Quick Response Cyber Attack Checklist and Graphic

PUBLISHED: Jun 12, 2017
Relevant to: Ambulatory Care, Behavioral Health, Clinical Lab, Home Health, Hospice, Hospitals, Long Term Care, Medical Office

The U.S. Department of Health & Human Services (HHS), Office for Civil Rights (OCR) has developed a checklist and a corresponding Infographic that explains the steps for a HIPAA covered entity or its business associate (the entity) to take in response to a cyber-related security incident.

Links to the Cyber Security Checklist and the Cyber Security Infographic are provided below. Also included with this notice is an example policy, Response To Cyber Attack.

In summary, entities should take the following steps in the event of a cyber attack or similar emergency:

  • Execute response and mitigation procedures and contingency plans:
  • Immediately fix any technical or other problems to stop the incident.
  • Take steps to mitigate any impermissible disclosure of protected health information which may be done by the entity’s own information technology staff, or by an outside entity brought in to help (which would be a business associate, if it has access to protected health information for that purpose).
  • Report the crime to other law enforcement agencies:
  • Includes state or local law enforcement, the Federal Bureau of Investigation (FBI), and/or the Secret Service.
  • These reports should not include protected health information, unless otherwise permitted by the HIPAA Privacy Rule.
    • Note: If a law enforcement official tells the entity that any potential breach report would impede a criminal investigation or harm national security, the entity must delay reporting a breach for the time the law enforcement official requests in writing, or for 30 days, if the request is made orally.
  • Report all cyber threat indicators to the appropriate federal and information-sharing and analysis organizations (ISAOs):
  • Including the Department of Homeland Security, the HHS Assistant Secretary for Preparedness and Response, and private-sector cyber-threat ISAOs.
  • Such reports should not include protected health information.
  • Report the breach to the Office of Civil Rights (OCR) as soon as possible, but no later than 60 days after the discovery of a breach affecting 500 or more individuals:
  • Must also notify affected individuals and the media unless a law enforcement official has requested a delay in the reporting.
  • OCR presumes all cyber-related security incidents where protected health information was accessed, acquired, used, or disclosed are reportable breaches unless the information was encrypted by the entity at the time of the incident or the entity determines, through a written risk assessment, that there was a low probability that the information was compromised during the breach.
  • An entity that discovers a breach affecting fewer than 500 individuals has an obligation to notify:
    • Individuals without unreasonable delay, but no later than 60 days after discovery
    • OCR within 60 days after the end of the calendar year in which the breach was discovered.

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