HHS Office for Civil Rights Settles HIPAA Cybersecurity Investigation with Vision Upright MRI

Small Health Care Providers Also Must Comply with the HIPAA Rules  

Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) announced a settlement with Vision Upright MRI, a small California health care provider that conducts magnetic resonance imaging and related services, concerning potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Breach Notification and Security Rules. The settlement resolves an OCR investigation concerning the breach of an unsecured server containing the medical images of 21,778 individuals. 

OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules, which set forth the requirements that covered entities (health plans, health care clearinghouses, and most health care providers), and business associates must follow to protect the privacy and security of protected health information (PHI). The Risk Analysis provision of the Security Rule requires a regulated organization to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI) held by that organization. The Breach Notification Rule requires HIPAA covered entities and their business associates to provide notification following a breach of unsecured protected health information.

“Cybersecurity threats affect large and small covered health care providers,” said OCR Acting Director Anthony Archeval. “Small providers also must conduct accurate and thorough risk analyses to identify potential risks and vulnerabilities to protected health information and secure them.”

OCR initiated a compliance review of Vision Upright MRI after learning that the provider experienced a breach of ePHI stored on its Picture Archiving and Communication System (PACS) server for storing, retrieving, managing, and accessing radiology images, due to an unauthorized third party’s impermissible access. OCR’s investigation revealed that Vision Upright MRI had never conducted a HIPAA risk analysis and that it had failed to complete timely breach notification, within 60 days of discovering the breach, to the 21,778 individuals affected.

Under the terms of the resolution agreement, Vision Upright MRI agreed to implement a corrective action plan that will be monitored by OCR for two years and paid $5,000 to OCR.  Vision Upright MRI will also take steps to improve its compliance with the HIPAA Security and Breach Notification Rules and protect the security of ePHI, including:

• Providing required breach notifications to affected individuals, HHS and the media;
• Submitting to OCR its most recently completed risk analysis to include all electronic media, regardless of its source or location (i.e. electronic equipment, data systems, programs, off-site data storage and applications) that contains, stores, transmits or receives ePHI;
• Developing and implementing a risk management plan to address and mitigate any security risks and vulnerabilities identified in its risk analysis;
• Developing, maintaining, and revising, as necessary, written policies and procedures to comply with the HIPAA Rules; and
• Providing workforce training on HIPAA policies and procedures to all workforce members that have access to ePHI.

OCR recommends that health care providers, health plans, clearinghouses, and business associates that are covered by HIPAA take the following steps to mitigate or prevent cyber-threats:

• Identify where ePHI is located in the organization, including how ePHI enters, flows through, and leaves the organization’s information systems.
• Integrate risk analysis and risk management into the organization’s business processes.
• Ensure that audit controls are in place to record and examine information system activity.
• Implement regular reviews of information system activity.
• Utilize mechanisms to authenticate information to ensure only authorized users are accessing ePHI.
• Encrypt ePHI in transit and at rest to guard against unauthorized access to ePHI when appropriate.
• Incorporate lessons learned from incidents into the organization’s overall security management process.
• Provide workforce members with regular HIPAA training that is specific to the organization and to the workforce members’ respective job duties.

The resolution agreement and corrective action plan may be found at: https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/hhs-ocr-hipaa-racap-vum/index.html

OCR is committed to enforcing the HIPAA Rules that protect the privacy and security of individuals’ protected health information. Please see OCR’s guidance and webinar on the HIPAA Security Rule Risk Analysis requirement. Guidance about the Privacy, Security, and Breach Notification Rules can also be found on OCR’s website.

If you believe that your or another person’s health information privacy or civil rights have been violated, you can file a complaint with OCR at https://www.hhs.gov/ocr/complaints/index.html.

Follow HHS OCR on X (formerly Twitter) at @HHSOCR.