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Today’s next generation of fraud detection technologies can go a long way to supporting a HIPAA HITECH compliance effort and prevent privacy violations, misuse and abuse. Simply put, these systems provide visibility across multiple data channels to offer a comprehensive view of what is going on in your environment. Leading solutions offer screen-by-screen replay of user activity which offers “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 on specific events is also available. These solutions can actively target violations and unauthorized access.
More and more, leading healthcare institutions are migrating to the new fraud monitoring technologies. This new approach moves far beyond the logging and monitoring solutions that may “check a box” for compliance, but do little to address advanced audit requirements or fill in the “gaps” inherent in traditional logging systems. The benefits of monitoring data across applications and extending visibility beyond healthcare applications are essential to leading organizations seeking to protect patient privacy and their brand.
Let’s explore some of the areas that this new approach can assist with:
Common Healthcare Monitoring Scenarios
- Is a given user is logged in at multiple locations or while on vacation or absent from work? Accessing systems after hours?
- Is a particular user is accessing areas not appropriate for their job or function?
- Are physicians are 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, improper record access 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.
Developing A Rules Based Approach
Continuous monitoring of user activity provides a comprehensive view of who, did what, when, and often even provides insight into why a particular activity occurred. Capturing data in this manner and applying a rules based approach to identifying risks and possible abuse, misuse and error in data can significantly improve audit performance.
Auditing Needs We Commonly Encounter and Assist With
- Developing a baseline of activity across a healthcare organization and using that to uncover and target areas at higher risk for patient privacy violations.
- Monitoring third-party activities, including call centers and claims processors and service providers, for a higher than baseline occurrence of out of band activity.
- Monitoring access to medical record, specifically highly sensitive material such as HIV test results where the inappropriate disclosure of such information may cause a patient harm.
- Identifying employees or other providers who demonstrate patterns of unauthorized access. Providing visibility into record access of VIP, high profile or opt out patients.
- Examining employee or provider look ups along high risk patterns: same last name, same street address, same zip code, etc.
- Enabling review of physician access and review of employee as patient access (employees as patients create a potential for misuse and/or abuse often out of concern or curiosity).
- Reviewing and auditing access by remote users. Providing the ability to review external third-party record access as well as the ability to monitor third-party activity for fraud, out-of-band approvals or requests and access appropriate to role.
Monitoring and Data Capture During a “Break Glass” Emergency
In many healthcare provider settings, there is the potential for a “break-the-glass” emergency which refers to an instance where it becomes necessary for individuals to violate access protocols to provide lifesaving or critical care. In these scenarios, it is essential to capture, document and retain user activity and information access for future audit and review. With enterprise fraud management solutions in place, this special audit trail is automatically created, encrypted and digitally signed. The records are retained in a sealed repository preserving the records as required.
Possible scenarios where this data capture may be required include a) account problems such as a locked password due to failed entry attempts or lack of a user account (visiting clinician required to assist during an emergency), b) authentication problems such as an authentication system failure, or c) an emergency situation forces personnel to respond in a way that exceeds their authorization.
During such a situation, it is essential that the entire activity trail is captured and preserved for later review. With monitoring in place, no paper logging is required. Today’s enterprise fraud management technologies can even trigger alerts when such a scenario occurs. Having an automatic, comprehensive audit trail has the potential to limit any required disclosure to the actual event and activity rather than a “worst case” access scenario.
Responding to Emerging “Accounting of Disclosure Requirements”
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 saved hours in responding to these requests.
In Conclusion:
Leading healthcare institutions seeking to get more out of their audit and compliance efforts should be exploring next generation solutions and not relying exclusively on incomplete or inadequate logs.
