Fix Vulnerabilities
Think about service providers. If service providers
were involved, examine what personal information they can access and
decide if you need to change their access privileges. Also, ensure your
service providers are taking the necessary steps to make sure another
breach does not occur. If your service providers say they have remedied
vulnerabilities, verify that they really fixed things.
Check your network segmentation. When you set up
your network, you likely segmented it so that a breach on one server or
in one site could not lead to a breach on another server or site. Work
with your forensics experts to analyze whether your segmentation plan
was effective in containing the breach. If you need to make any changes,
do so now.
Work with your forensics experts. Find out if
measures such as encryption were enabled when the breach happened.
Analyze backup or preserved data. Review logs to determine who had
access to the data at the time of the breach. Also, analyze who
currently has access, determine whether that access is needed, and
restrict access if it is not. Verify the types of information
compromised, the number of people affected, and whether you have contact
information for those people. When you get the forensic reports, take
the recommended remedial measures as soon as possible.
Have a communications plan. Create a comprehensive
plan that reaches all affected audiences — employees, customers,
investors, business partners, and other stakeholders. Don’t make
misleading statements about the breach. And don’t withhold key details
that might help consumers protect themselves and their information.
Also, don’t publicly share information that might put consumers at
further risk.
Anticipate questions that people will ask. Then, put
top-tier questions and clear, plain-language answers on your website
where they are easy to find. Good communication up front can limit
customers’ concerns and frustration, saving your company time and money
later.
| Covered entities and business associates must only provide the required notifications if the breach involved unsecured protected health information. Unsecured protected health information is protected health information that has not been rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the Secretary in guidance. This guidance was first issued in April 2009 with a request for public comment. The guidance was reissued after consideration of public comment received and specifies encryption and destruction as the technologies and methodologies for rendering protected health information unusable, unreadable, or indecipherable to unauthorized individuals. Additionally, the guidance also applies to unsecured personal health record identifiable health information under the FTC regulations. Covered entities and business associates, as well as entities regulated by the FTC regulations, that secure information as specified by the guidance are relieved from providing notifications following the breach of such information. ...read more |
| A breach is, generally, an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information. An impermissible use or disclosure of protected health information is presumed to be a breach unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the protected health information has been compromised based on a risk assessment of at least the following factors: The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification;The unauthorized person who used the protected health information or to whom the disclosure was made;Whether the protected health information was actually acquired or viewed; andThe extent to which the risk to the protected health information has been mitigated.Covered entities and business associates, where applicable, have discretion to provide the required breach notifications following an impermissible ...read more |
| Covered entities and business associates, as applicable, have the burden of demonstrating that all required notifications have been provided or that a use or disclosure of unsecured protected health information did not constitute a breach. Thus, with respect to an impermissible use or disclosure, a covered entity (or business associate) should maintain documentation that all required notifications were made, or, alternatively, documentation to demonstrate that notification was not required: (1) its risk assessment demonstrating a low probability that the protected health information has been compromised by the impermissible use or disclosure; or (2) the application of any other exceptions to the definition of “breach.” Covered entities are also required to comply with certain administrative requirements with respect to breach notification. For example, covered entities must have in place written policies and procedures regarding breach notification, must train employees on these policies and procedures, and must develop and apply appropriate ...read more |
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1/21/25 Healthcare Data Breaches and Their Devastating Impact
1/21/25 Your Essential Guide to Data Breach Reporting Procedures
1/21/25 Understanding Your Obligations in Data Breach Reporting
11/16/22 Administrative Requirements and Burden of Proof
11/16/22 Notification by a Business Associat
11/16/22 Breach Notification Requirements
11/16/22 Unsecured Protected Health Information and Guidance
11/16/22 Guidance to Render Unsecured Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals
11/16/22 Definition of Breach
11/16/22 Breach Notification Rule
11/16/22 Notify Individuals
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