Idaho State University (ISU) has agreed to pay $400,000 to the U.S. Department of Health Human Services (HHS) to settle alleged violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule. The settlement involves the breach of unsecured electronic protected health information (ePHI) of approximately 17,500 patients at ISU’s Pocatello Family Medicine Clinic. That breach was reported on this blog in August 2011.
ISU operates 29 outpatient clinics and is responsible for providing health information technology systems security at those clinics. Between four and eight of those ISU clinics are subject to the HIPAA Privacy and Security Rules, including the clinic where the breach occurred.
The HHS Office for Civil Rights (OCR) opened an investigation after ISU notified HHS of the breach in which the ePHI of approximately 17,500 patients was unsecured for at least 10 months, due to the disabling of firewall protections at servers maintained by ISU. OCR’s investigation indicated that ISU’s risk analyses and assessments of its clinics were incomplete and inadequately identified potential risks or vulnerabilities. ISU also failed to assess the likelihood of potential risks occurring:
i. ISU did not conduct an analysis of the risk to the confidentiality of ePHI as part of its security management process from April 1, 2007 until November 26, 2012;
ii. ISU did not adequately implement security measures sufficient to reduce the risks and vulnerabilities to a reasonable and appropriate level from April 1, 2007 until November 26, 2012; and
iii. ISU did not adequately implement procedures to regularly review records of information system activity to determine if any ePHI was used or disclosed in an inappropriate manner from April 1, 2007 until June 6, 2012.
OCR concluded that ISU did not apply proper security measures and policies to address risks to ePHI and did not have procedures for routine review of their information system in place, which could have detected the firewall breach much sooner.
“Risk analysis, ongoing risk management, and routine information system reviews are the cornerstones of an effective HIPAA security compliance program,” said OCR Director Leon Rodriguez. “Proper security measures and policies help mitigate potential risk to patient information.”
ISU has agreed to a comprehensive corrective action plan to address the issues uncovered by the investigation and its failure to ensure uniform implementation of required HIPAA Security Rule protections at each of its covered clinics.
The Resolution Agreement does not constitute an admission of liability by ISU.