HIPAA News for Small and Mid-Sized Practices

Ursnif Trojan Steals Contacts and Sends Spear Phishing Emails

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The banking Trojan Ursnif, one of the most commonly used banking Trojans, has previously been used to attack financial institutions. However, it would appear the actors behind the malware have broadened their horizons, with attacks now being conducted on a wide range of organizations across many different industries, including healthcare.

The new version of the Ursnif Trojan was detected by researchers at security firm Barkly. The malware arrived in a phishing email that appeared to have been sent in response to a message sent to another organization.

The spear phishing email included the message thread from past conversations, suggesting the email account of the contact had been compromised. The email contained a Word document as an attachment with the message “Morning, Please see attached and confirm.”  While such a message would arouse suspicion if that was the only content in the email body, the inclusion of the message thread added legitimacy to the email.

The document contained a malicious macro that ran Powershell commands which tried to download the malicious payload; however, in contrast to many malware campaigns, rather than running the macro immediately, it is not run until the Word document is closed – an anti-sandbox technique.

If the payload is downloaded, in addition to the user’s device being compromised, their email account will be used to send out further spear phishing emails to all of that user’s contacts.

Barkly notes that If installed, the malware can perform man-in-the-middle attacks and can steal information as it is entered into the browser. The purpose of the Ursnif Trojan is to steal a wide range of credentials, including bank account information and credit card details. Ursnif Trojan is also able to take screenshots from the user’s device and log keystrokes.

Barkly reports that this is not the first time the firm has identified malware campaigns that use this tactic to spread malware, but this is the first time that the Ursnif Trojan has been used in this way, showing the threat is evolving.

Since the emails appear to come from a trusted sender, and include message threads, the likelihood of the emails and attachments being opened is far greater.

Barky reports that currently the malware is not being picked up by many anti-virus solutions, and its ability to delete itself after executing makes the threat hard to detect and analyze.

Further details on the threat, including the domains used by the malware and SHA256 hashes for the Word document, Macro, and Ursnif payload can be found on this link.

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How Can Healthcare Organizations Prevent Phishing Attacks?

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The threat from phishing is greater than ever before. Healthcare organizations must now invest heavily in phishing defenses to counter the threat and prevent phishing attacks and the theft of credentials and protected health information.

Phishing on an Industrial Scale

More phishing websites are being developed than ever before. The scale of the problem was highlighted in the Q3 Quarterly Threat Trends Report from Webroot. In December 2016, Webroot reported there were more than 13,000 new phishing websites created every day – Around 390,000 new phishing webpages every month. By Q3, 2017, that figure had risen to more than 46,000 new phishing webpages a day – around 1,385,000 per month. The report indicated 63% of companies surveyed had experienced a phishing related security incident in the past two years.

Phishing webpages need to be created on that scale as they are now detected much more rapidly and added to blacklists. Phishing websites now typically remain active for between 4-6 hours, although that short time frame is sufficient for each site to capture many users’ credentials. Many of those websites also have an SSL certificate, so they appear to users to be secure websites. A website starting with HTTPS is no guarantee that it is not being used for phishing.

Study Provides Insight into Phishing Tactics

While phishers often use their own domains to phish for credentials, a recent report from Duo Security showed legitimate websites are increasingly being compromised and loaded with phishing kits. The study identified more than 3,200 unique fishing kits spread across 66,000 URLs. These phishing kits are being traded on underground marketplaces and sold to accomplished phishers and wannabe cybercriminals. 16% of those URLs were on HTTPS websites.

Duo Security notes that persistence is maintained by creating a .htaccess file that blocks the IP addresses of threat intelligence gathering firms to prevent detection. The Webroot report also highlighted an increase in the use of benign domains for phishing.

The phishing kits are typically loaded into the wp-content, wp-includes, and wp-admin paths of WordPress sites, and the signin, images, js, home, myaccount, and css folders on other sites. Organizations should monitor for file changes in those directories to ensure their sites are not hijacked by phishers. Strong passwords should also be used along with non-standard usernames and rate limiting on login attempts to improve resilience against brute force attacks.

How to Prevent Phishing Attacks

Unfortunately, there is no single solution that will allow organizations to prevent phishing attacks, although it is possible to reduce risk to an acceptable level. In the healthcare industry, phishing defenses are a requirement of HIPAA and steps must be taken to reduce risk to a reasonable and acceptable level. The failure to address the risk from phishing can result in financial penalties for noncompliance.

Defenses should include a combination of technological solutions to prevent the delivery of phishing emails and to block access to phishing URLs. Employees must also receive regular training to help them identify phishing emails.

As OCR pointed out in its July Cybersecurity newsletter, HIPAA (45 C.F.R. § 164.308(a)(5)(i)) requires organizations to provide regular security awareness training to employees to help prevent phishing attacks. OCR explained that “An organization’s training program should be an ongoing, evolving process and flexible enough to educate workforce members on new cybersecurity threats and how to respond to them.”

Due to the increased use of HTTPS, it is no longer sufficient for users to check that the site is secure to avoid phishing scams. While a site starting with HTTPS does give an indication that the site is secure, it is important that end users do not automatically trust those websites and let their guard down. Just because a website has an SSL certificate it does not mean it can be trusted. Users should also be told to pay particular attention to the domain name to make sure that they are visiting their intended website, and always to exercise caution before deciding to disclose any login credentials.

Even with security awareness training, employees cannot be expected to recognize all phishing attempts. Phishers are developing increasingly sophisticated phishing emails that are barely distinguishable from genuine emails. Websites are harder to identify as malicious, emails are well written and convincing, and corporate branding and logos are often used to fool end users. Technological solutions are therefore required to reduce the number of emails that reach inboxes, and to prevent users from visiting malicious links when they do.

A spam filtering solution is essential for reducing the volume of emails that are delivered. Organizations should also consider using a web filtering solution that can block access to known phishing websites. The most effective real-time URL filtering solutions do not rely on blacklists and banned IP addresses to block attacks. Blacklists still have their uses and can prevent phishing attacks, but phishing websites are typically only active for a few hours – Before the sites are identified as malicious and added to blacklists. A range of additional detection mechanisms are required to block phishing websites. Due to the increase in phishing sites on secure websites, web filters should be able to decrypt, scan, and re-encrypt web traffic.

Healthcare organizations should also sign up to threat intelligence services to receive alerts about industry-specific attacks. To avoid being swamped with irrelevant threat information, services should be tailored to ensure only treat information relevant to each organization is received.

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Is G Suite HIPAA Compliant?

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Is G Suite HIPAA compliant? Can G Suite be used by HIPAA-covered entities without violating HIPAA Rules?

Google has developed G Suite to include privacy and security protections to keep data secure, and those protections are of a sufficiently high standard to meet the requirements of the HIPAA Security Rule. Google will also sign a business associate agreement (BAA) with HIPAA covered entities. So, is G Suite HIPAA compliant? G Suite can be used without violating HIPAA Rules, but HIPAA compliance is more about the user than the cloud service provider.

Making G Suite HIPAA Compliant (by default it isn’t)

As with any secure cloud service or platform, it is possible to use it in a manner that violates HIPAA Rules. In the case of G Suite, all the safeguards are in place to allow HIPAA covered entities to use G Suite in a HIPAA compliant manner, but it is up to the covered entity to ensure that G Suite is configured correctly. It is possible to use G Suite and violate HIPAA Rules.

Obtain a BAA from Google

One important requirement of HIPAA is to obtain a signed, HIPAA-compliant business associate agreement (BAA).

Google first agreed to sign a business associate agreement with healthcare organizations in 2013, back when G Suite was known as Google Apps. The BAA must be obtained prior to G Suite being used to store, maintain, or transmit electronic protected health information. Even though privacy and security controls are in place, the failure to obtain a BAA would be a HIPAA violation.

Obtaining a signed BAA from Google is the first step toward HIPAA compliance, but a BAA alone will not guarantee compliance with HIPAA Rules.

Configure Access Controls

Before G Suite can be used with any ePHI, the G Suite account and services must be configured correctly via the admin console. Access controls must be set up to restrict access to the services that are used with PHI to authorized individuals only. You should set up user groups, as this is the easiest way of providing – and blocking – access to PHI, and logs and alerts must be also be configured.

You should also make sure all additional services are switched off if they are not required, switch on services that include PHI ‘on for some organizations,’ and services that do not involve PHI can be switched on for everyone.

Set Device Controls

HIPAA-covered entities must also ensure that the devices that are used to access G Suite include appropriate security controls. For example, if a smartphone can be used to access G Suite, if that device is lost or stolen, it should not be possible for the device to be used by unauthorized individuals. A login must be required to be entered on all mobiles before access to G Suite is granted, and devices configured to automatically lock. Technology that allows the remote erasure of all data (PHI) stored on mobile devices should also be considered. HIPAA-covered entities should also set up two-factor authentication.

Not All Google Services are Covered by the BAA

You may want to use certain Google services even if they are not covered by the BAA, but those services cannot be used for storing or communicating PHI. For example, Google+ and Google Talk are not included in the BAA and cannot be used with any PHI.

If you do decide to leave these services on, you must ensure that your policies prohibit the use of PHI with these services and that those policies are effectively communicated to all employees. Employees must also receive training on G Suite with respect to PHI to ensure HIPAA Rules are not accidentally violated.

What Services in G Suite are HIPAA Compliant?

At the time of writing, only the following core services of G Suite are covered by Google’s BAA, and can therefore be used with PHI:

  • Gmail (Not free Gmail accounts)
  • Calendar
  • Drive
  • Apps Script
  • Keep
  • Sites
  • Jamboard
  • Hangouts (Chat messaging only)
  • Google Cloud Search
  • Vault

Google Drive

In the case of Google Drive, it is essential to limit sharing to specific people. Otherwise it is possible that folders and files could be accessed by anyone over the Internet> drives should be configured to only allow access by specific individuals or groups. Any files uploaded to Google Drive should not include any PHI in titles of files, folders, or Team Drives.

Gmail

Gmail, the free email service offered by Google, is not the same as G Suite. Simply using a Gmail account (@gmail.com) to send PHI is not permitted. The content of Gmail messages is scanned by third parties. If PHI is included, it is potentially being ‘accessed’ by third parties, and deleting an email does not guarantee removal from Google’s servers. Free Gmail accounts are not HIPAA compliant.

G Suite HIPAA Compliance is the Responsibility of Users

Google encourages healthcare organizations to use G Suite and has done what it can to make G Suite HIPAA compliant, but Google clearly states it is the responsibility of the user to ensure that the requirements of HIPAA are satisfied.

Google help healthcare organziations make G Suite HIPAA compliant, Google has developed guidance for healthcare organizations on setting up G Suite: See Google’s G Suite HIPAA Implementation Guide.

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Stop Hacks and Improve Electronic Data Security Act (SHIELD Act) Introduced by NY AG

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The Stop Hacks and Improve Electronic Data Security Act (SHIELD Act) has been introduced into the legislature in New York by Attorney General Eric T. Schneiderman. The aim of the act is to protect New Yorkers from needless breaches of their personal information and to ensure they are notified when such breaches occur.

The program bill, which was sponsored by Senator David Carlucci (D-Clarkstown) and Assembly member Brian Kavanagh (D-Manhattan), is intended to improve protections for New York residents without placing an unnecessary burden on businesses.

The introduction of the SHIELD Act comes weeks after the announcement of the Equifax data breach which impacted more than 8 million New Yorkers. In 2016, more than 1,300 data breaches were reported to the New York attorney general’s office – a 60% increase in breaches from the previous year.

Attorney General Schneiderman explained that New York’s data security laws are “weak and outdated” and require an urgent update. While federal laws require some organizations to implement data security controls, in New York, there are no obligations for businesses to implement safeguards to secure the personal identifying information of New Yorkers if the data held on residents does not include a Social Security number.

The SHIELD Act will require all businesses, regardless of where they are based, to adopt reasonable administrative, physical, and technical safeguards for if they hold the sensitive data of New Yorkers. The laws will also apply if entities do not do business in the state of New York.

While many states have introduced data breach notification laws that require individuals impacted by breaches of information such as username/password combos and biometric data to be notified of the incidents, in New York, there are no such requirements. The Shield Act will change that and bring state laws in line with many other U.S. states.

Breach notification requirements will be updated to include breaches of username/password combos, biometric data, and protected health information covered by HIPAA laws. Breach notifications will be required if unauthorized individuals are discovered to have gained access to personal information as well as in cases of data theft.

Attorney General Schneiderman is encouraging businesses to go above and beyond the requirements of the SHIRLD Act and receive independent certification of their security controls to make sure they exceed the minimum required standards.

A flexible standard is being introduced for small businesses to ease the regulatory burden. Safeguards can be appropriate to the organization’s size for businesses employing fewer than 50 members of staff if gross revenue is under $3 million or they have less than $5 million in assets.

HIPAA-covered entities, organizations compliant with the Gramm-Leach-Bliley, and NYS DFS regulations will be deemed to already be compliant with the data security requirements of the SHIELD Act.

The failure to comply with the provisions of the SHIELD Act will be deemed to be a violation of General Business Law (GBL § 349) and will allow the state attorney general to bring suit and seek civil penalties under GBL § 350(d).

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HIMSS Draws Attention to Five Current Cybersecurity Threats

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In its October Cybersecurity report, HIMSS draws attention to five current cybersecurity threats that could potentially be used against healthcare organizations to gain access to networks and protected health information.

Wi-Fi Attacks

Security researchers have identified a new attack method called a key reinstallation (CRACK) attack that can be conducted on WiFi networks using the WPA2 protocol. These attacks take advantage of a flaw in the way the protocol performs a 4-way handshake when a user attempts to connect to the network. By manipulating and replaying the cryptographic handshake messages, it would be possible to reinstall a key that was already in use and to intercept all communications. The use of a VPN when using Wi-Fi networks is strongly recommended to limit the potential for this attack scenario and man-in-the-middle attacks.

BadRabbit Ransomware

Limited BadRabbit ransomware attacks have occurred in the United States, although the NotPetya style ransomware attacks have been extensive in Ukraine. As with NotPetya, it is believed the intention is to cause disruption rather than for financial gain. The attacks are now known to use NSA exploits that were also used in other global ransomware attacks. Mitigations include ensuring software and operating systems are kept 100% up to date and all patches are applied promptly. It is also essential for that backups are regularly performed. Backups should be stored securely on at least two different media, with one copy stored securely offsite on an air-gapped device.

Advanced Persistent Threats

A campaign conducted by an APT group known as Dragonfly has been ongoing since at least May 2017. The APT group is targeting critical infrastructure organizations. The typical attack scenario is to target small networks with relatively poor security, and once access has been gained, to move laterally to major networks with high value assets. While the group has primarily been attacking the energy sector, the healthcare industry is also at risk. Further information on the threat and the indicators of compromise can be found on the US-CERT website.

DDE Attacks

In October, security researchers warned of the risk of Dynamic Data Exchange (DDE) attacks targeting Outlook users. This attack scenario involves the use of calendar invites sent via phishing emails. The invites are sent in Rich Text Format, and opening the invites could potentially result in the installation of malware. Sophos warned of the threat and suggested one possible mitigation is to view emails in plaintext. These attacks will present a warning indicating attachments and email and calendar invites contain links to other files. Users should click no when asked to update documents with data from the linked files.

Medical Device Security

HIMSS has drawn attention to the threat of attacks on medical devices, pointing out that these are a soft-spot and typically have poor cybersecurity protections. As was pointed out with the APT critical infrastructure attacks, it is these soft spots that malicious actors look to take advantage of to gain access to networks and data. HIMSS has warned healthcare organizations to heed the advice of analysts, who predict the devices will be targeted with ransomware. Steps should be taken to isolate the devices and back up any data stored on the devices, or the computers and networks to which they connect.

Medical device security was also the subject of the Office for Civil Rights October cybersecurity newsletter.

While not specifically mentioned in its list of current cybersecurity threats, the threat from phishing is ongoing and remains one of the most serious threats to the confidentiality, integrity, and availability of PHI. The threat can be reduced with anti-phishing defenses such as spam filtering software and with training to improve security awareness.

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Survey Reveals Sharing EHR Passwords is Commonplace

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While data on the practice of password sharing in healthcare is limited, one survey suggests the practice of sharing EHR passwords is commonplace, especially with interns, medical students, and nurses.

The research was conducted by Ayal Hassidim, MD of the Hadassah-Hebrew University Medical Center, Jerusalem, and also involved researchers from Duke University, Harvard Medical School, Ben Gurion University of the Negev, and Hadassah-Hebrew University Medical Center. The study was conducted on 299 medical students, nurses, medical residents, and interns and the results of the survey were recently published in Healthcare Informatics Research.

The information stored in EHRs is sensitive and must be protected. Regulations such as HIPAA control access to that information. All individuals that require access to the information in EHR systems must be issued with a unique user ID and password.

Any attempts to access protected health information must be logged to allow healthcare organizations to monitor for unauthorized access. If login credentials are shared with other individuals, it is no longer possible to accurately record which individuals have viewed health information – a violation of HIPAA Rules. The researchers note that sharing EHR passwords is one of the most common HIPAA violations and causes of healthcare data breaches.

The survey suggests that sharing EHR passwords is commonplace, even though the practice is prohibited by hospital policies and HIPAA Rules. 73% of all respondents admitted to using the password of another individual to access EHR records on at least one occasion. 57% of respondents estimated the number of times they had accessed EHR information – The average number of occasions was 4.75.

All medical students surveyed said they had accessed EHRs using the credentials of another individual, and 57% of nurses admitted to using another individual’s credentials to access EHRs. The reasons for doing so were highly varied.

Common reasons for sharing EHR passwords were permissions on the user’s account did not allow them to complete their work duties, technical problems prevented them from using their own credentials, and personal logins had not been issued, even though EHR access was required to complete work duties.

The researchers suggest the provision of timely and efficient care is often at odds with security protections. The researchers noted, “In an attempt to achieve better security, usability is hindered to the level the users feel that the right thing to do is to violate the security regulations altogether.”

The researchers made two recommendations: “Usability should be added as the fourth principal in planning EMRs and other PHI-containing medical records. Second, an additional option should be included for each EMR role that will grant it maximal privileges for one action. When this option is invoked, the senior physician/the PHI security officer would be informed. This would allow junior staff to perform urgent, lifesaving, decisions, without outwitting the EMR, and under formal retrospective supervision by the senior members in charge.”

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Tips for Reducing Mobile Device Security Risks

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An essential part of HIPAA compliance is reducing mobile device security risks to a reasonable and acceptable level.

As healthcare organizations turn to mobiles devices such as laptop computers, mobile phones, and tablets to improve efficiency and productivity, many are introducing risks that could all too easily result in a data breach and the exposure of protected health information (PHI).

As the breach reports submitted to the HHS’ Office for Civil Rights show, mobile devices are commonly involved in data breaches. Between January 2015 and the end of October 2017, 71 breaches have been reported to OCR that have involved mobile devices such as laptops, smartphones, tablets, and portable storage devices. Those breaches have resulted in the exposure of 1,303,760 patients and plan member records.

17 of those breaches have resulted in the exposure of more than 10,000 records, with the largest breach exposing 697,800 records. The majority of those breaches could have easily been avoided.
The Health Insurance Portability and Accountability Act (HIPAA) Security Rule does not demand encryption for mobile devices, yet such a security measure could have prevented a high percentage of the 71 data breaches reported to OCR.

When a mobile device containing ePHI is lost or stolen, the HIPAA Breach Notification Rule requires the breach to be reported and notifications to be sent to affected individuals. If PHI has been encrypted and a device containing ePHI is lost or stolen, notifications need not be sent as it would not be a HIPAA data breach. A breach report and patient notifications are only required for breaches of unencrypted PHI, unless the key to decrypt data is also obtained.

Even though HIPAA does not demand the use of encryption, it must be considered. If the decision is taken not to encrypt data, the decision must be documented and an alternative safeguard – or safeguards – must be employed to ensure the confidentiality, integrity, and availability of ePHI. That alternative safeguard(s) must provide a level of protection equivalent to encryption.

Before the decision about whether or not to encrypt data can be made, HIPAA covered entities must conduct an organization-wide risk analysis, which must include all mobile devices. All risks associated with the use of mobile devices must be assessed and mitigated – see 45 C.F.R. § 164.308(a)(1)(ii)(A)–(B).

OCR Reminds Covered Entities of Need to Address Risks Associated with Mobile Devices

In its October 2017 Cybersecurity Newsletter, OCR reminded covered entities of the risks associated with mobile devices that are used to create, receive, maintain, or transmit ePHI. HIPAA covered entities were reminded of the need to conduct an organization-wide risk assessment and develop a risk management plan to address all mobile device security risks identified during the risk analysis and reduce them to an appropriate and acceptable level.

While many covered entities allow the use of mobile devices, some prohibit the use of those devices to create, receive, maintain, or transmit ePHI. OCR reminds covered entities that if such a policy exists, it must be communicated to all staff and the policy must be enforced.

When mobile devices can be used to create, receive, maintain, or transmit ePHI, appropriate safeguards must be implemented to reduce risks to an appropriate and acceptable level. While loss or theft of mobile devices is an obvious risk, OCR draws attention to other risks associated with the devices, such as using them to access or send ePHI over unsecured Wi-Fi networks, viewing ePHI stored in the cloud, or accessing or sharing ePHI via file sharing services.

OCR also remined covered entities to ensure default settings on the devices are changed and how healthcare employees must be informed of mobile device security risks, taught best practices, and the correct way to uses the device to access, store, and transmit ePHI.

OCR offers the following advice to covered entities address mobile security risks and keep ePHI secure at all times.

To access OCR’s guidance – Click here.

OCR’s Tips for Reducing Mobile Device Security Risks

  • Implement policies and procedures regarding the use of mobile devices in the work place – especially when used to create, receive, maintain, or transmit ePHI.
  • Consider using Mobile Device Management (MDM) software to manage and secure mobile devices.
  • Install or enable automatic lock/logoff functionality.
  • Require authentication to use or unlock mobile devices.
  • Regularly install security patches and updates.
  • Install or enable encryption, anti-virus/anti-malware software, and remote wipe capabilities.
  • Use a privacy screen to prevent people close by from reading information on your screen.
  • Use only secure Wi-Fi connections.
  • Use a secure Virtual Private Network (VPN).
  • Reduce risks posed by third-party apps by prohibiting the downloading of third-party apps, using whitelisting to allow installation of only approved apps, securely separating ePHI from apps, and verifying that apps only have the minimum necessary permissions required.
  • Securely delete all PHI stored on a mobile device before discarding or reusing the mobile device.
  • Include training on how to securely use mobile devices in workforce training programs.

Penalties for Failing to Address Mobile Security Risks

The failure to address mobile device security risks could result in a data breach and a penalty for noncompliance with HIPAA Rules. Over the past few years there have been several settlements reached between OCR and HIPAA covered entities for the failure to address mobile device security risks.

These include:

Covered Entity HIPAA Violation Individuals Impacted Penalty
Children’s Medical Center of Dallas Theft of unencrypted devices 6,262 $3.2 million
Oregon Health & Science University Loss of unencrypted laptop / Storage on cloud server without BAA 4,361 $2,700,000
Cardionet Theft of an unencrypted laptop computer 1,391 $2.5 million
Catholic Health Care Services of the Archdiocese of Philadelphia Theft of mobile device 412 $650,000

Addressing Mobile Device Security Risks

Mobile device security risks must be reduced to a reasonable and appropriate level.  Some of the mobile device security risks, together with mitigations, have been summarized in the infographic below. (Click image to enlarge)

mobile device security risks

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OCR Clarifies HIPAA Rules on Sharing Patient Information After Opioid Overdose

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The U.S. Department of Health and Human Services’ Office for Civil Rights has cleared confusion about HIPAA Rules on sharing patient information after an opioid overdose. The HIPAA Privacy Rule permits healthcare providers to share limited PHI in certain emergency and dangerous situations. Those situations include natural disasters and during drug overdoses, if sharing information can prevent or lessen a serious and imminent threat to a patient’s health or safety.

Some healthcare providers have misunderstood the HIPAA Privacy Rule provisions, and believe permission to disclose information to the patient’s loved ones or caregivers must be obtained from the patient before any PHI can be disclosed.

In an emergency or crisis situation, such as during a drug overdose, healthcare providers are permitted to share limited PHI with a patient’s loved ones and caregivers without permission first having been obtained from the patient.

During an opioid overdose, healthcare providers can share health information with the patient’s family members, close friends, and caregivers if:

  • The healthcare provider determines, based on professional judgement, that sharing information about an incapacitated or unconscious patient is in the best interests of the patient, provided the information shared is limited to that directly related to the individual’s involvement in the patient’s care or payment of care. Information on the overdose can be shared, but not unrelated health information unless permission has been obtained.
  • Informing the above individuals would help to prevent or lessen a serious threat to the patient’s health and safety – Such as continued opioid abuse on discharge.

In cases when a patient is not unconscious or incapacitated and has decision-making capability, healthcare providers must give the patient the opportunity to object to the disclosure of their overdose to loved ones, close friends, caregivers, or individuals involved in the payment for care. If a patient has decision making capability, or if permission to share the information is denied, healthcare providers cannot share information unless “there is a serious and imminent threat of harm to health.”

There will be situations when a patient is only temporarily incapacitated, and their decision-making capability will be recovered during the course of treatment. In such cases, it is down to the discretion of the healthcare provider whether health information is shared while the patient is incapacitated, the type of information that is shared, and how much. When the patient regains consciousness and decision-making capability, permission must then be obtained before any further disclosures of health information are made.

OCR also points out that it is not only HIPAA Rules that may apply in such situations, explaining “HIPAA does not interfere with state laws or medical ethics rules that are more protective of patient privacy.”

The guidance on HIPAA Rules on sharing patient information after opioid overdose can be viewed on this link.

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Phishing Attacks Using Malicious URLs Rose 600 Percent in Q3, 2017

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As recent healthcare breach notices have shown, phishing poses a major threat to the confidentiality of protected health information (PHI). The past few weeks have seen several healthcare organizations announce email accounts containing the PHI of thousands of patients have been accessed by unauthorized individuals as a result of healthcare employees responding to phishing emails.

Report Shows Massive Rise in Phishing Attacks Using Malicious URLs

This week has seen the publication of a new report that confirms there has been a major increase in malicious email volume over the past few months.

Proofpoint’s Quarterly Threat Report, published on October 26, shows malicious email volume soared in quarter 3, 2017. Compared to the volume of malicious emails recorded in quarter 2, there was an 85% rise in malicious emails in Q3.

While attachments have long been used to deliver malware downloaders and other malicious code, Q3 saw a massive rise in phishing attacks using malicious URLs. Clicking those links directs end users to websites where malware is downloaded or login credentials are harvested.

Proofpoint’s analysis shows there was a staggering 600% increase in phishing attacks using malicious URLs in Q3. Compared to 2016, the use of malicious URLs has increased by a staggering 2,200%. The volume of malicious emails has not been that high since 2014.

Locky is Back With a Vengeance

For its report, Proofpoint analyzed more than one billion emails and hundreds of millions of social media posts, and identified and analyzed more than 150 million malware samples.

Out of all of the email threats analyzed, 64% were used to deliver ransomware. At the start of the year, Cerber ransomware was the biggest ransomware threat, having taken over from Locky, but in Q3, Locky came back with a vengeance. Locky ransomware accounted for 55% of all malicious payloads and 86% of all ransomware payloads. There were also notable increases in other ransomware variants, including Philadelphia and Globelmposter.

The second biggest threat was banking Trojans, which accounted for 24% of all malicious payloads. Proofpoint’s report shows the Dridex Trojan has fallen out of favor somewhat, with The Trick now the biggest threat in this category. Downloaders accounted for 6% of malicious emails and information stealers 5%.

In the first half of 2016, exploit kits were being extensively used to deliver malware and ransomware, although exploit kit activity dwindled throughout the year and all but stopped by 2017. However, exploit kit activity is climbing once again, with the Rig the most commonly used exploit kit. Proofpoint notes that rather than just using exploits, the actors behind these EKs are now incorporating social engineering techniques into their campaigns to fool users into downloading malware.

Social media attacks also rose, in particular so called “angler attacks” via Twitter. These attacks involve the registration of bogus support accounts. Twitter is monitored for customers who are experiencing difficulty with software, and when a complaint is made, the user is sent a tweet from the bogus account containing malicious links.

Proofpoint also noted a 12% rise in email fraud in Q3, up 32% from last year, and a notable rise in typosquatting and domain spoofing. The registration of suspicious domains now outnumbers defensive domain registrations by 20 to 1.

The advice to all organizations is to implement robust spam filtering software to block malicious emails, use solutions to block malicious URLS such as web filters, use email authentication to stop domain spoofing, and to take steps to protect brands on social media. The risk from look-alike domains can be greatly reduced with defense domain purchases – registering all similar domains before the typosquatters do.

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