Oregon Health & Science University (OHSU) has agreed to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules following an investigation by the U.S. Department of Health and Human Services Office for Civil Rights (OCR) that found widespread and diverse problems at OHSU, which will be addressed through a comprehensive three-year corrective action plan. The settlement includes a monetary payment by OHSU to the Department for $2,700,000.
OCR’s investigation began after OHSU submitted multiple breach reports affecting thousands of individuals, including two reports involving unencrypted laptops and another large breach involving a stolen unencrypted thumb drive. These incidents each garnered significant local and national press coverage. OCR’s investigation uncovered evidence of widespread vulnerabilities within OHSU’s HIPAA compliance program, including the storage of the electronic protected health information (ePHI) of over 3,000 individuals on a cloud-based server without a business associate agreement. OCR found significant risk of harm to 1,361 of these individuals due to the sensitive nature of their diagnoses. The server stored a variety of ePHI including credit card and payment information, diagnoses, procedures, photos, driver’s license numbers and Social Security numbers.
OHSU performed risk analyses in 2003, 2005, 2006, 2008, 2010, and 2013, but OCR’s investigation found that these analyses did not cover all ePHI in OHSU’s enterprise, as required by the Security Rule. While the analyses identified vulnerabilities and risks to ePHI located in many areas of the organization, OHSU did not act in a timely manner to implement measures to address these documented risks and vulnerabilities to a reasonable and appropriate level. OHSU also lacked policies and procedures to prevent, detect, contain, and correct security violations and failed to implement a mechanism to encrypt and decrypt ePHI or an equivalent alternative measure for ePHI maintained on its workstations, despite having identified this lack of encryption as a risk.
“From well-publicized large scale breaches and findings in their own risk analyses, OHSU had every opportunity to address security management processes that were insufficient. Furthermore, OHSU should have addressed the lack of a business associate agreement before allowing a vendor to store ePHI,” said OCR Director Jocelyn Samuels. “This settlement underscores the importance of leadership engagement and why it is so critical for the C-suite to take HIPAA compliance seriously.”
OHSU is a large public academic health center and research university centered in Portland, Oregon, comprising two hospitals, and multiple general and specialty clinics throughout Portland and throughout the State of Oregon.
You can view the resolution agreement and corrective action plan on OCR’s website at:
To learn more about non-discrimination and health information privacy laws, your civil rights, and privacy rights in health care and human service settings, and to find information on filing a complaint, visit us at http://www.hhs.gov/hipaa/index.html.