UW Medicine, Privacy Manager - Breach: 76,183 individuals, Nov 2013.

The University of Washington Medicine (UWM) has agreed to settle charges that it potentially violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule by failing to implement policies and procedures to prevent, detect, contain, and correct security violations. UWM is an affiliated covered entity, which includes designated health care components and other entities under the control of the University of Washington, including University of Washington Medical Center, the primary teaching hospital of the University of Washington School of Medicine. Affiliated covered entities must have in place appropriate policies and processes to assure HIPAA compliance with respect to each of the entities that are part of the affiliated group. The settlement includes a monetary payment of $750,000, a corrective action plan, and annual reports on the organization's compliance efforts.

The U.S. Department of Health and Human Services Office for Civil Rights (OCR) initiated its investigation of the UWM following receipt of a breach report on November 27, 2013, which indicated that the electronic protected health information (e-PHI) of approximately 90,000 individuals was accessed after an employee downloaded an email attachment that contained malicious malware. The malware compromised the organization's IT system, affecting the data of two different groups of patients: 1) approximately 76,000 patients involving a combination of patient names, medical record numbers, dates of service, and/or charges or bill balances; and 2) approximately 15,000 patients involving names, medical record numbers, other demographics such as address and phone number, dates of birth, charges or bill balances, social security numbers, insurance identification or Medicare numbers.

OCR's investigation indicated UWM's security policies required its affiliated entities to have up-to-date, documented system-level risk assessments and to implement safeguards in compliance with the Security Rule. However, UWM did not ensure that all of its affiliated entities were properly conducting risk assessments and appropriately responding to the potential risks and vulnerabilities in their respective environments.

"All too often we see covered entities with a limited risk analysis that focuses on a specific system such as the electronic medical record or that fails to provide appropriate oversight and accountability for all parts of the enterprise," said OCR Director Jocelyn Samuels. "An effective risk analysis is one that is comprehensive in scope and is conducted across the organization to sufficiently address the risks and vulnerabilities to patient data."

The Resolution Agreement and Corrective Action Plan can be found on the OCR website at: http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/uwm/index.html

HHS offers guidance on how your organization can conduct a HIPAA Risk Analysis: http://www.healthit.gov/providers-professionals/security-risk-assessment