Health Information Management

HIPAA Q&A: You've got questions. We've got answers!

HIM-HIPAA Insider, September 14, 2015

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

Q: Can you explain the difference between a security incident and a data breach? I feel like there's a lot of confusion around this. What are the legal requirements between the two for a healthcare provider or a business associate?

A: A breach is a subset of security incidents. For example, if a laptop is stolen and it is encrypted, that's a security incident but not a breach. Another example would be a hacker attempting to hack a firewall but failing—again, that would be a security incident and not a breach.

A breach occurs when the data is compromised. The Breach Notification Rule does not include a definition of what "compromised" means, but it does describe what represents a breach. A breach is the unauthorized disclosure of unsecure electronic or non-electronic PHI. If the PHI is electronic, it's not secure if it's not encrypted at the level set by the National Institute of Standards and Technology or not totally and completely destroyed. If the PHI is non-electronic and it's not totally and completely destroyed, it's not secure.

If a breach of unsecure PHI occurs, business associates are required to report the breach to the CE as soon as feasible but no later than 60 calendar days. The CE has the responsibility of assuming the breach is reportable initially, conducting the four-factor risk assessment, and, if necessary, notifying individuals and the OCR as soon as feasible but no later than 60 calendar days.

Remember that most states have enacted breach notification laws, and some are more stringent than HIPAA. Where state laws are more stringent than HIPAA—in other words, where they expand the breach response and reporting requirements—state law preempts HIPAA.

Editor’s note: Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, Oregon, answered this question for HCPro’s Briefings on HIPAA newsletter. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions.
 



Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular