As a growing number of medical facilities are struck by ransomware, the US Department of Health and Human Services (HHS) has published a fact sheet describing how businesses that process electronic Protected Health Information (ePHI) should defend against and respond to ransomware. Most of the recommendations are known IT security best practices.
The presence of ransomware (or any malware) on a covered entity’s or business associate’s computer systems is a security incident under the HIPAA Security Rule. A security incident is defined as the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system. See the definition of security incident at 45 C.F.R. 164.304. Once the ransomware is detected, the covered entity or business associate must initiate its security incident and response and reporting procedures. See 45 C.F.R. 164.308(a)(6).
However, it also mentions that any unauthorized affect on ePHI must be reported as a HIPAA breach.
Whether or not the presence of ransomware would be a breach under the HIPAA Rules is a fact-specific determination. A breach under the HIPAA Rules is defined as, “…the acquisition, access, use, or disclosure of PHI in a manner not permitted under the [HIPAA Privacy Rule] which compromises the security or privacy of the PHI.” See 45 C.F.R. 164.402.6
When electronic protected health information (ePHI) is encrypted as the result of a ransomware attack, a breach has occurred [emphasis added] because the ePHI encrypted by the ransomware was acquired (i.e., unauthorized individuals have taken possession or control of the information), and thus is a “disclosure” not permitted under the HIPAA Privacy Rule.
Unless the covered entity or business associate can demonstrate that there is a “…low probability that the PHI has been compromised,” based on the factors set forth in the Breach Notification Rule, a breach of PHI is presumed to have occurred [emphasis added]. The entity must then comply with the applicable breach notification provisions, including notification to affected individuals without unreasonable delay, to the Secretary of HHS, and to the media (for breaches affecting over 500 individuals) in accordance with HIPAA breach notification requirements. See 45 C.F.R. 164.400-414.
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To demonstrate that there is a low probability that the protected health information (PHI) has been compromised because of a breach, a risk assessment considering at least the following four factors (see 45 C.F.R. 164.402(2)) must be conducted:
1. the nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification;
2. the unauthorized person who used the PHI or to whom the disclosure was made;
3. whether the PHI was actually acquired or viewed; and
4. the extent to which the risk to the PHI has been mitigated.
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Although entities are required to consider the four factors listed above in conducting their risk assessments to determine whether there is a low probability of compromise of the ePHI, entities are encouraged to consider additional factors, as needed, to appropriately evaluate the risk that the PHI has been compromised. If, for example, there is high risk of unavailability of the data, or high risk to the integrity of the data, such additional factors may indicate compromise. In those cases, entities must provide notification to individuals without unreasonable delay, particularly given that any delay may impact healthcare service and patient safety.
The information security field tends to think of a breach as a loss of confidentiality. However, this document makes it clear that HHS considers a loss of integrity and/or availability to be a breach as well. Check out my guide for strategic defenses against ransomware.
Image credit: Tom Magliery. Some rights reserved.