business associate

In this series on establishing security classifications for your company’s information, last week’s post looked at one aspect – the widely varying definitions of Protected Information under state PII breach notification statutes. But if your organization is a covered entity or business associate under the Health Insurance Portability and Accountability Act (HIPAA), the definition of Protected Health information (PHI) is also a key puzzle piece for your classification scheme.

HIPAA establishes national standards for the use and disclosure of PHI, and also for the safeguarding of individuals’ electronic PHI, by covered entities and business associates. Merely having information commonly thought of as “protected health information” does not mean that HIPAA applies. And there are some surprises in which organizations are – and are not – covered by HIPAA. So, that’s the first question to answer – is your company a HIPAA covered entity or business associate?

My New Year’s resolutions will likely be broken early and often in 2016. My consequences are mostly non-monetary: a few more pounds, a little less savings, and not winning the triathlon in my age group. Your consequences, as a HIPAA-covered entity or business associate, for not complying with the Privacy and Security Rules could be much greater, and could put you into serious debt to the HHS Office of Civil Rights (OCR). Therefore, we propose that you resolve now to become fully HIPAA compliant in 2016.

OCR delivered an early holiday gift, wrapped in the Director’s Sept. 23, 2015, report to the Office of Inspector General. In that report, she disclosed that OCR will launch Phase 2 of its HIPAA audit program in early 2016, focusing on noncompliance issues for both covered entities and business associates.

So, grab that cup of hot cocoa and peruse this review of 2014-2015 HIPAA enforcement actions, which should help identify noncompliance issues on which OCR will focus in 2016. 

While data breaches have become a common occurrence, the epic breach of the Office of Personal Management (“OPM”) records stands out for many reasons. The hackers obtained PII on at least 21.5 million people and accessed highly confidential background check and security clearance information, including personal details such as fingerprint data and financial history. But what is most shocking is that the federal government was aware of security flaws within OPM’s computer system for years before the breach, yet never addressed those vulnerabilities.

 will be missed, but his wisdom will endure. Who else could have observed “No one goes there nowadays. It’s too crowded”? The information governance equivalent is “No one has information anymore. There’s too much of it.” In the last decade we have witnessed the systemic utilitization of computing power. Data used to be housed predominantly within a company’s own systems, but now, through remote storage, SaaS, PaaS, and other cloud solutions, more and more information is hosted by third-party providers. Also, as marketplace forces compel organizations to leverage or outsource functions that used to reside internally, operational service providers increasingly create, receive, maintain, and process information on the organization’s behalf.

It follows that information governance (the organization’s approach to satisfying information compliance and controlling information risk while maximizing information value) can no longer simply be an internally-focused exercise. IG “has come to a fork in the road, and must take it.” Service provider selection, contracting, and oversight are now primary vehicles of information governance – because when it comes to governing your organization’s information, “the future ain’t what it used to be.”