On May 7, 2014, the U.S. Department of Health and Human Services Office for Civil Rights ("OCR") announced the largest settlement to date under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). New York and Presbyterian Hospital ("NYP") and Columbia University ("Columbia") agreed to pay $4.8 million and enter into resolution agreements as the result of a breach of NYP's data system resulting in the disclosure of personal information of 6,800 patients.
NYP and Columbia are each covered entities under HIPAA and participate in a joint arrangement where they operate a shared data network and a shared network firewall that is administered by employees of both entities. The shared network links to NYP patient information systems containing electronic protected health information ("e-PHI").
The breach occurred when a Columbia physician tried to deactivate a personally-owned computer server on the network containing the e-PHI of NYP patients. According to OCR, due to a lack of technical safeguards, deactivation of the server resulted in e-PHI being accessible on internet search engines. NYP and Columbia learned of the breach after receiving a complaint from an individual who found the e-PHI of the individual's deceased partner, a former patient of NYP, on the internet. The OCR investigation revealed that neither NYP or Columbia made efforts before the breach to ensure that the server was secure and contained appropriate software protections, and neither entity conducted an accurate risk analysis that identified all systems that access patients' e-PHI.
Under the settlement agreement, NYP will pay $3,300,000 and Columbia will pay $1,500,000. Also, the entities entered into separate resolution agreements that require corrective action. The corrective steps that NYP must take include:
Modify its existing risk analysis process, including developing a complete inventory of all electronic equipment, data systems, and applications that contain or store e-PHI;
Develop and implement a risk management plan to address and mitigate security risks and vulnerabilities found in the risk analysis. The plan must be reviewed by OCR;
Review and revise policies and procedures for authorizing access to NYP e-PHI;
Implement a process for evaluating environmental and operational changes that affect the security of NYP e-PHI;
Review and revise policies and procedures on device and media controls, including identifying criteria for the use of such devices and procedures for obtaining authorization for the use of personal devices and media that use NYP e-PHI systems;
Develop an enhanced privacy and security awareness training program to train workforce members and affiliated staff on the necessity of prohibitions on the purchase, use or administration of computer equipment that accesses NYP e-PHI, except under the explicit management of NYP IT personnel.
Columbia must take many of the same corrective steps. NYP's corrective action plan also requires it to collaborate with Columbia to implement the corrective actions described above.
In addition to being the largest HIPAA settlement to date, this is the first settlement involving multiple covered entities. According to a statement by an OCR spokeswoman, "When entities participate in joint compliance arrangements, they share the burden of addressing the risks to [PHI]. Our cases against NYP and [Columbia] should remind health care organizations of the need to make data security central to how they manage their information systems."
This settlement is another reminder of the importance that OCR places on an accurate risk analysis that identifies all places within a system that e-PHI resides. To avoid shared settlement payments, covered entities that permit shared access to e-PHI should closely read the NYP and Columbia resolution agreements and implement the described action items.