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Creating an Effective 
Cyber Security Strategy 
________ 
Key Attributes for Success, Challenges and 
Critical Success Factors 
● Angela Duncan Diop, ND, CHCIO, VP of Information Systems 
Unity Health Care, Inc. ● 
A CHIME Leadership Education and Development Forum in collaboration with iHT2 
#LEAD14
ANATOMY OF A BREACH 
A CHIME Leadership Education and Development Forum in collaboration with iHT2
INTRODUCTION
Unity Health Care, Inc. 
Federally 
Qualified Health 
Center 
Over 100,000 
unique patients in 
2013 
30 sites; health 
centers, homeless 
service sites, 
school based 
health centers, 
correctional sites, 
and a mobile site 
Mission 
Promoting healthier communities through 
compassion and comprehensive health and human 
services, regardless of ability to pay. 
4
Unity’s Patients 
• Patient population is 
racially and ethnically 
diverse and largely 
minority 
• Substantial health 
disparities and poor 
health outcomes exist 
• Great need for accessible 
and comprehensive 
primary care services 
5
Data is like water – it always flows through the cracks 
THE INCIDENT
Description 
• A personal laptop 
containing data from a 
nutrition and exercise 
program 
• Student assisting in the 
analysis of data saved it 
to a flash drive. 
• Loaded to a personal 
computer. 
• Stolen from a student’s 
home in a burglary. 
FreeDigitalPhotos.net
Description 
• Type of Incident: Theft 
• Location of Breach: 
Laptop computer - 
unencripted 
• Approximate number 
of individuals affected 
by the breach: 305 
FreeDigitalPhotos.net
To breach or not to breach – that is the question. 
THE CALL
Type of PHI Involved 
• Demographic information – name and DOB 
• Clinical Information -diagnosis/conditions 
• The data consisted of names, dates of birth, 
weight, body mass index, and for a limited 
number of participants, information regarding 
a history of hypertension or diabetes.
Risk Assessment 
• Consulted our HIPAA auditor 
• Consulted our attorney 
• Met/discussed with our Executive 
Management team 
• Decided to treat the incident as a breach
Never let a good crisis go to waste 
THE RESPONSE
Created a Team 
• Appointed a breach 
response team 
– Privacy Officer 
– VP of Information Systems 
– Legal Counsel 
– VP of Clinical 
Administration 
– Deputy Chief Medical 
Officer 
– VP of Human Resources
Gap Analysis &Corrective Action 
Plan 
• Overall responsibility – 
Privacy Officer or VP of IS 
• Identifies the steps that 
led to incident 
• Captures key info 
surrounding the incident 
– Description 
– Issues/Gaps 
– Lead 
– Due date
Incident Response Plan 
• Plan that the team 
creates and follows to 
address the incident 
– Investigation 
– Risk Assessment 
– Notifications – 
Patients, HHS, Staff 
Exe Man Team, Exe. 
Board 
– Corrective actions
Milk the crisis for all it’s worth 
EPILOGUE
Benefits Gained 
• Blue print for responding to a breach 
• Breach team 
• Breach management policy 
• Breach insurance 
• Retraining of staff 
• Heightened awareness by senior leadership 
and Board
Q & A 
Angela Duncan Diop, ND, CHCIO 
adiop@unityhealthcare.org 
A CHIME Leadership Education and Development Forum in collaboration with iHT2 
@AngelaDiop 
@UnityHealthCare

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CHIME LEAD DC 2014 “Key Attributes for Success, Challenges and Critical Success Factors” with Angela Diop, ND, CHCIO, VP of Information Systems, Unity Health Care, Inc.

  • 1. Creating an Effective Cyber Security Strategy ________ Key Attributes for Success, Challenges and Critical Success Factors ● Angela Duncan Diop, ND, CHCIO, VP of Information Systems Unity Health Care, Inc. ● A CHIME Leadership Education and Development Forum in collaboration with iHT2 #LEAD14
  • 2. ANATOMY OF A BREACH A CHIME Leadership Education and Development Forum in collaboration with iHT2
  • 4. Unity Health Care, Inc. Federally Qualified Health Center Over 100,000 unique patients in 2013 30 sites; health centers, homeless service sites, school based health centers, correctional sites, and a mobile site Mission Promoting healthier communities through compassion and comprehensive health and human services, regardless of ability to pay. 4
  • 5. Unity’s Patients • Patient population is racially and ethnically diverse and largely minority • Substantial health disparities and poor health outcomes exist • Great need for accessible and comprehensive primary care services 5
  • 6. Data is like water – it always flows through the cracks THE INCIDENT
  • 7. Description • A personal laptop containing data from a nutrition and exercise program • Student assisting in the analysis of data saved it to a flash drive. • Loaded to a personal computer. • Stolen from a student’s home in a burglary. FreeDigitalPhotos.net
  • 8. Description • Type of Incident: Theft • Location of Breach: Laptop computer - unencripted • Approximate number of individuals affected by the breach: 305 FreeDigitalPhotos.net
  • 9. To breach or not to breach – that is the question. THE CALL
  • 10. Type of PHI Involved • Demographic information – name and DOB • Clinical Information -diagnosis/conditions • The data consisted of names, dates of birth, weight, body mass index, and for a limited number of participants, information regarding a history of hypertension or diabetes.
  • 11. Risk Assessment • Consulted our HIPAA auditor • Consulted our attorney • Met/discussed with our Executive Management team • Decided to treat the incident as a breach
  • 12. Never let a good crisis go to waste THE RESPONSE
  • 13. Created a Team • Appointed a breach response team – Privacy Officer – VP of Information Systems – Legal Counsel – VP of Clinical Administration – Deputy Chief Medical Officer – VP of Human Resources
  • 14. Gap Analysis &Corrective Action Plan • Overall responsibility – Privacy Officer or VP of IS • Identifies the steps that led to incident • Captures key info surrounding the incident – Description – Issues/Gaps – Lead – Due date
  • 15. Incident Response Plan • Plan that the team creates and follows to address the incident – Investigation – Risk Assessment – Notifications – Patients, HHS, Staff Exe Man Team, Exe. Board – Corrective actions
  • 16. Milk the crisis for all it’s worth EPILOGUE
  • 17. Benefits Gained • Blue print for responding to a breach • Breach team • Breach management policy • Breach insurance • Retraining of staff • Heightened awareness by senior leadership and Board
  • 18. Q & A Angela Duncan Diop, ND, CHCIO adiop@unityhealthcare.org A CHIME Leadership Education and Development Forum in collaboration with iHT2 @AngelaDiop @UnityHealthCare

Editor's Notes

  1. 4