DataBreaches.Net

Menu
  • About
  • Breach Notification Laws
  • Privacy Policy
  • Transparency Report
Menu

When do covered entities need to report ransomware incidents to HHS?

Posted on March 24, 2016 by Dissent

At the PHI Protection Network conference last week, we spent a lot of time discussing the increasing rate of ransomware attacks. I asked a number of people whether they thought that ransomware attacks that (merely) locked up the data with no evidence of exfiltration had to be reported to HHS.  I got a variety of answers, so I put some hypothetical scenarios to HHS and asked them to clarify. Lesley Cothran, a Public Affairs Specialist, answered for the department:

Under HIPAA, an impermissible use or disclosure of protected health information is presumed to be a breach (and therefore, notification is required) unless the entity 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:

1. The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification;

2. The unauthorized person who used the protected health information or to whom the disclosure was made;

3. Whether the protected health information was actually acquired or viewed; and

4. The extent to which the risk to the protected health information has been mitigated.

Because it is considered to be a “disclosure” if access has been provided (without regard to whether or not the information actually was accessed or viewed), and hackers using ransomware do have access to the data, an impermissible disclosure has occurred – and notification is presumably required – unless a “low probability of compromise” has been demonstrated, and “whether the [PHI] was actually acquired or viewed” is only one of the
factors.

So… how would you demonstrate a “low probability of compromise” in a ransomware attack? If you can demonstrate by logs that no data were exfiltrated and you can figure out what happened once the attackers got in, and if you have a full backup of patient data so that you can restore from backup after removing malware and you feel confident that no patient data has been corrupted or altered, would you feel that you had adequately demonstrated low risk and that notification was not required?  Or do you think more is required to justify no need for notification?

Related posts:

  • The Ransomware Superhero of Normal, Illinois
Category: Commentaries and AnalysesFederalHealth DataMalware

Post navigation

← Ontario hospital website may have infected visitors with ransomware, security firm says
Elliot J. Martin Chiropractic notification to patients of HIPAA breach →

1 thought on “When do covered entities need to report ransomware incidents to HHS?”

  1. John Nelson says:
    March 24, 2016 at 3:58 pm

    Yes, that is exactly the standard I would use. If you took the type to set up audit trails around your PHI, you can use them to show what did NOT happen. Often, that’s more important than showing what did happen.

Comments are closed.

Now more than ever

"Stand with Ukraine:" above raised hands. The illustration is in blue and yellow, the colors of Ukraine's flag.

Search

Browse by Categories

Recent Posts

  • Texas Centers for Infectious Disease Associates Notifies Individuals of Data Breach in 2024
  • Battlefords Union Hospitals notifies patients of employee snooping in their records
  • Alert: Scattered Spider has added North American airline and transportation organizations to their target list
  • Northern Light Health patients affected by security incident at Compumedics; 10 healthcare entities affected
  • Privacy commissioner reviewing reported Ontario Health atHome data breach
  • CMS warns Medicare providers of fraud scheme
  • Ex-student charged with wave of cyber attacks on Sydney uni
  • Detaining Hackers Before the Crime? Tamil Nadu’s Supreme Court Approves Preventive Custody for Cyber Offenders
  • Potential Cyberattack Scrambles Columbia University Computer Systems
  • 222,000 customer records allegedly from Manhattan Parking Group leaked

No, You Can’t Buy a Post or an Interview

This site does not accept sponsored posts or link-back arrangements. Inquiries about either are ignored.

And despite what some trolls may try to claim: DataBreaches has never accepted even one dime to interview or report on anyone. Nor will DataBreaches ever pay anyone for data or to interview them.

Want to Get Our RSS Feed?

Grab it here:

https://databreaches.net/feed/

RSS Recent Posts on PogoWasRight.org

  • Germany Wants Apple, Google to Remove DeepSeek From Their App Stores
  • Supreme Court upholds Texas law requiring age verification on porn sites
  • Justices nix Medicaid ‘right’ to choose doctor, defunding Planned Parenthood in South Carolina
  • European Commission publishes its plan to enable more effective law enforcement access to data
  • Sacred Secrets: The Biblical Case for Privacy and Data Protection
  • Microsoft’s Departing Privacy Chief Calls for Regulator Outreach
  • Nestle USA Settles Suit Over Job-Application Medical Questions

Have a News Tip?

Email: Tips[at]DataBreaches.net

Signal: +1 516-776-7756

Contact Me

Email: info[at]databreaches.net

Mastodon: Infosec.Exchange/@PogoWasRight

Signal: +1 516-776-7756

DMCA Concern: dmca[at]databreaches.net
© 2009 – 2025 DataBreaches.net and DataBreaches LLC. All rights reserved.