Winning the compliance game with enterprise fraud management

July 6, 2011
How medical institutions can overcome the challenges of creating and maintaining an audit trail.

HIPAA, the final Privacy Rule and various state regulations governing patient privacy all have one thing in common. They all require organizations to demonstrate access to personal health information (PHI) on a minimum need-to-know basis. That places the burden of governing access on the institution. In an audit situation, that means the organization must be able to demonstrate “Who? Did what? When?” and present a comprehensive record of information access. In an ideal situation, this would be merely a matter of printing out some access logs and shoring up areas of weakness, right? Sounds simple enough, doesn't it?

Mind the gap: Insufficient data capture leads to incomplete audit trails
However, HIPAA compliance still proves to be elusive at a number of hospitals and healthcare institutions. The transition to electronic records and the sheer volume of data have made the situation challenging at best. Further complicating matters are the gaps that are present in current log files and systems. Traditional logging methods only capture about 25 percent of the data, leaving huge gaps in the PHI audit trail. Even worse, the Privacy Rule requires an explanation of “why” the data was accessed so audit information created with this rule in mind has to go beyond the login name, date/timestamp and action taken to provide context to the data access. This is data that is just plain missing from most traditional system logs; they were never designed to capture it. With HIPAA fines at some hospitals exceeding $1 million, solutions to the missing data problems must be found.

Raising the bar: HITECH adds new challenges to compliance efforts
As of February 2010, the Health Information Technology for Economic and Clinical Health (HITECH) Act made significant changes to the Health Information Portability and Accountability Act (HIPAA) of 1996. These changes include: strengthening of the data breach notification laws with specific guidance on breach disclosure, specifications surrounding PHI access disclosure and the ability to impose larger fines. The HITECH Act also extends the data protection requirements beyond the individual organization to include business associates as well.

Organizations seeking to demonstrate compliance with the new guidelines must be able to specify the details of any given access event to limit fines and ensure that any breach disclosure accurately reflects the size of the occurrence. For example, in the absence of data to quantify the actual PHI access, organizations must report on the highest possible number of records. Knowing precisely who accessed what can permit an organization to disclose what actually happened (the viewing of a handful of records versus accessing a database with thousands of patient accounts), thereby limiting fines and potential brand damage. Inadequate logs that leave auditors and investigators guessing can't do that. Only the next generation of detection technologies, enterprise fraud management (EFM) and misuse solutions can do that.

Enterprise fraud and misuse management: Using next-generation fraud technologies
Today's next generation of fraud detection technologies can go a long way to supporting a HIPAA-HITECH compliance effort. Simply put, these systems provide 100% visibility across multiple data channels to offer a comprehensive view of what is going on in your environment. A few even offer screen-by-screen replay of user activity that features “context to keystrokes” and provides the ability to look at each screen viewed by a particular user. Through this method, organizations can understand and capture the “why” of data access. Monitoring and alerting of specific events is also available. These solutions can actively target violations and unauthorized access. Here are a few of the common monitoring scenarios:

  • Is a given user logged in at multiple locations or while on vacation or absent from work? Accessing systems after hours?
  • Is a particular user accessing areas not appropriate for his or her job or function?
  • Are physicians accessing records outside their specialty?
  • Are employees accessing high-profile or VIP accounts inappropriately? Are staff members inappropriately accessing PHI within the institution?
  • Are users accessing accounts more than 30 days after the date of service? Has key information on the account changed (address, services rendered, etc.)?

In healthcare, one of the most pernicious issues is accidental access of PHI rather than outright fraud (although fraud is still an issue). Take for example, VIP snooping in healthcare. While certainly a HIPAA violation, few would consider the desire to “sneak a peek” at an admission file fraud. Even so, these violations cost hospitals hundreds of thousands of dollars in fines annually, and the resulting personnel action results in loss of staff and productivity. Fortunately, there is a better way.

Lastly, an additional area to consider is responding to patient requests for information surrounding PHI access. Current proposed federal legislation would require that healthcare providers and their affiliates respond to requests for information with a detailed accounting of all access to a patient's PHI going back three years. Many forward-looking institutions are seeking a way to respond to this new proposed requirement as well as state disclosure laws governing PHI. Many enterprise fraud management systems are designed to handle these information requests at the press of a button and can capture the history of information access across multiple systems. Having these systems in place can mean countless hours saved in responding to these requests.

Gartner report on EFM
The financial services sector has been an early adopter of EFM systems, since fraudsters often target financial accounts (because that's where the money is); however, other sectors, such as healthcare, insurance and government, are increasingly purchasing fraud and misuse management systems, often to respond to government regulations.1

If your organization is interested in learning more about how these systems can support your tactical fraud and misuse prevention objectives (i.e., for a specific product or channel), I encourage you to download the current Gartner MarketScope on Enterprise Fraud Management and Misuse. This independent report, authored by leading analyst Avivah Litan, provides overview information about how organizations are using these technologies today as well as reviews of solutions and providers in the category. Download your complimentary copy now here:

About the author
Christine Meyers is the product marketing manager for Attachmate Luminet and has been writing on emerging technologies, risk and compliance for over a decade. She tweets regularly about security, risk and compliance via @LuminetEFM.
For more information on Attachmate solutions:

1. Litan A. MarketScope for Enterprise Fraud and Misuse Management. Gartner, Inc. January 2011.

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