If a CSP stores only encrypted ePHI and does not have a decryption key, is it a HIPAA business associate?


Yes, because the CSP receives and maintains (e.g., to process and/or store) electronic protected health information (ePHI) for a covered entity or another business associate.  Lacking an encryption key for the encrypted data it receives and maintains does not exempt a CSP from business associate status and associated obligations under the HIPAA Rules.  An entity that maintains ePHI on behalf of a covered entity (or another business associate) is a business associate, even if the entity cannot actually view the ePHI.[1]  Thus, a CSP that maintains encrypted ePHI on behalf a covered entity (or another business associate) is a business associate, even if it does not hold a decryption key[i] and therefore cannot view the information.  For convenience purposes this guidance uses the term no-view services to describe the situation in which the CSP maintains encrypted ePHI on behalf of a covered entity (or another business associate) without having access to the decryption key.

While encryption protects ePHI by significantly reducing the risk of the information being viewed by unauthorized persons, such protections alone cannot adequately safeguard the confidentiality, integrity, and availability of ePHI as required by the Security Rule.  Encryption does not maintain the integrity and availability of the ePHI, such as ensuring that the information is not corrupted by malware, or ensuring through contingency planning that the data remains available to authorized persons even during emergency or disaster situations.  Further, encryption does not address other safeguards that are also important to maintaining confidentiality, such as administrative safeguards to analyze risks to the ePHI or physical safeguards for systems and servers that may house the ePHI.


Security Rule Considerations

All CSPs that are business associates must comply with the applicable standards and implementation specifications of the Security Rule with respect to ePHI.  However, in cases where a CSP is providing only no-view services to a covered entity (or business associate) customer, certain Security Rule requirements that apply to the ePHI maintained by the CSP may be satisfied for both parties through the actions of one of the parties.  In particular, where only the customer controls who is able to view the ePHI maintained by the CSP, certain access controls, such as authentication or unique user identification, may be the responsibility of the customer, while others, such as encryption, may be the responsibility of the CSP business associate.  Which access controls are to be implemented by the customer and which are to be implemented by the CSP may depend on the respective security risk management plans of the parties as well as the terms of the BAA.  For example, if a customer implements its own reasonable and appropriate user authentication controls and agrees that the CSP providing no-view services need not implement additional procedures to authenticate (verify the identity of) a person or entity seeking access to ePHI, these Security Rule access control responsibilities would be met for both parties by the action of the customer.

However, as a business associate, the CSP is still responsible under the Security Rule for implementing other reasonable and appropriate controls to limit access to information systems that maintain customer ePHI.  For example, even when the parties have agreed that the customer is responsible for authenticating access to ePHI, the CSP may still be required to implement appropriate internal controls to assure only authorized access to the administrative tools that manage the resources (e.g., storage, memory, network interfaces, CPUs) critical to the operation of its information systems.  For example, a CSP that is a business associate needs to consider and address, as part of its risk analysis and risk management process, the risks of a malicious actor having unauthorized access to its system’s administrative tools, which could impact system operations and impact the confidentiality, integrity and availability of the customer’s ePHI.  CSPs should also consider the risks of using unpatched or obsolete administrative tools.  The CSP and the customer should each confirm in writing, in either the BAA or other documents, how each party will address the Security Rule requirements. 

Note that where the contractual agreements between a CSP and customer provide that the customer will control and implement certain security features of the cloud service consistent with the Security Rule, and the customer fails to do so, OCR will consider this factor as important and relevant during any investigation into compliance of either the customer or the CSP.  A CSP is not responsible for the compliance failures that are attributable solely to the actions or inactions of the customer, as determined by the facts and circumstances of the particular case.

Privacy Rule Considerations

A business associate may only use and disclose PHI as permitted by its BAA and the Privacy Rule, or as otherwise required by law.  While a CSP that provides only no-view services to a covered entity or business associate customer may not control who views the ePHI, the CSP still must ensure that it itself only uses and discloses the encrypted information as permitted by its BAA and the Privacy Rule, or as otherwise required by law.  This includes, for example, ensuring the CSP does not impermissibly use the ePHI by blocking or terminating access by the customer to the ePHI.[ii]

Further, a BAA must include provisions that require the business associate to, among other things, make available PHI as necessary for the covered entity to meet its obligations to provide individuals with their rights to access, amend, and receive an accounting of certain disclosures of PHI in compliance with 45 CFR § 164.504(e)(2)(ii)(E)-(G).  The BAA between a no-view CSP and a covered entity or business associate customer should describe in what manner the no-view CSP will meet these obligations – for example, a CSP may agree in the BAA that it will make the ePHI available to the customer for the purpose of incorporating amendments to ePHI requested by the individual, but only the customer will make those amendments.

Breach Notification Rule Considerations

As a business associate, a CSP that offers only no-view services to a covered entity or business associate still must comply with the HIPAA breach notification requirements that apply to business associates.  In particular, a business associate is responsible for notifying the covered entity (or the business associate with which it has contracted) of breaches of unsecured PHI.  See 45 CFR § 164.410.  Unsecured PHI is PHI that has not been destroyed or is not encrypted at the levels specified in HHS’ Guidance to Render Unsecured Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals.[iii]  If the ePHI that has been breached is encrypted consistent with the HIPAA standards set forth in 45 CFR § 164.402(2) and HHS’ Guidance,[iv] the incident falls within the breach “safe harbor” and the CSP business associate is not required to report the incident to its customer.  However, if the ePHI is encrypted, but not at a level that meets the HIPAA standards or the decryption key was also breached, then the incident must be reported to its customer as a breach, unless one of the exceptions to the definition of “breach” applies.  See 45 CFR § 164.402.  See also 45 CFR § 164.410 for more information about breach notification obligations for business associates.

[i] A key used to encrypt and decrypt data, also called a cryptographic key, is “[a] parameter used in conjunction with a cryptographic algorithm that determines its operation in such a way that an entity with knowledge of the key can reproduce or reverse the operation, while an entity without knowledge of the key cannot.”  See NIST SP 800-47 Part 1 Revision 4, Recommendation for Key Management Part 1: General (January 2016). Available at http://nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-57pt1r4.pdf

[ii] See OCR FAQ regarding impermissible blocking of covered entity access to ePHI by a business associate http://www.hhs.gov/hipaa/for-professionals/faq/2074/may-a-business-associate-of-a-hipaa-covered-entity-block-or-terminate-access/index.html.

[iii] See OCR guidance regarding unsecured PHI that is subject to the Breach Notification Rule requirements http://www.hhs.gov/hipaa/for-professionals/breach-notification/guidance/index.html.

[iv] Ibid.

Content created by Office for Civil Rights (OCR)
Content last reviewed on October 6, 2016