services -

monitoring patients and promoting healthy behavior through mobile phones and other portable devices

The Washington Post reported today about a service offered through Voxiva whereby expectant mothers receive free text messages concerning prenatal health advice. The pilot program has been in place since February and since then more than 100,000 expectant mothers are reported to have participated in the program. These technologies clearly are in line with initiatives in this country to move to electronic health records. However, whether these methods for delivering health care take hold remains to be seen. As the WP notes, while these technologies are attractive, there are challenges:

• As noted by WP reporter Steven Overly, communicating to a wide variety of patients through a "wide variety of mobile devices, operating systems and network speeds" raises significant challenges. 
• Another issue, of course, is HIPAA and how these communications and devices will meet the privacy and security requirements under those regulations.
• Human error easily could cause the wrong messages to be sent to the wrong patients creating data breach, malpractice and other risks.
• One of our more recent posts highlights the concern about information maintained on cellphones and other mobile devices and what happens to that information when the phones are discarded. 
• Employers who provide phones to their employees and have the right to review text messages, see recent U.S. Supreme Court decision in Quon v. City of Ontario, can easily find themselves with access to all kinds of medical information of employees and possibly their dependents who give their doctors their cell phone number. This risks here could be significant.   

As with the adoption of any new technology or new application of technology, companies and employers should be careful to think through all of the issues and take appropriate preventive steps toward minimizing risks.

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The folks at Identity Theft 911 remind us of the need to be "smart" about handling smartphones. In a recent post, the company warns that the wealth of data on these devices can substantially expose an individual if his or her device(s) are not purged upon disposal. The same is true, of course, for employers with respect to the phones and other devices they make available to their employees, as well as the employees' own devices which employers permit to access their systems.

Whether because of personal preference, workforce turnover, technological advancement, a better provider contract, or business needs generally, phones and other communications devices are updated frequently. This typically results in the disposal of old devices which can have significant amounts of data stored on them. This data may include not only the personal information of the user of the phone, but sensitive company information, as well as personal information of other employees or the company's customers. 

Employers should be taking steps to ensure these devices are handled properly. From a technical perspective, Identity Theft 911 notes that fortunately there are a number of ways to ensure that all sensitive data are cleared from a phone's memory before it is thrown away. They warn, however, that it may not be enough to use a handset's option to restore it to factory settings. Rather, the phone's SIM card(s) which stores information should also be obtained, removed, purged, and/or destroyed, as appropriate.

From an employment policy perspective, employers should consider establishing policies to better manage the use of these devices. Policies such as:

• limiting the kinds of devices that can be used,
• maintaining an inventory of the devices being used,
• controlling the information that can be stored on the devices, and
• securing/purging devices upon termination of employment,

can go a long way to minimizing risk of a data breach involving sensitive personal and company information. Of course, employers that take these steps need to be mindful of employees' expectation of privacy with respect to personal information that may be stored together with company information.  Such policies should be a part of any Written Information Security Program (WISP).

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In March 2010, we reported on a decision by the U.S. District Court for the District of New Jersey that allowed an employee's retaliation claim to proceed to trial under the New Jersey Conscientious Employee Protection Act (“CEPA”) on the ground that he was engaged in protected whistle blowing activity - voicing concerns regarding his employer’s handling of data security. A California Appellate Court recently adopted a similar line of reasoning. 

Rather than addressing an employee’s concerns, a company fired the employee for questioning whether the company’s networks and information systems adequately protected HIPAA patient information contained on those systems. Cutler v. Dike, 2010 WL 3341663 (Cal. Ct. App. Aug 26, 2010) (unpublished). Based on his employment contract, the employee reasonably believed that his job included acting as the company’s privacy officer. As the court found, the employee also reasonably believed:

the database used to test the company’s . . . software contained confidential patient information which would be exposed in violation of HIPAA, because [the company president] had told him it was patient information . . . [and that] confidential patient data would be used in the future as the program was implemented.

The employee had refused to participate in configuring the computer system as directed and voiced his objections that doing so would violate HIPAA rules and regulations. In response, the company president recommended that the employee resign or risk being fired “since you have chosen to be very negative about issues in the organization.” The employee sued the employer for wrongful termination and the jury found against the employer. The employer appealed the jury verdict.

The court began by citing the relevant section of the California Labor Code (Section 1102.5), which states:

[a]n employer may not retaliate against an employee for refusing to participate in an activity that would result in a violation of state or federal statute, or a violation or noncompliance with a state or federal rule or regulation.

The court went on to hold, “[T]he protection of confidential patient information is clearly the type of general public interest that supports a cause of action for wrongful termination in violation of public policy.” Accordingly, the court upheld the jury’s finding of liability against the employer for wrongful termination in violation of public policy.

Employers across the country generally are prohibited from retaliating against employees for refusing to participate in activities that are impermissible under state or federal law or regulations. This includes retaliating against employees that raise concerns under the HIPAA privacy and security regulations, or other data security mandates under federal or state laws, such as those in Massachusetts, Connecticut, or New Jersey. Employers may find themselves responding to more of these kinds of concerns from employees as employees are more aware of breaches reported in the media over the past few years and become anxious over their own sensitive personal information in their employer’s possession.

An employer should avoid reacting to an employee’s complaint of weaknesses in its data system by firing or disciplining the employee. Shooting the messenger is not acceptable. The company should investigate the issues which have been raised and, if necessary, address them appropriately. Employers are better served by employees who feel secure enough to come forward with unpleasant news, than by suppressing such reports and enduring embarrassing and costly disclosures later. Of course, vulnerabilities can be minimized by taking the preventive steps required under many state and federal laws to safeguard personal and confidential information.  

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Federal contractors are subject to numerous requirements under federal law and, as we have previously highlighted here, need to keep pace with changes in law and regulation. 

Under the Federal Information Security Management Act of 2002 (FISMA) each federal agency is required to develop, document, and implement an agency-wide program to provide information security for the information and information systems that support the operations and assets of the agency, including those provided or managed by another agency, contractor, or other source. Accordingly, FISMA provides authority for the imposition of requirements on those companies which qualify as federal contractors. 

By way of example, the Centers for Medicare and Medicaid Services (CMS), as well as the Department of Veterans Affairs impose specific requirements on their contractors.   

Adding new data protection requirements for federal contractors who use or handle U.S. Department of Defense (DOD) information, the DOD earlier this year issued an advanced notice of proposed rulemaking regarding amendments, 75 F.R. 9563, to the Defense Federal Acquisition Regulation Supplement (DFARS). 

The proposed amendments require “adequate security,” defined as “protection measures … commensurate with the risks of loss, misuse, or unauthorized access to or modification of information,” and have three main subparts; basic safeguarding, enhanced safeguarding, and cyber intrusion reporting. 

Basic safeguards, required for any unclassified DOD information, include:

• Designating  the level of access and dissemination of informationProtecting DOD information on public computer or Web sites
• Transmitting electronic information using technology and processes that provide the best level of security and privacy
• Transmitting voice and fax information on with reasonable assurances that access is limited
• Protect information by at least one physical or electronic barrier
• Sanitize media in accordance with the National Institute of Standards and Technology (NIST) before external release or disposal
• Provide protection against computer intrusions and the unauthorized release of data. 

In addition to the basic safeguards outlined above, contractors are required to implement enhanced safeguards to certain types of data. The enhanced safeguards include:

• Encryption/Storage controls
• Network intrusion protection
• Implement information security controls

Additionally, a reporting requirement has now been proposed, requiring contractors to report to the DOD within 72 hours of any cyber intrusion event that affects DOD information resident on or transiting the contractor’s unclassified information systems.

The new proposed DOD amendments, along with the various other federal contractor requirements, including those imposed by CMS and the Department of Veterans Affairs, highlight the necessity for companies that qualify as federal contractors to be up to date on their legal obligations or risk loss of their federal contractor status. 

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In another favorable decision for companies, the Maine Supreme Court ruled on September 21, 2010 that consumers affected by a data breach could not claim damages from the company unless they suffered uncompensated financial losses or some other tangible injury. 

The Maine Supreme Court addressed the following:

In the absence of physical harm or economic loss or identity

theft, do time and effort alone, spent in a reasonable effort to

avoid or remediate reasonably foreseeable harm, constitute a

cognizable injury for which damages may be recovered under

Maine law of negligence and/or implied contract?

The Court ruled they do not. Additionally, the Court went on to state that "[t]he tort of negligence does not compensate individuals for the typical annoyances or inconveniences that are a part of everyday life….An individual's time alone, is not legally protected from the negligence of others."

The underlying suits were filed following a breach, and fraudulent use, which resulted when card holder data of nearly 4.2 million people was stolen. The lawsuits alleged the company was negligent in protecting card holder data and failed to notify of the breach in a timely fashion.  The above holding was issued when the District Court Judge who heard the underlying case, agreed to let the state Supreme Court decide whether the plaintiffs could sue the company for the time and effort put into avoiding or mitigating harm from fraudulent charges on their cards.

Two other cases are similarly instructive. In 2003 the Minnesota Supreme Court found that an invasion of privacy cause of action requires that the dissemination resulted in “publicity” of private facts. Because the disclosure was internal to other employees, and not to the public at large, the Court held the dissemination was insufficient publicity to support an invasion of privacy claim against the employer. Further, in Guin v. Brazos Higher Educ. Serv. Corp. Inc., 2006 U.S.Dist. LEXIS 4846(D. Minn. Feb. 2, 2006), the District Court dismissed plaintiff’s negligence claim holding that the threat of future harm not yet realized will not support a claim for negligence which requires a showing of an injury.

Companies and employers must be on notice of these decisions when faced with individual lawsuits following data breaches. 

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A UK law firm may find itself subject to significant penalties following reports of a data breach affecting thousands of people.  The recent 2010 ABA Annual Meeting in San Francisco devoted two sessions to the topic, specifically dealing with “cloud computing,” and the risks and ethical issues it raises for law firms. As data privacy and security risks mount for all businesses, they are perhaps even more critical for law firms. 

Law schools in the United States teach their students about a long-standing and fundamental tenet of the legal profession – the attorney-client privilege. It is indeed the general obligation of attorneys to keep client communications confidential. Law schools generally do not teach, at least not nearly to the same degree, how lawyers as law firm business owners ought to protect the personal information of their clients from unauthorized acquisition or access, without hampering their practice.

This primer is intended to provide a brief discussion of the key issues for law firms and some helpful steps for developing a plan to safeguard such information.

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The most frequent question we hear from clients who want to develop or tighten their data privacy and security policies and procedures: Where do we start?

In most cases, the first step for the group charged with this task is to understand the organization's "information risk." This means, in short, examining what information the company has, the nature of that information, how it moves through the organization and to/from its vendors, and the company's current set of safeguards. The process for gaining this understanding is generally referred to as a risk assessment. 

Click here for a power point presentation on key features of a risk assessment.

Risk assessments come in many forms and should be designed to fit your particular organization. 

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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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Update - On September 29, 2010, Governor Arnold Schwarzenegger for the third time vetoed S.B. 1166.

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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