Guidance to Render Unsecured Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals
Protected
health information (PHI) is rendered unusable, unreadable, or
indecipherable to unauthorized individuals if one or more of the
following applies:
- Electronic PHI has been encrypted as specified in the HIPAA
Security Rule by “the use of an algorithmic process to transform data
into a form in which there is a low probability of assigning meaning
without use of a confidential process or key” (45 CFR 164.304 definition
of encryption) and such confidential process or key that might enable
decryption has not been breached. To avoid a breach of the confidential
process or key, these decryption tools should be stored on a device or
at a location separate from the data they are used to encrypt or
decrypt. The encryption processes identified below have been tested by
the National Institute of Standards and Technology (NIST) and judged to
meet this standard.
- Valid encryption processes for data at rest are consistent with NIST Special Publication 800-111, Guide to Storage Encryption Technologies for End User Devices.1
- Valid encryption processes for data in motion are those which comply, as appropriate, with NIST Special Publications 800-52, Guidelines for the Selection and Use of Transport Layer Security (TLS) Implementations; 800-77, Guide to IPsec VPNs; or 800-113, Guide to SSL VPNs, or others which are Federal Information Processing Standards (FIPS) 140-2 validated.
- The media on which the PHI is stored or recorded has been destroyed in one of the following ways:
- Paper, film, or other hard copy media have been shredded or
destroyed such that the PHI cannot be read or otherwise cannot be
reconstructed. Redaction is specifically excluded as a means of data
destruction.
- Electronic media have been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, Guidelines for Media Sanitization such that the PHI cannot be retrieved.
| 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 ...read more |
| 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 ...read more |
| 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 |
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