CIPP-US practice question 17 of 25

SCENARIO Please use the following to answer the next QUESTION: You are the chief privacy officer at HealthCo, a major hospital in a large U.S. city…

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SCENARIO Please use the following to answer the next QUESTION: You are the chief privacy officer at HealthCo, a major hospital in a large U.S. city in state A. HealthCo is a HIPAA-covered entity that provides healthcare services to more than 100,000 patients. A third-party cloud computing service provider, CloudHealth, stores and manages the electronic protected health information (ePHI) of these individuals on behalf of HealthCo. CloudHealth stores the data in state B. As part of HealthCo’s business associate agreement (BAA) with CloudHealth, HealthCo requires CloudHealth to implement security measures, including industry standard encryption practices, to adequately protect the data. However, HealthCo did not perform due diligence on CloudHealth before entering the contract, and has not conducted audits of CloudHealth’s security measures. A CloudHealth employee has recently become the victim of a phishing attack. When the employee unintentionally clicked on a link from a suspicious email, the PHI of more than 10,000 HealthCo patients was compromised. It has since been published online. The HealthCo cybersecurity team quickly identifies the perpetrator as a known hacker who has launched similar attacks on other hospitals – ones that exposed the PHI of public figures including celebrities and politicians. During the course of its investigation, HealthCo discovers that CloudHealth has not encrypted the PHI in accordance with the terms of its contract. In addition, CloudHealth has not provided privacy or security training to its employees. Law enforcement has requested that HealthCo provide its investigative report of the breach and a copy of the PHI of the individuals affected. A patient affected by the breach then sues HealthCo, claiming that the company did not adequately protect the individual’s ePHI, and that he has suffered substantial harm as a result of the exposed data. The patient’s attorney has submitted a discovery request for the ePHI exposed in the breach. What is the most effective kind of training CloudHealth could have given its employees to help prevent this type of data breach?

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Explanation

Phishing is a form of social engineering that involves sending fraudulent emails or other messages that appear to come from a legitimate source, but are designed to trick recipients into revealing sensitive information, such as passwords, account numbers, or personal identifiers1. Phishing is one of the most common and effective methods of cyberattacks, and it can lead to data breaches, identity theft, ransomware infections, or other serious consequences2. Therefore, training on how to recognize and avoid phishing attempts is crucial for any organization that handles sensitive data, especially ePHI, which is subject to strict regulations under HIPAA3. Training on techniques for identifying phishing attempts can help employees to spot the signs of a phishing email, such as: Sender’s address or domain name that does not match the expected source or contains spelling errors4 Generic salutations or impersonal tone that do not address the recipient by name or use proper grammar4 Urgent or threatening language that creates a sense of pressure or fear and asks the recipient to take immediate action, such as clicking on a link, opening an attachment, or providing information4 Suspicious links or attachments that may contain malware or lead to fake websites that mimic the appearance of a legitimate site, but have a different URL or request login credentials or other data4 Requests for sensitive information that are unusual or out of context, such as asking for passwords, account numbers, or personal identifiers that the sender should already have or should not need4 Training on techniques for identifying phishing attempts can also help employees to learn how to respond to a phishing email, such as: Not clicking on any links or opening any attachments in the email4 Not replying to the email or providing any information to the sender4 Reporting the email to the IT department or security team and deleting it from the inbox4 Verifying the legitimacy of the email by contacting the sender directly using a different channel, such as phone or another email address4 Updating the antivirus software and scanning the device for any malware infection4 Training on techniques for identifying phishing attempts is the most effective kind of training that CloudHealth could have given its employees to help prevent this type of data breach, because it would have enabled them to recognize the phishing email that compromised the PHI of more than 10,000 HealthCo patients, and to avoid falling victim to it. Training on the terms of the contractual agreement with HealthCo, the difference between confidential and non-public information, or CloudHealth’s HR policy regarding the role of employees involved in data breaches, while important, would not have been as effective in preventing this specific type of data breach, because they would not have addressed the root cause of the breach, which was the phishing email. Reference: 1: IAPP, Phishing, https://iapp.org/resources/glossary/phishing/ 2: SpinOne, The Top 5 Phishing Awareness Training Providers 2023, https://spinbackup.com/blog/phishing-awareness-training-best-providers/ 3: IAPP, HIPAA, https://iapp.org/resources/glossary/hipaa/ 4: Expert Insights, The Top 11 Phishing Awareness Training and Simulation Solutions, https://expertinsights.com/insights/the-top-11-phishing-awareness-training-and-simulationsolutions/

Question 17 of 25

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