In-Person Direct Access Provides Additional Information

An in-person on-site discovery will allow you to view what the EMR notes look like at different points in time, and gain access to inactive or deleted records. Check out this blog to learn more!


So in-person direct access is what often is required to be able to get a complete view of what happened because some of the data doesn’t show when you’re just looking at the produced printed charts, such as routing history, what the notes look like at different points in time and access to inactive or deleted records. Communications, as I mentioned, here are some screenshots from some popular HIS systems that follow.

EPIC   Notes View

So this is Epic and here you see the notes view and when you’re entering into the system, there’s routing which can give you additional detail about what happened in terms of the routing of the notes. You have a note time, a filed time, and a note time. In this case, all these records with exception of this one down here, the 10:04 AM note time was filed 15 minutes later. So it’s important to have both date and timestamps because sometimes, the file times are many days after discharge or nowhere contemporaneously to the events and that’s important if notes are being entered into this EMR days after something awful happened, you really want to know when those notes were filed. If they’re filed long after things went wrong, oftentimes, that suggests that fabrication of the EMR took place. You can see here, here’s some of the routing, it allows for you to specify different recipients and so knowing that routing of information, that’s important because it’s not always evident when you’re looking at the chart. Here’s an example of adding a note and you can see here, there’s the ability to copy and paste different notations. The date and time on these notes when you first go to create a note, default to the current computer’s clock time but it’s totally possible to change the date and time to put it back in time by dates or hours and that information is relevant. Here’s an example of the Cerner notes. Again, Cerner allows the user to change the date to something other than the current date and time. And it still stores, again, the creation time of that note, even if the note purports to be days earlier. And there are also different filters here, when you’re looking at the EMR with power notes on Cerner, there are different filters, such as my notes only, there’s inactive, active, and so on.

Watch other videos making up this 4 part series, Unlocking the EMR Audit Trail.

Part 1 of 4: “The Keys to Unlocking Electronic Medical Records”
https://enigmaforensics.com/blog/keys-to-unlocking-the-emr-audit-trails-electronic-medical-records/
Part 2 of 4: “HIPPA”
https://enigmaforensics.com/blog/health-insurance-portability-and-accountability-act-of-1996-hipaa/
Part 3 of 4: “Navigating to Trial or Settlement”
https://enigmaforensics.com/blog/navigating-to-trial-or-settlement/
Part 4 of 4: “In-Person Direct Access”
https://enigmaforensics.com/blog/in-person-direct-access-provides-additional-information/

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Why is the Health Insurance Portability and Accountability Act of 1996 so important? It keeps our healthcare systems in check! Check out this video with transcripts to learn how it affects patient’s rights to request their own Electronic Medical Records (EMR’s).

Lee Neubecker: So HIPAA is the Health Insurance Portability and Accountability Act of 1996 and why this is important is all the hospital information system providers, have to certify that their software is HIPAA compliant. Otherwise, the hospitals receiving Medicare reimbursement wouldn’t be able to use the software. So, the presumption should be that any healthcare organization that is receiving Medicare funding is compliant with the rules of HIPAA and we’ll talk through what that requires here.

HIPAA Audit Trail Requirements: EMR / EHR

  1. Application audit trail audit trails
    1. EMR Opened / Accessed
    2. EMR Closed
    3. EMR Created
    4. EMR Edited (Original and Replacement Value) with last update time
    5. EMR Deleted
  2. System level audit trails
    1. Successful or unsuccessful logon event by username
    2. Date and time of each logon or logoff attempt
    3. Specific device used to logon
    4. Application user successfully or unsuccessfully accessed
  3. User audit trails
    1. Monitor and log user activity in an ePHI application 
    2. Record events initiated  by the user
    3. Commands directly initiated by the user
    4. Log access to ePHI files and resources
  4. Healthcare organizations must retain records at least six years
  5. States with stricter retention requirements must be honored

First, HIPAA requires that there be application audit trails that show when the EMR was open, accessed, closed, created, edited, the original value, replacement value, who updated it? When, from what computer, whether it was deleted? Your system-level audit trails, which has to do with the logons of the user to the system when they logged on, what computer was at the nurses’ station? Was it the computer that was actually bedside with the patient? So all of that can be relevant, especially in establishing whether or not a healthcare provider was with the patient at an important time.

User audit log trails monitor the user activity within a specific EPHI application. It records events, what commands were issued, and so on. Healthcare organizations must retain these records for at least six years and typically, if there’s an issue where litigation is involved at the point in time that they’re notified, their risk management committee will collect the records and make preservation of the available data. Some states have stricter retention requirements beyond six years and in those cases, the state rules should apply according to HIPAA.

HIPAA Audit Trail Requirements: Must Track

  1. Each time a user logins
  2. Whenever changes are made to databases
  3. When new users are added
  4. Access levels for each user
  5. File access by users
  6. Logins to operating systems
  7. Firewall logs
  8. Anti-malware logs

Other requirements of HIPAA include the following.

When a user logs on when changes are made to the databases, when users are added, access level for each user, what rights they have, the file access by the user. Logins to the operating system, firewall logs, anti-malware logs and more. So there’s a lot of requirements that hospitals are compliant and other health care organizations that are receiving Medicare funding follow these requirements.

Example Audit Trail: Meditech

Example Audit Trail: Meditech

Lee Neubecker: Here’s an example of what an audit trail log looks like. I know it’s probably a little bit difficult to see all of this but what we see, this one’s a

Meditech and what you’ll see here is there’s a run date.

The date and time the report was run.
The runtime, the username, the specific database being accessed, and who the patient was.
Then across the top, you have different data columns such as date, time, the user, what action, were they modifying, exporting, viewing?
The description of the action? Then you have the device being used to access it. It also shows here that there’s a confidential flag and certain records which may or may not be produced.
And then there’s the ability for someone to, you know, Dr. Smith could enter something and emulate another user and you don’t often see the notion that someone else emulated another user when you’re viewing the progress note or printed chart. So the audit trail is important.
Now, unfortunately, this audit trail doesn’t show you the specific changes being made and oftentimes, what’s necessary is you actually have to get a direct in-camera inspection of the Meditech or other HIS system to be able to record and document what the care provider sees.

Watch other videos making up this 4 part series, Unlocking the EMR Audit Trail.

Part 1 of 4: “The Keys to Unlocking Electronic Medical Records”
https://enigmaforensics.com/blog/keys-to-unlocking-the-emr-audit-trails-electronic-medical-records/
Part 2 of 4: “HIPPA”
https://enigmaforensics.com/blog/health-insurance-portability-and-accountability-act-of-1996-hipaa/
Part 3 of 4: “Navigating to Trial or Settlement”
https://enigmaforensics.com/blog/navigating-to-trial-or-settlement/
Part 4 of 4: “In-Person Direct Access”
https://enigmaforensics.com/blog/in-person-direct-access-provides-additional-information/

Cloud Cyber Risk

Cloud-based storage of an organization’s data attracts cyber hackers like bees to honey. Hackers take time to study and find flaws to breach, extract and sell personal information data. Data Experts Lee Neubecker and John Blair discuss cloud data compliance and legal regulations put in place to protect cloud-based data.

Compliance and Privacy Laws

Cloud cyber risk goes hand in hand when storing data on the Cloud. New compliance and privacy laws have been enacted to protect this cloud-based private information. The State of Illinois has passed a privacy law that specifically addresses how companies gather and store private data.

The Illinois Policy Group, an independent organization that generates public policy, explained that in 2008, Illinois enacted the BIPA, the most stringent law of any state regarding the consent, notice and disclosure procedures private entities must follow when collecting, storing or using people’s biometric information, such as fingerprints, iris scans and face prints. This law forces companies into compliance and makes them more responsible for the collection and storage of private data ultimately, decreasing exposure to cyber risk.

Data Experts Lee Neubecker and John Blair say because of BIPA companies are now more aware of how they secure and store data. They discuss other data compliance and privacy laws such as; California Consumer Privacy Act (CCPA) and Health Insurance Portability and Accountability Act (HIPAA) and how these laws help regulate the healthcare industry and other organizations when storing consumer data, and vendor data in the cloud ultimately protecting the consumer. Watch this video interview to learn more.

View Part 2 of our 3-Part Series on Cloud Data

Part 2 of our 3-Part Series on Cloud Data

Lee Neubecker: Hi I am back again with John Blair. We’re continuing our discussion on cloud security and helping to minimize your cyber risk of having data in the cloud. And today, we’re going to be talking more about some of the compliance and regulatory issues and legal issues that companies face that are having their data and customer data, vendor data in the cloud. So, John, can you tell me a little bit about some of the regulations that impact the healthcare sector specifically?


John Blair: Yeah, the primary one is going to be HIPAA and associated as subsequent acts like HITECH and things like that that augment HIPAA and some of them more clearly defined some of the rules and regulations, primarily Security Rule and Privacy Rule. So those are going to be the ones that primarily come into play, but there are also individual state versions of healthcare acts that you need to abide by and each state has one so you also need to abide by the state regulations as well.

LN: Interesting. So it really, if a company’s operating in multiple states, they have a lot of issues to be looking at.

JB: They have a lot of regulations to be aware of and to be compliant with, yep.

LN: So I know here in Illinois, we have the Illinois Biometric Information Protection Act, otherwise known as BIPA and that’s been creating a lot of stir with Facebook recently had a settlement.

JB: Yep.

LN: And apparently Illinois Residents that have Facebook accounts might be entitled to around $200 per person.

JB: Yep.

LN: If you are in Illinois and have Facebook, so possibly you will be notified.

JB: Yeah, Illinois is the only one.

LN: And do you think it will be through Facebook Messenger?

JB: I do not but Illinois because of that law, Illinois residents are the only ones that are getting anything out of that lawsuit because of that, specifically because of that law.

LN: Got it.

JB: So I don’t know the details of the law but on the surface, it seems to be headed the right direction.

LN: Right, essentially they took the position that your biometric information, unlike your cell phone or your social security number, you can’t change it.

JB: Right.

LN: So if that data becomes compromised such as your facial vector map,

JB: Yeah.

LN: Or your fingerprint or your DNA, that you can’t swap it, it’s part of who you are.

JB: Right and those, you know, we’re finally headed in the right direction where it’s being considered personal.

LN: Yeah.

JB: So which I totally agree with.

LN: We also had just last month the California Consumer Privacy Act, known as CCPA went into effect and that’s got a huge impact on anyone who does business with California residents.

JB: Yeah, that is yet to, I think people were preparing for that prior to that but it’s going forward, I’m sure there’s going to be a lot of repercussions from that because there’s going to be obviously companies and entities that don’t prepare well for that and are going to get caught up in it because it covers, California is a huge state, a lot of people so there’s going to be some lawsuits.

LN: So it’s also been such that if you’re making medical devices for consumers and you have that information, relaying over 3G, 4G networks, we’ve got CPAP machines, pacemakers, all other types Of information. LN: All kinds of monitors

JB: Yep.

LN: And that information going to the cloud, if you’re a California resident and that information gets breached, it could be used by marketers or it could be used In other ways to target people.

JB: Yeah hospitals are going to need to really step up their game with respect to that particular regulation. Hospitals traditionally are a little bit behind technically speaking from an IT point of view, they’re very much on the bleeding edge from a medical device IT point of view but they tend to lag behind because you can’t, it’s hard to afford both

LN: Yeah.

JB: But this is going to, you know, how they allow individuals or access to their networks, what they allow in and what they allow out because that’s the channel these medical devices use is going to be very, very important that they get more control over those things.

LN: So as it relates to healthcare, what are some of the concerns about when a data incident is discovered to actually turn out to be a data breach, what types of reporting and notification requirements are unique to the healthcare sector?

JB: Well, first and foremost, you need to evaluate the situation and then have in conjunction with your legal team and compliance teams, establish whether or not you do officially declare it a breach which means you need to investigate it, you need to involve any vendors that were involved with that data because it may have been the vendor that you’ve contracted with that actually had the breach of the disclosure and not you but since they’re your vendor, you’re also on the hook and that flows all the way up from business associates, which is what those two entities will be up to the covered entity who actually owns the data. So after a thorough investigation and consultation with legal and compliance, a determination needs to be made whether or not you’ve formally declared a breach. And if so, then there’s all kinds of HIPAA standards that come into play about notification to the government, notification to each individual affected by the breach, what needs to take place with respect to that notification, there’s a timeline involved that needs to be met. So there’s all declaring it a breach is a very formal and arduous task.

LN: Yeah, not a pleasant one.

JB: No.

LN: In our next segment on securing data in the cloud, we’re going to be talking more about when a breach is discovered, some of the issues related to reporting the breach and what that can mean to an entity, especially if it’s not handled correctly. So thanks for being on the show again.

JB: Thanks, Lee.

View Part 1 of our 3-Part series on Data Cloud Storage

BIPPA Laws

To learn more about HIPAA

https://www.hhs.gov/hipaa/index.html

Illinois BIPPA policy

https://www.illinoispolicy.org/

Understanding EMR Audit Trails

Understanding EMR Audit Trails is important to any company dealing with (PHI). They must have all the necessary security measures in place and follow them to ensure HIPAA Compliance.

Understanding EMR Audit Trails is essential to a patient’s medical history In medical malpractice litigation. The Health Insurance Portability and Accountability Act (HIPAA) requires that the Electronic Medical Records (EMR) maintain an audit trail including all of the metadata. This EMR audit trail is a piece of highly relevant evidence as to who accessed what in the record, what entries were made and/or changed, by whom and when. Computer Forensic experts are key to effective electronic discovery during medical malpractice litigation.

How do hospitals record, protect, and store data? HIPAA sets the guidelines for the most highly sought after information by the world’s best technology hackers. Medical records are worth 4 times more than credit card information. Managing Personal Healthcare Information (PHI) places Healthcare facilities at risk of cyber attack 24/7, 365 days a year.

Check out this video with Enigma Forensics, President & CEO, Lee Neubecker, and John Blair, a noted Healthcare Industry Cyber Security Expert where they discuss the importance of protecting Personally Identifiable Information (PII).

Lee Neubecker and John Blair

Understanding EMR Audit Trails video transcript follows:

This is the third of the last video in the three-part series on Health Care Industry Cyber Threats:
Watch Part 1, Watch Part 2

Lee Neubecker: Hi, I have John Blair, a cyber security expert in the field of healthcare, and John is also involved with understanding patient medical, electronic medical record (EMR) audit trails, so I asked him to come on the show and talk a little bit about that with me. John, thanks for coming back on the show.

John Blair: Thanks, Lee. Glad to be back.

LN: So John, can you tell everyone a little bit about what HIPAA requires of healthcare organizations as it relates to tracking data of caregiving and the patients?

JB: Sure. Most of this is obviously directed at hospitals, but HIPAA also has things called business associates, and any interaction from any entity with, or any user with, PHI is going to be subject to these audit logging. Hospitals use systems called EMRs, so generally those, the audit trails are built into the EMRs by default, but obviously entities can turn those off if they so choose or configure them differently. HIPAA requires that you pretty much log any interaction, whether it’s read-only, view-only, edit, whatever that interaction might be. Identify the user, identify the time, what was done to the record, and that has to be maintained for several years. So it doesn’t matter what a user does with the record. Even if they just view it, that counts as a valid interaction and has to be logged and maintained.

LN: In fact, all of these hospital software systems out there have to be HIPAA compliant, or else the hospitals wouldn’t be able to use the software packages. Isn’t that true?

JB: Right, right. There’s a lot of federal regulations regarding that, that the standards that these systems have to meet in order to get refunds or rebates from the government.

LN: So Medicare funding, reimbursement, obviously is important.

JB: All of that stuff. And audit logs of user activity and interactions, or any interaction with PHI, is a critical component of that.

LN: You know, what I’ve seen is sometimes despite the software packages being EMR, audit trail compliant, that there’s the ability for the software that’s deployed to be altered so that the audit trails aren’t retained as long as required by law.

JB: Yeah, sometimes the storage of the audit logs, it can be overwhelming. So oftentimes they are archived offsite or inappropriate access is given to the audit log itself. And then it possibly can be changed, which ruins the integrity of the log, obviously, and that would be a very bad thing should something come up down the road and you needed that log.

LN: Yeah, and certainly, someone who has the master database administrator password to that back-end system, they could do whatever they wanted.

JB: Yup. But there’s supposed to be logs of that activity, as well, and reviews of those logs, but you’re absolutely right. If you’re an administrator, you can do a lot of damage.

LN: Yeah, I’ve assisted clients before involved in litigation, medical malpractice litigation, with just seeking the truth of what’s there in the records. Most of the time, they think many hospitals are compliant and do have those audit trail records.

JB: Absolutely.

LN: But, they don’t necessarily want to make that data readily available.

JB: No, they don’t. And it depends, it’s a case-by-case scenario, under the advice of counsel and things like that, but it’s very, very sensitive information, and obviously, it’s a public relations nightmare to have a breach of patient data, so they take those things very, very seriously.

LN: Absolutely. So can you tell everyone what PHI stands for?

JB: It’s Protected Health Information, as defined by HHS, there are 18 very specific fields that comprise PHI. PHI is a subset of PII, which is Personally Identifiable Information, but with respect to healthcare, it’s primarily PHI that we’re worried about and those 18 identifiable fields.

LN: Why would hackers want to target health care records?

JB: It’s far more valuable now than several years ago, it was credit card information, basically for year after year. Now, the credit card companies and technology with respect to how quickly a card can be replaced and deactivated. And so, just more money in it to steal medical information. And there’s more flexibility, as well. You can go get drugs, you can do a variety of things, whereas, with the credit card, it’s just money.

LN: If people wanted to launch a targeted scam on individuals, certainly having records that would enable them to filter patients that have Alzheimer’s, might give them an unfair advantage at duping people out of their savings.

JB: Absolutely. Because generally if you get someone’s entire record, you’re getting everything about them: their Soc number, their address, phone numbers, relatives, I mean, all this information is now at your disposal. And loans can be taken out in their names, it’s just a disaster waiting to happen.

LN: So Electronic Medical Records, known as EMR, represent an important target that hackers seek, because of the value of that information, and the uniqueness.

JB: Yup. The price of those records, per record, now varies, but I believe it’s in the $150, $200 range per record if it’s a breach now, and laptops can hold hundreds of thousands of records. So it can be very, very expensive.

LN: But it seems that this is a problem, too, that it isn’t just localized to any one area, it’s universal.

JB: Yeah, it’s across the board. Anyone dealing with PHI has this problem.

LN: How does the cost of a patient medical record compare to a credit card record, compare to the black market?

JB: Yeah, for the last several years, medical records have gained in value every year, while financial records, credit card information have devalued. And it’s to the point now where medical information’s worth four times as much as financial information. And that’s only increasing.

LN: So does that mean that people that work in the healthcare sector in IT and security are going to get paid four times as much as the people of the financial sector?

JB: I wish.

LN: Well, thanks again for being on the show, this was a lot of good stuff. I appreciate this.

JB: Thanks, Lee, appreciate it.

Other related stories about EMR Audit Trails

Other resources to learn more about EMR Audit Trails.

https://www.cdc.gov/phlp/publications/topic/hipaa.html

Keys to a Secure Supply Chain

The world is data-driven. Companies face an overwhelming barrage of big data. Neubecker and Blair discuss the certifications necessary to ensure constant data security.

Cyber Security is Crucial to Supply Chain

Companies face an overwhelming barrage of endless data that contains sensitive information and involves a variety of supply chain vendors. The world is data-driven and securing your supply chain will help minimize your risk of cyberattacks. Here are some keys ways to help you understand more about securing your data beginning with supply chain vendors.

Check out this video with Enigma Forensics, Lee Neubecker, President & CEO, and John Blair, noted Healthcare Industry Cyber Security Expert dissect big data and the certifications needed to understand how to secure your supply chain to help monitor the risks.

2nd video in a three-part series

This is the second video transcript of a three-part series.

Lee Neubecker: Hi, thank you for doing this show, John.

John Blair: No problem.

LN: I appreciate you coming back on.

JB: Thanks Lee, glad to have you here.

LN: So, we’re going to talk today a little bit about what organizations should be doing to monitor the risk associated with their supply chain.

JB: Okay.

LN: And John, if you can, give me an understanding of what are things that you look for when selecting a vendor or city that might be hosting your data.

JB: Right.

LN: Or running parts of your operation.

JB: Well, the world is data-driven, and so your evaluation of vendors is critical and should be focused on their interaction with your data, what their subcontractors are going to do, are you going to allow them to have subcontractors? Where are those subcontractors located? And by all means, get some sort of attestation, that their environment that you’re now relying on, has been audited, you know, the SOC 2’s, those types of things, go a very long way in giving you some level of comfort that they’re operating their controls effectively and that you can rely on ’em.

LN: Great, can you explain to our viewers what essentially a SOC 2 certification is, and why you care about that with a vendor?

JB: That one, the SOC 2, there are multiples ones, but a SOC 2 Type 2 is the standard. There are five Trust Principles associated with it. The biggest one used probably, 75 percent of the time is security. And that’s where you, the vendor would offer, whatever service you’re interested in, the SOC report would be scoped for that service, and then the auditors evaluate that service according to the security principle that’s defined by SOC.

LN: So, typically they’re looking at physical security measures, as well,

JB: Yep.

LN: that extend just beyond data,

JB: Right.

LN: but physical security measures that help to protect your data.

JB: Right, SOC defines objectives, and then the organization defines controls within those objectives, so the objectives are the boundaries, and then the organization defines the controls, but generally speaking, they are the IT basics, chain management, software development, life cycle, physical security, logical security, network security, data storage and security, transmission security, those types of things are almost always covered under the security principle.

LN: Isn’t it true that someone could have all the certs out there and still get compromised?

JB: Oh, absolutely. The certs are not a guarantee, by any stretch. They are just, you know, as we’ve said, they’re meant to give you a level of comfort in the control environment of the people you are now, basically trusting with your data.

LN: And so, as you go out, and you select vendors if you do this diligence and you find vendors that have a certain level of attestation, and various certs that you care about, that might help you if data breach happened, to show that you actually practiced good faith and due diligence, in selecting your vendors.

JB: No, absolutely, and HIPPA requires it, so if you did some sort of due diligence at least, at least you have a story to tell. If you don’t have a story to tell, then that’s where things start going off the rails almost immediately, because you didn’t do anything, and that’s never a good thing.

LN: Well, thanks for being on the show again.

JB: My pleasure, thank you.

More about cybersecurity

Information on HIPPA website for security professionals

https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html