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

Today the White House issued a Cybersecurity Legislative Proposal. The proposed legislation focuses on protecting the American people, the nation’s critical infrastructure, and the federal government's computers and networks.  While legislation of this nature would simplify the breach reporting process for businesses, and overall streamline cybersecurity laws, a number of legislative attempts to do this have previously failed.  It is important to note that while this proposal sets forth some guidelines, the specific details of how each provision would be instituted are not yet clear

Our critical infrastructure – such as the electricity grid, financial sector, and transportation networks that sustain our way of life – have suffered repeated cyber intrusion, and cyber crime has increased dramatically over the law decade. The President has thus made cybersecurity an Administration priority. 

1.  To protect the American people, the proposed legislation calls for a national data breach reporting law which would simplify and standardize the existing patchwork of 47 state laws that contain these requirements. Additionally, the proposal calls for penalties for computer criminals and clarifies the penalties for computer crimes, synchronizes them with other crimes, and sets mandatory minimums for cyber intrusions into critical infrastructure.
2. To protect our nation’s critical infrastructure the proposal calls on legislative changes to fully protect this infrastructure. Specifically, proposal will enable the Department of Homeland Security (DHS) to quickly help a private-sector company, state, or local government when that organization asks for its help. It also clarifies the type of assistance that DHS can provide to the requesting organization.

Additionally, the proposal permits businesses, states, and local governments to share information about cyber threats or incidents with DHS. To fully address these entities’ concerns, it also provides them with immunity when sharing cybersecurity information with DHS. At the same time, the proposal mandates robust privacy oversight to ensure that the voluntarily shared information does not impinge on individual privacy and civil liberties.

Further, the proposal emphasizes transparency to help market forces ensure that critical-infrastructure operators are accountable for their cybersecurity.

Finally, the proposal requires DHS to work with industry to identify the core critical-infrastructure operators and to prioritize the most important cyber threats and vulnerabilities for those operators. Critical infrastructure operators would then take steps to address cyber threats, develop risk mitigation plans, and permit DHS to modify the processes which are implemented if they are insufficient. 

3.  To protect federal government computers and networks the legislative proposal includes: an update to the Federal Information Security Management Act (FISMA) as well as formalizing DHS’ current role in managing cybersecurity for the Federal Government’s civilian computers and networks, in order to provide departments and agencies with a shared source of expertise; giving DHS more flexibility in hiring highly-qualified cybersecurity professionals; the permanency of DHS’s authority to oversee intrusion prevention systems for all Federal Executive Branch civilian computers while codifying strong privacy and civil liberties protections, congressional reporting requirements, and an annual certification process; and preventions on states requiring companies to build their data centers in that state, as opposed to in the cloud, except where expressly authorized by federal law.

The Administration’s proposal also attempts to ensure the protection of individuals’ privacy and civil liberties through a framework designed expressly to address the challenges of cybersecurity. Some of these provisions include: requiring federal agencies (and likely federal contractors) to follow privacy and civil liberties procedures; limitations on monitoring, collecting, using, retaining, and sharing of information; requiring efforts to remove identifying information unrelated to cybersecurity threats; as well as immunity provisions for those business which comply with the proposal’s requirements.  

As the proposal concludes: 

Our Nation is at risk… [t]he Administration has responded to Congress’ call for input on the cybersecurity legislation that our Nation needs, and we look forward to engaging with Congress as they move forward on this issue.

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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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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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In a uniquely timed second showing of enforcement authority, the Department of Health and Human Services (HHS) announced on February 24, 2011 a one million dollar settlement with a Massachusetts hospital that allegedly breached patient data.  This settlement announcement comes only days after HHS announced a 4.3 million dollar HIPAA Privacy Rule fine.  The Massachusetts hospital settlement resulted from a hospital employee who took home documents containing sensitive personal information on patients. The employee then lost those documents while commuting to work.  

While the settlement did not include an admission of liability, in addition to the monetary settlement, and submitting to HHS oversight, the hospital must also adopt more stringent privacy practices and retain an independent security and privacy monitor. The investigation of the incident found the hospital failed to implement reasonable and appropriate standards to protect the privacy of patient information removed from the facility.  Under the settlement, the hospital must present new privacy and data security administrative, physical, and technical safeguards policies and procedures for HHS approval. Specifically, these policies and procedures must address the physical removal and transportation of protected health information and encryption of portable storage devices.  Despite a general prohibition on employees physically removing protected health information from the hospital,  HHS permitted an exception when the information is removed by an employee to perform his or her job duties.  Additionally, the hospital must implement training for all employees.  

This settlement, when considered with the 4.3 million dollar fine, likely signals how HHS will approach future enforcement actions.  In light of this, covered entities must seriously examine their privacy and security obligations, including implementing appropriate policies and procedures regarding the safeguarding of information.

 

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As we have discussed before, data breach notification is one of the most rapidly emerging areas of law. Good security incident procedures as well as effective training can help avoid the risk of data breach. (Sample data breach training). 

A case in point: Connecticut's Attorney General has filed a civil action against Health Net of the Northeast Inc. (“Health Net”) for failing to secure approximately 446,000 individuals’ patient information on a missing portable computer disk drive, and for failing to provide prompt notice of the breach. Among other things, the suit alleges Health Net violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health (HITECH) Act, when it failed to provide prompt notice, failed to encrypt the data, failed to provide for and implement appropriate policies to safeguard the information, and failed to supervise and train its workforce on safeguarding protected health information and personal information. 

As this suit demonstrates, state Attorneys General will use the authority granted by HITECH to enforce the privacy and security protections of HIPAA for protected health information, as many breaches involving such information may not be covered by state data breach laws. Such enforcement will only add to the cost of a data breach, which, according to the 2009 Ponemon Institute Annual Cost of a Data Breach study, continues to rise.

While a company’s first line of defense always should be a comprehensive data security policy, preparation should include an effective security incident procedure. Several key questions, some of which will form the foundation for any good security incident procedure, must be answered immediately following a breach: 

• How did the breach occur?
• Are measures in place to contain the breach?
• What information was compromised? 
• Whose information was compromised?
• Will the local authorities be alerted?
• What potential breach notice laws are implicated?
• Does notice of the breach have to be provided?
• If so, to whom and how will notice be provided?
• Does the company have applicable insurance to cover the notification process?
• Will any monitoring service be provided for affected individuals?
• Are measures in place for public relations implications?

However, a security incident procedure is only as strong as the awareness you create among your employees as to what constitutes a data breach and who to notify in the event of a possible breach. Therefore, in addition to an effective security incident procedure, it is essential that training, like the sample above, be provided to employees on a regular basis.   

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 According to the newly revised Federal Trade Commission (“FTC”) Guides, employers may face liability for employees’ commenting on their employer’s services or products on “new media,” such as blogs or social networking sites, if the employment relationship is not disclosed. Potential liability may exist even if the comments were not sponsored or authorized by the employer. 

The revised Guides took effect December 1, 2009. They address the application of Section 5 of the FTC Act (15 U.S.C 45) to the use of endorsements and testimonials in advertising and provide examples of the application of Section 5, including examples that could lead to potential employer liability. One such example specifies liability for an employee’s blog posting concerning his employers’ product, where the employment relationship is not previously disclosed:

An online message board designated for discussions of new music download technology is frequented by MP3 player enthusiasts. They exchange information about new products, utilities, and the functionality of numerous playback devices. Unbeknownst to the message board community, an employee of a leading playback device manufacturer has been posting messages on the discussion board promoting the manufacturer’s product. Knowledge of this poster’s employment likely would affect the weight or credibility of her endorsement. Therefore, the poster should clearly and conspicuously disclose her relationship to the manufacturer to members and readers of the message board.”

In comments to the proposed revisions, the Commission agreed that the establishment of appropriate procedures governing “new media” would be a factor in its determination as to whether law enforcement action is appropriate. Tellingly, the Commission stated that it has brought enforcement actions against companies “whose failure to establish or maintain appropriate internal procedures” had resulted in consumer injury. However, the Commission refused to spell out the procedures companies should put in place to monitor compliance with the principles set forth in the Guides, leaving companies to determine for themselves the process that would best fulfill their responsibilities. 

In light of the FTC’s clear recognition of “new media” and enforcement goal, employers should adopt social media and blogging policies as soon as possible. Employers should consider policies and procedures which address employee use of blog or social networking sites. Those policies, like this sample policy, should articulate the types of disclosure employees must include when they discuss their employers or their employers’ products or services. 

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Co-Author:  Joseph J. Lazzarotti, Esq.

Health Net Inc., one of the nation’s largest publicly traded managed health care companies, recently notified authorities and informed affected persons, with a statement on its website, that the unencrypted personal information of 1.5 million current and former members, stored on a portable disk drive, is missing from the company's Connecticut office. The company is now working to send written notices to affected individuals in four states—Arizona, New York, New Jersey and Connecticut.

Coordinating a data breach response, responding to the questions and complaints of affected persons, and negotiating with vendors to provide monitoring services are time-consuming, tedious tasks that require a strong sense of an organization’s public image, good judgment and excellent communication skills. Having the right person to drive this effort internally is critical. 

Additionally, companies that experience data breaches increasingly are becoming subject to federal and state agency inquiries. In this case, at least two states have announced investigations. Connecticut Attorney General Richard Blumenthal said his office will investigate the loss of the portable disk drive that he believed held the unencrypted health, personal, and financial information of some 450,000 Connecticut residents. Blumenthal also vowed to probe a six-month lag in notifying affected individuals of the breach. In a letter dated November 19, 2009, Arizona Attorney General Terry Goddard’s office requested information about the breach from Health Net, also noting the time between the breach and when affected persons were notified. It is critical that an organization’s Privacy Officer be prepared to respond to these inquiries, with the assistance of internal or external counsel when appropriate.

A breach of personal information, particularly one of this size, reminds us of the need for companies to take steps to implement policies and practices that safeguard sensitive personal and company confidential information. The first step is to appoint a person to spearhead a data breach response– typically the Chief Privacy or Information Officer. Among the duties and responsibilities of a Privacy Officer is being the company’s first line of defense when responding to a data breach, including directing the investigation of the breach, coordinating the notification process, addressing the concerns of affected persons and responding to government agency inquiries. For a sample Privacy Officer job description, click here.  

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Joining the growing number of states which have enacted laws regulating the destruction of records to prevent possible identity theft, the Rhode Island Legislature passed H. 5092 on October 29, 2009. The bill requires businesses and government agencies to completely destroy records containing personal information, or render the personal information unusable, before disposing of records whether in electronic and paper form. Not surprisingly, H. 5092 comes on the heels of Texas’s Attorney General settling related violations for nearly $1,000,000 with Select Medical, and over $600,000 with Radio Shack.

As with most legislation of this nature, including the FTC’s data disposal rule, the law provides two means by which covered entities may destroy records: either by modifying the personal data to make it entirely unreadable or indecipherable through any means, or by taking reasonable steps to shred, erase, or otherwise destroy records. The bill also exempts certain covered entities whose destruction practices are covered by federal law or who contract with data disposal firms (who would be subject to the data disposal law). The need for such measures is further underlined by the overzealous office workers who used documents containing personal information as “confetti” during the New York Yankees World Series parade. 

Underlying the consequential nature of proper destruction, this bill permits individuals to sue to recover actual damages, and permits the state attorney general to seek fines or sue on behalf of individuals, with each record not properly disposed of being counted as a separate violation.

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The Department of Health and Human Services (HHS) published interim final regulations on October 30, 2009, to update existing enforcement regulations under HIPAA for statutory revisions made by the Health Information Technology for Economic and Clinical Health (HITECH) Act. These regulations become effective November 30, 2009, and only address the provisions of the HITECH Act already in effect.

The interim final regulations, among other things, implement the increases in civil penalties and the four categories of violations and corresponding penalties established by the HITECH Act. Also, under the Act and the regulations, penalties will apply even where the covered entity did not know (and with the exercise of reasonable diligence would not have known) of the violation. However, HHS has the authority to reduce penalties in certain circumstances.

There have been a number of recent changes that enhance and strengthen HIPAA's enforcement provisions - the HITECH Act, the interim final regulations discussed above and agency reorganization. These measures suggest an increasing likelihood of enforcement concerning the HIPAA privacy and security regulations.  As a result, health care providers and health plans should be reviewing their compliance with HIPAA and preparing for additional guidance expected to be issued shortly.

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