Therapists must have proper protocols and security measures in place to prevent data breaches and a response plan to mitigate the impacts in case of a breach. Understanding the effects of a breach and how to create policies within a practice allows therapists to avoid this risk to their HIPAA compliance.
How does a data breach impact therapist practices?
A data breach within a therapist's practice involves a security incident where client information, such as personal details, therapy notes, diagnoses, treatment plans, or other confidential data, has been compromised or exposed to unauthorized individuals. This creates a breach of patient trust, potential legal consequences, reputational damage, and financial burdens for therapists.
Related: What is a data breach?
Steps for therapists to take in the event of a data breach
Conduct a thorough risk assessment
A comprehensive risk assessment helps identify the potential harm resulting from the breach. This consists of evaluating the types of information compromised, the potential impact on affected individuals, and the likelihood of misuse or harm. This assessment will influence all further actions and strategies.
Read more: How to perform a risk assessment
Notification
Notify affected individuals promptly, in compliance with HIPAA guidelines and relevant state laws, about the breach and the potential risks associated with their compromised information. Provide clear and concise information about the incident, the type of data involved, the steps they can take to protect themselves, and any support services offered.
Review and update policies and procedures
Evaluate existing policies and procedures related to data privacy and security. Update them as necessary to address any identified risks from the risk assessment and ensure that they align with HIPAA requirements. Ensure that all staff members are familiar with and adhere to these policies.
Establish and improve incident response protocols
Develop or improve an incident response plan that outlines clear steps to take in case of a future data breach. This is a necessary step if there are no current protocols or the existing protocols are ineffective. This plan should include roles and responsibilities, communication strategies, coordination with external parties (legal counsel or cybersecurity experts), and ongoing monitoring and evaluation.
Investigation and documentation
Conduct a thorough investigation into the breach to determine its root cause, the extent of the data compromised, and any vulnerabilities that allowed it to occur. Document the findings, actions taken, and remediation efforts.
Notification and reporting
Determine whether the breach meets the criteria for notification to affected individuals, the Office for Civil Rights (OCR), or other regulatory bodies. Follow the appropriate notification and reporting requirements within the specified timeframe.
Collaborate with legal and cybersecurity professionals
Engage legal and cybersecurity professionals or software tailored to HIPAA compliance to provide guidance and oversight. They can help ensure that the practice remains in compliance with applicable laws, regulations, and industry standards.
Reporting to the Office for Civil Rights (OCR):
A therapist should report a HIPAA data breach to the Office for Civil Rights in the following circumstances:
- Breach of 500 or more individuals: If a data breach affects 500 or more individuals, therapists must report the breach to the OCR within 60 days of its discovery.
- Breach of fewer than 500 individuals: If a data breach affects fewer than 500 individuals, therapists should maintain a breach log and submit an annual report summarizing all breaches that occurred during the calendar year to the OCR.
- Immediate notification: If a breach poses a significant risk of harm to individuals, therapists should promptly notify affected patients, the OCR, and potentially the media. The notification should include relevant details of the breach, mitigation measures taken, and support offered to affected individuals.
Related: What is the OCR and what does it do?
Communicating with patients in the event of a data breach
Once a breach has been discovered and assessed, therapists should communicate it to affected patients without unreasonable delay. A clear and concise breach notification letter, personalized for each affected patient, should be addressed to each patient. This includes a description of the breach, types of compromised information, potential risks, and steps taken to mitigate the situation.
Goals after the data breach
The long-term goals of a therapist's practice following a data breach should focus on strengthening data protection and cybersecurity. Openly addressing any vulnerabilities or weaknesses in data security measures and outlining the enhanced measures implemented to prevent similar incidents can help rebuild trust.
Related: HIPAA Compliant Email: The Definitive Guide
Kirsten Peremore
