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PATRICK	ROUGEAU	
Compliance	Officer	
MARC	HASKELSON	
President	&	CEO
Horror	Story	—		
The	$750,000	HIPAA	Mistake	
Recent	HIPAA	Trends	—		
and	What	They	Mean	for	Your	Business	
What	Does	HIPAA	Require?	
How	Does	My	Current	ProtecLon	Level		
Measure	Up	to	These	Requirements?	
How	Do	I	Bridge	the	Gap?
The	$750,000	HIPAA	Mistake	
University	of	Washington	2013	Breach	
ü  School	of	Medicine	employee	accidentally	
downloads	malware	
ü  Health	rec	ords	of	90,000	paLents	are	
breached	
ü  OCR	invesLgates,	discovers	other										
HIPAA	Security	Rule	violaEons	
ü  UW	forced	to	pay	$750,000	in	fines		
Source:	Healthcare	IT	News
Recent	HIPAA	Trends	—		
and	What	They	Mean	for	You	
The	5	Leading	HIPAA	ViolaEons	
Source:	NueMD	
5.				Third-Party	Disclosure	
	
4.				Improper	Disposal	
	
3.				Employee	Dishonesty	
	
2.				Hacking	
…	
1.				Lost	or	Stolen	Devices
Recent	HIPAA	Trends	—		
and	What	They	Mean	for	You	
Enforcement	is	on	the	Rise	
Source:	HHS.gov	
		2003*								2004									2005									2006									2007									2008								2009										2010											2011											2012											2013									2014												
*	ParAal	Year
Recent	HIPAA	Trends	—		
and	What	They	Mean	for	You	
2015:	Biggest	Year	Ever	for	ePHI	Breaches	(and	“Security	Rule”	ViolaEons)	
Source:	Forbes	
All	potenEal	violaEons	of		
the	HIPAA	Security	Rule
Is	Your	ePHI	in	ViolaAon…	Here?	
What	if	your	physician	
accesses	PHI	on	a	device	
outside	your	firewall	—	
and	the	data	is	hacked?	
of	medical	doctors	use	
mobile	devices	to	access	
ePHI	such	as	paLent	
records.	
81%	
Source:	American	Bar	AssociaLon	
of	HIPAA	violaLons	
involve	lost	or	stolen	
mobile	devices.	
40%
What	Does	HIPAA	Actually	Require?	
Technical	Safeguards	
ü  Have	I	established	and	implemented	
procedures	to	create	and	maintain	
retrievable	exact	copies	of	ePHI?	
ü  Have	I	established	procedures	to	restore	
ANY	loss	of	ePHI	stored	electronically?	
ü  Have	I	implemented	a	mechanism	to	
encrypt	ePHI?
What	Does	HIPAA	Actually	Require?	
ü  Is	my	data	securely	stored	in	an	offsite	
locaLon?	
ü  Have	I	implemented	policies	and	
procedures	to	restrict	access	to	ePHI	
ü  Have	I	limited	physical	access	to	electronic	
informaLon	systems	at	the	faciliLes	my	
ePHI	is	being	housed?	
ü  Have	I	implemented	procedures	to	
securely	terminate	ePHI	–	both	electronic	
and	physical	
Physical	Safeguards
What	Does	HIPAA	Actually	Require?	
ü  Have	I	conducted	a	risk	analysis	to	expose	
potenLal	security	violaLons	
ü  Have	I	established	procedures	to	enable	
business	conLnuity	in	the	event	of	an	
emergency?	
ü  Have	I	implemented	procedures	for	
periodic	tesLng	and	revision	of	my	
conLnuity	plan?	
AdministraEve	Safeguards
How	Does	My	Current		
ProtecAon	Level	Measure	Up?	
Define	the	Scope		
of	Your	Audit	
Where	is	my	ePHI	data	located?	
What	are	security	parameters?	
Who	has	access	to	it?	
Can	I	track	potenLal	IT	incidents?	
Are	my	employees	trained?	
Have	I	undertaken	a	risk	analysis?
How	Does	My	Current		
ProtecAon	Level	Measure	Up?	
Define	the	Scope		
of	Your	Audit	
Desktops	and	laptops	
What	assets	store	or	access	ePHI?	
Servers	
External	hard	drives	
Cloud	applicaLons	(like	Office	365)	
Company	phones	
Emails	
Business	associates
How	Does	My	Current		
ProtecAon	Level	Measure	Up?	
IdenEfy	Threats	
to	These	Assets	
Can	they	be	picked	up	and	removed?	
Common	Physical	threats	
Secure	Access	
Data	backups?	Where?	Who	can	access?	
Employees	
Natural	disasters	
Hardware	
Passwords
How	Does	My	Current		
ProtecAon	Level	Measure	Up?	
IdenEfy	Threats	
to	These	Assets	
Virus	
Common	Virtual	Threats	
Phishing	
Spyware	
Cyber	Crime	
Trojans
Bridging	the	Gap	
From	your	current	
protecLon	level…	 to	HIPAA	compliance.
1.	Develop	ConEngency	OperaEons
Cloud	Backup	 Tapes	&	Disks	
Develop	ConEngency	OperaEons
2.	Develop	a	Business	ConEnuity	Plan
3.	Encrypt	Your	Data	
Both	in	flight	and	at	rest.	
HIPAA	Security	Rule:	
45	CFR	§	164.304		
NIST	encrypLon	standards		
for	ePHI	in	moLon…	
NIST	encrypLon	standards		
for	ePHI	at	rest…	
“…	requires	appropriate	administraLve,		
physical	and	technical	safeguards	to	ensure	
the	confidenLality,	integrity,	and	security	of	
electronic	protected	health	informaLon.”	
TLS	encrypEon	
AES	256-bit	encrypEon	
Source:	NaLonal	InsLtute	of	Science	and	Technology
4.	Use	Vendors	With	Dependable	Infrastructure	
Source:	NaLonal	InsLtute	of	Science	and	Technology	
ü  Facility	Security	Plan	 ü  Secure	Data	Centers		 ü  Access	Control
5.	Ensure	You’re	Properly	Disposing	of	ePHI	
Security	implicaLons	&	HIPAA-compliance	implicaLons
6.	IdenEfy	the	Right	Business	Associates	
Not	just	any	BA	—		
but	the	right	one.	 of	ePHI	breaches	are	the	fault	
of	a	Business	Associate.	
30%	
Source:	Ponemon	InsLtute,	Third	Annual	Benchmark	Study	on	PaLent	Privacy	&	Data	Security
Don’t	Take	on	the	ePHI	Risk	Alone…	
Trust	the	Experts	
Technical	Safeguards	
ISO-27001	CerLficaLon	
256-AES	EncrypLon	
Endpoint	EncrypLon	
Physical	Safeguards	
Redundant	Ler-4	data	centers	
Secured	in	the	cloud	
24/7	live	support	
AdministraEve	Safeguards	
Business	Associate	Agreements	
Fully	Managed	and	Monitored	
Policies	and	Procedures	Dedicated	to	ePHI
Securing	Your	ePHI	in	the	cloud	 Achieve	HIPAA	Compliance	Today!	
Compliance	QuesAons?	
For	more	informaAon,	contact:	
646-747-0556	
patrick.rougeau@keepitsafe.com	
855-854-4722	ext	507	
marc@compliancygroup.com	
MARC	HASKELSON	PATRICK	ROUGEAU

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