Personal Information: Data Breaches Are Frequent, but Evidence of Resulting Identity Theft Is Limited; However, the Full Extent Is Unknown
Released: 2007-07-05T00:00:00

Letter

Background

Breaches of sensitive personal data in recent years at companies, universities, government agencies, and other organizations have heightened public awareness about data security and the risks of identity theft, and have led to the introduction of breach notification requirements in many state legislatures. As of April 2007, at least 36 states had enacted some form of law requiring that affected individuals be notified in the event of a data breach; California’s law, enacted in 2002, was the first such state requirement. States’ notification requirements vary, particularly with regard to the applicable notification standard—the event or circumstance that triggers a required notification. Requirements also vary in terms of the data to which they apply—for example, some apply to paper documents as well as electronic records.

There is currently no federal statute that requires most companies and other entities that experience a data breach to notify individuals whose personal information was lost or stolen. However, the Gramm-Leach-Bliley Act established requirements for federally supervised financial institutions to safeguard customer information. To clarify these requirements, the federal banking regulators issued interagency guidance in 2005 to the banks, thrifts, and credit unions they supervise related to their handling of data breaches. Under this guidance, these institutions are expected to develop and implement a response program to address unauthorized access to customer information maintained by the institution or its service providers; and if they experience a breach, they are to notify their primary federal regulator as soon as possible and—depending on the circumstances of the incident—notify their affected customers. In addition, in September 2006 the President’s Identity Theft Task Force developed guidance for federal agencies on responding to breaches involving agency data, including the factors to consider in determining whether to notify affected individuals. The task force released a strategic plan for combating identity theft in April 2007, which contained among its recommendations a proposal for establishing a national breach notification requirement. Further, in December 2006, the Department of Veterans Affairs Information Security Enhancement Act of 2006 became law, which, among other things, requires VA to prescribe regulations providing for the notification of data breaches occurring at the department. A number of bills have been introduced in Congress that would more broadly require companies and other entities to notify individuals when such breaches occur, and Congress has held several hearings related to data breaches.

Identity theft occurs when individuals’ identifying information is used without authorization in an attempt to commit fraud or other crimes. There are two primary forms of identity theft. First, identity thieves can use financial account identifiers, such as credit card or bank account numbers, to take over an individual’s existing accounts to make unauthorized charges or withdraw money. Second, thieves can use identifying data, which can include such things as SSNs and driver’s license numbers, to open new financial accounts and incur charges and credit in an individual’s name, without that person’s knowledge. This second form of identity theft is potentially the most damaging because, among other things, it can take some time before a victim becomes aware of the problem, and it can cause substantial harm to the victim’s credit rating. While some identity theft victims can resolve their problems quickly, others face substantial costs and inconvenience repairing damage to their credit records. According to FTC, millions of Americans have their identities stolen each year. Roughly 85 percent of these cases involve the misuse of existing accounts and 35 percent involve new account creation or other fraud. (Twenty percent of the total involve both.) Identity thieves obtain sensitive personal information using a variety of methods. One potential source is a breach at an organization that maintains large amounts of sensitive personal information. However, identity theft can also occur as a result of the loss or theft of data maintained by an individual, such as a lost or stolen wallet or a thief digging through household trash.

The Identity Theft and Assumption Deterrence Act of 1998 made identity theft a federal crime and charged FTC with taking complaints from identity theft victims; sharing these complaints with federal, state, and local law enforcement agencies; and providing the victims with informational materials to assist them. Because identity theft is typically not a stand-alone crime but rather a component of one or more crimes such as bank fraud, credit card fraud, and mail fraud, a number of federal law enforcement agencies can have a role in investigating identity theft crimes, including the Federal Bureau of Investigation (FBI), U.S. Postal Inspection Service (USPIS), U.S. Secret Service (Secret Service), the Office of the Inspector General of the Social Security Administration, and Immigration and Customs Enforcement.

Available Evidence Indicates That Data Breaches Occur Frequently and Under Varying Circumstances

Available evidence from media reports, federal and state agencies, and private institutions, collectively, suggests that data breaches occur with some frequency. For example, our analysis of the lists of data breaches compiled by three private research and advocacy organizations shows more than 570 breaches reported by the news media from January 2005 through December 2006. Data breaches have occurred across a range of entities, including federal, state, and local government agencies; retailers; financial institutions; colleges and universities; and medical facilities. Breaches have varied in size and have resulted from both criminal actions and accidental incidents. Most of the breaches reported in the news media have involved data that included personal identifiers such as SSNs, while others have involved only account information such as credit card numbers.

Several Sources Indicate That Breaches of Sensitive Personal Information Are Frequent

No federal agency or other organization tracks all data breaches, and definitions of what constitutes a data breach may vary. Although there are no comprehensive data on the extent of data breaches nationwide, government officials, trade association representatives, researchers, and consumer and privacy advocates we interviewed agreed that breaches of sensitive personal information occur frequently. For example, representatives of a variety of organizations—including the Department of Justice, California’s Office of Privacy Protection, the Consumer Data Industry Association (a trade group representing many information resellers), and the Ponemon Institute (a private research organization)— characterized data breaches in the United States as being “prevalent” or “common.” Although we did not identify comprehensive data on the extent of data breaches, available information from several sources does corroborate the anecdotal evidence that such breaches occur frequently.

Media Reports

Over the past few years, several hundred data breaches have been reported each year by newspapers and other news media. Three private organizations that focus on information privacy and security issues— Privacy Rights Clearinghouse, Identity Theft Resource Center, and Attrition—track data breaches reported in newspapers, magazines, and other publicly available sources of news and information. Our analysis of the three lists of data breaches maintained by these organizations indicated that at least 572 breaches were reported in the news media from January 2005 through December 2006. These breaches were reported to have affected more than 80 million records. However, for several reasons, these lists likely understate the true extent of data breaches in the United States. First, organizations might not voluntarily disclose data breaches that they experience. Second, some breaches that organizations do disclose may not appear in the news media, particularly if the breach was limited in scope. Finally, the three organizations compiling these lists may not have identified all of the breaches reported in the news media—for example, many breaches did not appear on all three lists, suggesting that none represents an exhaustive list of all breaches that have appeared in the news.

Federal Law Enforcement Agencies

Officials at federal law enforcement agencies told us that each year they conduct a significant number of criminal investigations that involve alleged breaches of sensitive personal information. For example, officials of the FBI’s Cyber Division told us that presently it has more than 1,300 pending cases of computer or network intrusions where data breaches resulted from unauthorized electronic access to computer systems, such as hackings, at public and private organizations. Officials at the Secret Service, which investigates certain cases where financial information has been lost or stolen, told us that in 2006, the service opened 327 cases involving network intrusions or other breaches at retailers, banks, credit card processors, telephone companies, educational institutions, and other organizations. Officials noted that they have seen a steady increase in the number of data breaches since 1986, when they began tracking computer fraud violations. Investigators at USPIS, the division of the U.S. Postal Service that investigates mail fraud, external mail theft, fraudulent changes of addresses, and other postal-related crimes, told us that the agency does not specifically track the number of data breaches in the private sector. However, despite limited data, investigators said their impression is that such data breaches likely occur frequently.

House Government Reform Committee and DHS

To obtain information on the prevalence of data breaches at federal agencies, in July 2006 the House Government Reform Committee asked federal agencies to provide details about incidents involving the loss or compromise of any sensitive personal information held by an agency or contractor from January 1, 2003, through July 10, 2006. Our analysis of the committee’s report found that 17 agencies reported that they experienced at least one breach and, collectively, the agencies reported to the committee more than 788 separate incidents.

The Federal Information Security Management Act of 2002 requires all federal agencies to report computer security incidents to a federal incident response center. The U.S. Computer Emergency Readiness Team—a component of DHS that monitors computer security incidents at federal agencies—serves as this response center. As such, data breaches at federal agencies involving certain sensitive information must be reported to the team within 1 hour of discovery of the incident. DHS staff told us that they receive information about breaches at federal agencies on a daily basis. In fiscal year 2006, the center tracked 477 incidents at 59 federal agencies or at federal contractors with access to government-owned data, according to information available as of January 29, 2007. In addition, a March 2007 audit investigation found that at least 490 laptop computers owned by the Internal Revenue Service and containing taxpayer information had been lost or stolen since 2003.

Federal Banking Regulators

The 2005 guidance issued by the five federal banking regulators provided that a depository institution should notify its primary federal regulator when it becomes aware of an incident involving unauthorized access to or use of sensitive customer information. The guidance applies to breaches that have occurred at the financial institutions themselves, as well as third- party entities such as data processors that act as service providers and maintain customer information. The five regulators differ in their methods and criteria for tracking breaches, but collectively they have tracked several hundred breaches over the past few years at roughly 17,000 institutions they supervise and at third-party entities. For example, the Federal Deposit Insurance Corporation (FDIC)—the primary federal supervisor for more than 5,000 state-chartered banks that are not members of the Federal Reserve System—received reports of 194 breaches at its regulated institutions from May 2005 through December 2006, as well as reports of 14 breaches at third-party companies that also affected these institutions’ customers. Similarly, officials at the Office of Thrift Supervision—which supervises more than 860 savings associations—told us that from April 2005 through December 2006, 56 of its institutions reported breaches at the institution itself and approximately 72 reported breaches at third-party entities that maintained their customer information.

State Agencies

Some states require entities experiencing data breaches to report them to designated state agencies. For example, the New York State Information Security Breach and Notification Act requires entities that experience security breaches to notify the state Attorney General’s Office, Consumer Protection Board, and the state Office of Cyber Security and Critical Infrastructure Coordination in cases when New York residents must be notified. Such data breaches include the unauthorized acquisition of computerized data that compromises the security, confidentiality, or integrity of unencrypted private information. Officials of the Office of New York State Attorney General told us that from December 7, 2005, through October 5, 2006, their office received notice of 225 breaches. Similarly, a North Carolina law requires that breaches of personal information (maintained in computerized, paper, or other media) affecting at least 1,000 persons be reported to the Consumer Protection Division of the state Office of the Attorney General. An official in that office told us that from December 2005 through December 2006, it had received reports of 91 breach incidents.

Other Sources

Information that we obtained from several other sources suggests that breaches of sensitive personal information occur with some frequency across a variety of sectors. For example, EDUCAUSE, a nonprofit association that addresses technology issues in higher education, conducted a survey in 2005 on data security at higher education institutions in the United States and Canada. Twenty- six percent of the 490 institutions that responded said they had experienced a security incident in the past year that resulted in the compromise of confidential information.

The American Hospital Association collected information, at our request, in October 2006 from a nonrepresentative group of 46 large hospitals on breaches of sensitive personal information (excluding medical records) that they had experienced since January 2003. Collectively, 13 of the 46 hospitals reported a total of 17 data breach incidents.

The Ponemon Institute, a private company that researches privacy and security practices, conducted a survey of 51,433 U.S. adults and received responses from 9,154 (a response rate of about 18 percent). About 12 percent of the survey respondents said they recalled receiving notification of a data security breach involving their personal information.

The CMO Council, an organization serving marketing executives, reported that 16 percent of consumers who responded to a Web-based panel reported that a company had lost or compromised their personal, financial, or medical information. An additional 32 percent of respondents said they were not sure.

Several other studies, while not focusing specifically on breaches of sensitive personal information, have found more generally that information security vulnerabilities are widespread among U.S. and global companies.

Information from multiple sources indicates that data breaches at companies, government agencies, retailers, and other entities have occurred frequently in recent years, involving millions of records of sensitive personal information. We have reported in the past that no federal law explicitly requires most companies and other entities to safeguard all of the sensitive personal information they may hold. We also have suggested that to ensure that sensitive personal information is protected on a more consistent basis, Congress should consider expanding requirements to safeguard such information. The frequency of data breaches identified in this report underscores the need for entities in the public and private sectors to improve the security of sensitive personal information and further corroborates that additional federal action may be needed in this area.

Source, Cause, Size, and Content of Breaches Have Varied Widely

According to government officials, researchers, and media reports, data breaches have occurred among a wide variety of entities and as a result of both intentional actions and accidental losses. These breaches also have varied in size and in the types of data compromised.

Type of Entity

Data breaches have been reported at a wide range of public and private institutions, including federal, state, and local government agencies; public and private colleges and universities; hospitals and other medical facilities; retailers; banks and other financial institutions; information resellers; and others. For example, in the weeks leading up to the highly publicized 2005 CardSystems breach, the media also had reported breaches at, among other entities, a large hospital, a university, a global financial institution, a federal regulatory agency, and a major technology company.

According to Attrition, of the breaches it tracked as reported in the news media in 2005 and 2006, 33 percent of the breaches occurred at educational institutions, 32 percent at financial services institutions, 25 percent at government agencies, and 10 percent at medical facilities, although breaches reported in the news media may not be representative of all breaches. Similarly, the data security firm ID Analytics examined 70 data breaches that were reported by the news media from February through September 2005. According to company officials, 46 percent of these breaches occurred at educational institutions, 16 percent at financial institutions, 14 percent at retailers, 11 percent at government agencies, 7 percent at medical facilities, and 6 percent at information resellers.

Another way to analyze where data breaches have occurred is to look at the number of records breached (as opposed to the number of breaches themselves). Our analysis of the list maintained by Attrition found that 54 percent of breached records involved financial institutions, 34 percent involved government agencies, 4 percent involved educational institutions, and 3 percent involved medical facilities. ID Analytics’ report found that 57 percent of breached records involved financial institutions, 22 percent involved retailers, 13 percent involved educational institutions, 4 percent involved information resellers, 2 percent involved government agencies, and 2 percent involved medical facilities.

Cause of Breach

According to government officials, researchers, and media reports, data breaches of sensitive personal information have occurred as a result of both intentional actions as well as negligence or accidental losses. In some cases, individuals intentionally steal information for the purpose of committing fraud or identity theft. Breaches involving intentional actions have included: Hacking, or accessing computer systems without authorization. For example, in 2007 the retailer TJX Companies reported unauthorized intrusions into its computer systems that may have breached millions of customers’ credit card and driver’s license information.

Employee theft. For example, in 2006, a former employee of the American Red Cross pled guilty to stealing personally identifiable information from a blood donor database.

Theft of physical equipment. In 2005, for instance, a laptop containing the names and SSNs of more than 98,000 students, alumni, and others was stolen from the University of California at Berkeley.

Deception or misrepresentation to obtain unauthorized data. In 2005, the information reseller ChoicePoint acknowledged that the personal records it held on approximately 162,000 consumers had been compromised by individuals who posed as legitimate subscribers to the company’s information services.

Breaches involving negligence or accidental losses of data have included the following: Loss of laptop computers or other hardware. For example, in 2006, the Department of Labor reported that an employee lost a laptop containing personal information on 1,137 individuals.

Loss of data tapes. For example, in 2004, Bank of America lost backup tapes containing personal information of 1.2 million government charge card holders while the tapes were being transported to a data center.

Unintentional exposure on the Internet. In 2006, according to media reports, the U.S. Department of Education left unprotected on a Web site the personally identifiable information, including SSNs, of up to 21,000 recipients of federal student loans.

Improper disposal of data, such as leaving sensitive personal data on unshredded documents in a publicly accessible dumpster.

We did not identify comprehensive data that reliably provide overall statistics on the causes of known data breaches. However, our review of the 24 largest data breaches reported in the news media (discussed in more detail later in this report) found that 12 breaches apparently involved intentional acts by hackers or employees illegally accessing or using data, 5 involved stolen laptops or other computer equipment, 4 involved lost computer backup tapes, 2 involved the use of deception to gain access to data, and 1 involved the possible unauthorized disclosure of data. In addition, some studies indicate that most breaches reported in the news media resulted from intentional acts rather than accidental occurrences such as a lost laptop computer. For example, in its study of 70 breaches, ID Analytics determined that 48 involved thefts committed with the apparent intention of accessing sensitive data. Eleven of the breaches involved thefts where sensitive consumer information was apparently stolen inadvertently as part of another crime (such as the theft of a laptop computer for its resale value), and another 11 breaches involved accidental loss (such as misplacement of a laptop computer). However, these data may overrepresent the proportion of all breaches that involve criminal activity, as such breaches are probably more likely than accidental losses to be reported to authorities and by the news media.

Number of Records Breached

Our analysis of the list maintained by Attrition of breaches reported by the news media found the median number of records breached to be 8,650. However, these data breaches varied considerably in size—ranging, for example, from a breach involving 10 records at a law firm to a breach involving as many as tens of millions of records at a credit card processing company. The breaches involving federal agencies that were reported to the House Government Reform Committee also varied in size—for example, several affected fewer than five records, while a breach at VA affected 26.5 million records.

Types of Data Breached

Comprehensive information does not exist on the types of data involved in all known data breaches. Among the list maintained by Attrition of breaches reported by the news media in 2005 and 2006—which may not be representative of all breaches—more than half involved SSNs and 11 percent involved credit card numbers (and 3 percent of the total involved both). In the remaining breaches, other types of account or personal information were involved, or the type of data breached was not reported. Logically, there may be an association between the type of data compromised and the type of entity experiencing the breach. For example, several educational institutions have experienced breaches of SSNs, which they may maintain as student identifiers, and several retail stores have experienced breaches of credit card numbers, which they often maintain on their customers.

Consequences of Data Breaches Are Not Fully Known, but Clear Evidence of Identity Theft Has Been Found in Relatively Few Breaches

Comprehensive information on the outcomes of data breaches is not available. Several cases have been identified in which a data breach appears to have resulted in identity theft, but available data and information from law enforcement and industry association representatives indicated that most breaches have not resulted in detected incidents of identity theft. For example, of 24 very large breaches we reviewed, 3 appeared to have resulted in fraud on existing accounts and 1 in the unauthorized creation of new accounts. Determining the link between data breaches and identity theft is challenging because, among other things, identity theft victims often do not know how their personal information was obtained. However, the circumstances of a breach, including the type of information compromised and how the breach occurred, can greatly affect the potential risk of identity theft.

Federal Law Enforcement Agencies and Industry Associations Identified Limited Instances of Breaches Leading to Identity Theft

In general, representatives of law enforcement agencies, industry and trade associations, and consumer and privacy advocacy organizations told us that no comprehensive data are available on the consequences of data breaches. Several cases have been identified where there is evidence that a data breach resulted in identity theft, including account fraud or unauthorized creation of new accounts. At the same time, available data and information from the officials we contacted indicated that most breaches have not resulted in detected incidents of identity theft.

We asked representatives of the FBI, Secret Service, USPIS, and Immigration and Customs Enforcement—a component of DHS that has investigated cases where stolen identities were used to secure jobs—the extent to which data breaches they investigated resulted in some form of identity theft. Representatives of all of these agencies told us that their investigations of data breaches do not typically allow them to fully ascertain how stolen data are used. Similarly, they noted that investigations of identity theft do not always reveal the source of the data used to commit the crime.

However, the representatives were able to provide us with a limited number of examples in which data breaches they investigated had allegedly resulted in some form of identity theft. For example, in a 2006 investigation by USPIS, an employee of a credit card call center allegedly compromised at least 35 customers’ accounts and used some of the information to purchase approximately $65,000 in gift cards. The representatives of federal law enforcement agencies noted that cases in which data breaches have been linked to identity theft often have involved instances of unauthorized access by employees. For example, an official at Immigration and Customs Enforcement stated that her agency, in cooperation with other agencies, has investigated cases in which government employees allegedly had improperly accessed and sold sensitive personal information that was then used by illegal immigrants to secure employment.

In addition, in 2005 FTC settled charges with BJ’s Wholesale Club in which alleged security breaches resulted in several million dollars in fraudulent purchases using customers’ credit and debit card data. As discussed later in this report, FTC has also taken enforcement actions related to data breaches at several other companies, including ChoicePoint, CardSystems, and DSW, in which it uncovered evidence that the breaches resulted in identity theft.

Many of the law enforcement officials said that, based on their experience, data breaches that result in harm have usually involved fraud on existing accounts (such as credit card fraud) rather than the unauthorized creation of new accounts. Secret Service representatives noted that using illicit credit and debit card numbers and bank account information is much easier and less labor intensive than using personally identifiable information to fraudulently open new accounts. Officials at Secret Service, FBI, and USPIS all said that identity theft involving the creation of new accounts often results not from data breaches, but from other sources, such as retrieving personal information by sifting through a family’s household trash.

In examining a selection of five breaches that occurred from 2003 through 2005 that were reported as having involved five federal agencies— Department of Justice, FDIC, Internal Revenue Service, National Park Service, and the Navy—we found that the circumstances behind these breaches varied widely. At least two of the breaches occurred at vendors or contractors that held sensitive data on agency employees, rather than at the agency itself. In addition, we found that a breach reported in the news media as having involved the National Park Service actually involved a not-for-profit organization that manages eParks, according to a representative of that organization. Four of the five breaches reported as having involved federal agencies were not believed to have resulted in identity theft, according to officials of the entities involved. The breach at FDIC resulted in an estimated 27 cases of identity theft when data inappropriately accessed by a former FDIC intern were used to take out more than $425,000 in fraudulent loans in the names of FDIC employees, according to agency officials.

Industry and trade associations representing entities that maintain large amounts of information—banks, retailers, colleges, information resellers, and hospitals—told us that they had limited knowledge about the harm caused by data breaches that occur in their industries. However, in some cases, they provided information or anecdotal evidence on the extent to which such breaches may have led to some form of identity theft. For example, the 46 hospitals that the American Hospital Association surveyed at our request reported that of 17 breaches that had occurred since 2003, three had resulted in fraudulent activity on existing accounts and another three resulted in other forms of identity theft, including one case where the information was used to file false income tax refunds. The identity theft in these cases involved small numbers of victims—usually just one.

Representatives of the American Council on Education and two other higher education associations stated that while data breaches at colleges and universities were not uncommon, they were aware of little to no identity theft that had resulted from such breaches. Representatives of the American Bankers Association, the National Retail Federation, and the Consumer Data Industry Association told us they were unable to determine how prevalent data breaches are among their institutions or how often such breaches lead to consumer harm. Representatives at the National Retail Federation noted that breaches at retailers may be more likely to result in fraud on existing accounts than in new account creation, since most retailers do not maintain the personally identifiable information needed to steal someone’s identity.

Of 24 Large Publicly Reported Breaches, 4 Apparently Resulted in Known Cases of Identity Theft

Using lists of data breaches compiled by the Identity Theft Resource Center, Privacy Rights Clearinghouse, and Congressional Research Service, we identified the 24 largest breaches (measured by number of records) that were reported in the news media from January 2000 through June 2005. To gather information on these incidents, we interviewed or collected written responses from representatives of the entity experiencing the breach and reviewed publicly available information, such as media reports, news releases, testimonies, and court documents. In some cases, when feasible, we also spoke with law enforcement investigators. We identified those cases where this information collectively indicated that the breach appeared to have resulted in some form of identity theft. Ultimately, the determination of whether particular conduct violated a law prohibiting identity theft would be a matter of law for the courts.

Although these lists characterized each of these 24 incidents as data breaches, the circumstances of the incidents varied. While 19 of the incidents clearly met our definition of data breach (i.e. unauthorized or unintentional exposure, disclosure, or loss of sensitive personal information), four cases involved hackers who may or may not have actually accessed sensitive information. In one other incident, a university employee with access to sensitive personal data was indicted on unrelated fraud charges. A university official told us he did not believe this incident should necessarily be characterized as a data breach since there was no evidence the employee actually misused university data.

The available evidence that we reviewed indicated that 18 of these 24 breaches were not known to have resulted in any identity theft. As shown in table 1, three breaches were believed to have resulted in account fraud and one resulted in the unauthorized creation of new accounts. In two other cases, we were not able to gather sufficient information on whether harm appeared to have resulted from the breach. Further, because of the challenges in linking data breaches with identity theft, in some cases our review may not have uncovered instances of harm potentially resulting from these breaches. In some instances, investigators or company representatives reported that they were able to determine with a high degree of certainty—through forensic investigation or other means—that unauthorized parties had not accessed the data. In other instances, these representatives said that they were not aware of any account fraud that resulted, but they acknowledged that there was no way to know for sure. Moreover, determining potential harm may be particularly challenging with very large breaches because the volume of records involved can make it difficult to link individual victims to the breach.

The one large breach we identified that apparently resulted in the unauthorized creation of new accounts involved ChoicePoint, an information reseller. In 2005, the company acknowledged that the personal records it held on approximately 162,000 consumers had been compromised by individuals who posed as legitimate subscribers to the company’s information services. FTC reached a civil settlement in 2006 with the company that established a fund for consumer redress to reimburse potential victims of identity theft, and the agency has worked with law enforcement officials to identify such victims.

The three large breaches we identified that appeared to result in fraud on existing accounts included the following: CardSystems, a credit card payment processor, reported a May 2005 breach in which a hacker accessed data such as names, card account numbers, and expiration dates. The total number of compromised accounts is unclear. FTC staff alleged in a 2006 civil complaint that the breach had compromised data associated with tens of millions of credit and debit cards, but a CardSystems official stated in congressional testimony that only 239,000 accounts were compromised. Officials of the Office of the Comptroller of the Currency—who surveyed the national banks they supervise in order to determine the amount of fraudulent charges that resulted from the breach—said that customers of 110 banks were affected by this incident and losses of more than $13 million in fraudulent charges on customers’ cards were reported by 24 of these institutions.

DSW, a shoe retailer, said in an April 2005 news release that it had experienced a data breach in which a hacker accessed the names and card numbers associated with 1.4 million credit and debit card transactions at 108 of its stores, as well as checking account numbers and driver’s license numbers from 96,000 check transactions. According to a complaint filed by FTC in March of 2006, there allegedly have been fraudulent transactions on some of these accounts.

CD Universe, an Internet-based music store, reportedly experienced a breach in December 1999 in which a hacker accessed as many as 300,000 names, addresses, and credit card numbers from the company Web site, according to media reports and a company official. The hacker allegedly used some of the stolen credit card numbers to obtain money for himself.

Challenges Exist in Determining the Link between Data Breaches and Identity Theft

Determining the link between data breaches and identity theft is challenging for several reasons. First, identity theft victims often do not know how their personal information was obtained. According to FTC, in approximately 65 percent of the identity theft complaints it received from October 1, 2005, through August 31, 2006, the victim did not know or report how the information was compromised. Second, victims may misattribute how their data were obtained. For example, federal officials and representatives of a private group that assists victims said that consumers who are notified of a breach often assume that any perceived mistakes on their credit card statements or credit report were a result of the breach. As a result, no government agency maintains comprehensive data on the underlying cause of identity theft. FTC told us that its Identity Theft Data Clearinghouse is limited to self-reported complaints and therefore does not contain statistically reliable information that would allow the agency to determine a link between data breaches and identity theft. Similarly, according to FBI, data maintained by the Internet Crime Complaint Center does not include information sufficient to determine the link between data breaches and identity theft.

Third, law enforcement officials told us that in some cases, stolen data may be held for up to a year or more before being used to commit identity theft. Further, once stolen data have been sold or posted on the Web, fraudulent use of that information may continue for years. As a result, studies that attempt to measure the harm resulting from data breaches cannot necessarily rule out all future harm. Finally, conducting comprehensive studies of data breaches and identity theft can be hindered by issues of privacy and confidentiality. For example, companies that have experienced breaches may be unable or unwilling to provide information about affected individuals to researchers.

Some studies conducted by private researchers have sought to determine the extent to which data breaches result in identity theft, but our review found them to contain methodological limitations. One research firm conducted a study of four data breaches, analyzing credit and other application data for suspicious relationships that indicated fraud. The study estimated that no more than 0.10 percent of individuals whose data had been breached experienced resulting identity theft in the form of unauthorized new account creation. However, because the study reviewed only four data breaches, it cannot be considered representative of other breaches. Moreover, two of these breaches did not involve personally identifiable information and thus would not be expected to create a risk of fraud involving new account creation.

Another private research firm surveyed approximately 9,000 individuals about whether they had ever received a notification from an organization about the loss or theft of their personal information. Of the approximately 12 percent of individuals who reported they had received such a notification, 3 percent—or 33 people—said they believed they had suffered identity theft as a result. However, these data are subject to limitations; among other things, individuals are often unaware of whether any fraud they have suffered was, in fact, due to a data breach. A third firm projected in a study that 0.8 percent of consumers whose information a data breach compromised would experience fraud as a result. However, we question the reliability of this estimate, in part because of assumptions made about the number of consumers affected by data breaches.

Type of Data Compromised and Other Factors Influence Potential for Resulting Consumer Harm

The type of data compromised in a breach can effectively determine the potential harm that can result. For example, credit or debit card information such as card numbers and expiration dates generally cannot be used alone to open unauthorized new accounts. Some of the largest and most highly publicized data breaches in recent years largely involved credit or debit card data rather than personally identifiable information. As a result, these breaches put affected consumers at risk of account fraud but not necessarily at risk of fraud involving unauthorized creation of new accounts—the type of identity theft generally considered to have a more harmful direct effect on consumers. While credit and debit card fraud is a significant problem—the FTC estimates it results in billions of dollars in losses annually—existing laws limit consumer liability for such fraud and, as a matter of policy, some credit and debit card issuers may voluntarily cover all fraudulent charges. In contrast, the unauthorized creation of new accounts—such as using someone else’s identity to open credit card or bank accounts, originate home mortgages, file tax returns, or apply for government benefits—can result in substantial financial costs and other hardships.

In addition to the type of data compromised in a breach, several additional factors can influence the extent to which a breach presents the risk of identity theft. These include the following: Intent. Breaches that are the result of intentional acts—such as hacking into a server to obtain sensitive data—generally are considered to pose more risk than accidental breaches such as a lost laptop or the unintentional exposure of sensitive data on the Internet, according to federal agency officials. However, in some cases, such as the theft of a laptop containing personal information, it may be unknown whether the laptop was stolen for the hardware, the personal data, or both.

Encryption. Encryption—encoding data so that it can only be read by authorized individuals—can in some cases prevent unauthorized access. However, some forms of encryption are more effective than others, and encryption does not necessarily preclude fraudulent use of data—for example, if the key used to unencrypt the data is also compromised.

Hardware requirements. Data that only can be accessed using specialized equipment and software may be less likely to be misused in the case of a breach. For example, some entities that have lost data tapes have stated that criminals would require specific data reading equipment and expertise in how to use it to access the information.

Number of records. Larger breaches may pose a greater overall risk that at least one individual would become a victim of identity theft. At the same time, given the resources needed to commit identity theft, breaches of very large numbers of records may pose less risk to any one individual whose data were compromised.

Breach Notification Requirements Can Serve to Encourage Better Data Security Practices and Alert Consumers, but They Also Present Costs and Challenges

Breach notification requirements have several potential benefits, including creating incentives for entities to improve their data security practices (and thus prevent potential breaches from occurring), allowing affected consumers to take measures to prevent or mitigate identity theft, and serving to respect individuals’ basic right to know when their personal information is compromised. At the same time, breach notification requirements present costs, both for developing compliance strategies and for actual notifications in the event of a breach. Further, there is the risk of overnotification, or inundating consumers with frequent notifications of breaches that may present little or no risk of identity theft or other harm. Thus, policymakers face the challenge of setting a notification standard that allows individuals to take steps to protect themselves where the risk of harm exists, while ensuring they are only notified in cases where the level of risk warrants such action.

Notification Requirements May Create Incentives for Improved Data Security and Allow Consumers the Opportunity to Mitigate Risks

According to our review of studies and interviews with representatives in government, academia, and private industry, breach notification requirements have several potential benefits, as follows: Incentives for Improved Data Security. Breach notification requirements can provide an incentive for companies and other entities to increase their data security measures to avoid the possible financial and reputational risks that can be associated with a publicly reported data breach. Representatives we contacted in the private, nonprofit, and government sectors told us that they believe that existing breach notification requirements in state laws, or the breach notification provisions in federal banking regulatory guidance, have provided entities with incentives to improve data security practices. For example, some representatives of companies and other organizations noted that passage of state notification laws led to companies reexamining data security procedures and making improvements, such as encrypting sensitive data and restricting consumer data that can be accessed online. Similarly, federal banking regulators told us that they believe their notification guidance has motivated regulated institutions to enhance data security. For example, according to officials at the Office of Thrift Supervision, its institutions have taken steps such as improving electronic firewalls and implementing formal incident response reporting systems.

Prevention of Identity Theft. Breach notification can provide consumers with the opportunity to take steps to protect themselves from possible identity theft. For example, consumers whose account information has been breached can monitor their bank or credit card statements for suspicious activity or close the affected accounts. Consumers whose personally identifiable information, such as SSN, has been breached can review their credit reports for suspicious activity or may choose to purchase a credit monitoring product that alerts them to changes that could indicate identity theft. In addition, affected consumers can place a fraud alert on their credit reports, which requires businesses to take certain identity verification steps before issuing credit. In some states, consumers can implement credit freezes, which block unauthorized third parties from obtaining the consumer’s credit report or score. Limited information exists on the steps individuals actually take when notified of a breach. In the 2005 Ponemon Institute survey of individuals that received notification letters, 50 percent said they did nothing, while the rest indicated they took actions such as monitoring their credit reports, canceling credit or debit cards, or closing bank accounts.

Respecting Consumers’ Right to Know. Some consumer advocates and others have argued that consumers have a right to know how their information is being handled. According to this view, basic rights of privacy dictate that consumers should be informed when their personal information has been compromised, even if the risk of harm is minimal. The principle that individuals should have ready means of learning about the use of their personal information is embedded in the Fair Information Practices, a set of internationally recognized privacy protection principles.

Improving Public Awareness. Public reporting of data breaches may raise general awareness among consumers about the risks of identity theft and ways they can mitigate these risks, such as periodically reviewing their credit reports. In addition, publicity surrounding a data breach resulting from notification can serve to deter the use of stolen information because presumably the thief knows that the breach is likely being investigated and the stolen data are being carefully monitored.

Breach Notification Requirements Present a Variety of Potential Costs

According to company representatives, researchers, regulators, and others, there are several different types of costs that may be associated with breach notification requirements. To begin with, entities subject to breach notification requirements may incur certain costs, regardless of whether they actually suffer a breach, or—if they do—regardless of whether they have to notify consumers. For example, entities may incur costs for developing and formalizing incident response plans.

There are also the costs associated with actual notifications—potentially including printing, postage, legal, investigative, and public relations expenses. Although comprehensive data on these costs do not exist, a 2006 Ponemon Institute survey of companies experiencing a data breach found that 31 companies that responded incurred an average of $1.4 million per breach, or $54 per record breached, for costs related to mailing notification letters, call center expenses, courtesy discounts or services, and legal fees. Similarly, a study by Gartner Research found that ChoicePoint spent $79 per affected account following its 2005 breach for professional fees, legal expenses, and communications to affected customers. A representative of the San Jose Medical Group told us it spent $100,000 to send notification letters to 187,000 patients following a data breach that occurred in 2005. Entities also may incur costs related to staffing call centers to field inquiries from consumers about the breach. For example, representatives of the University of California at Berkeley told us that following a 2005 breach of 98,000 records, the university spent $75,000 in staffing, telecommunications, and other call center costs.

Finally, banks whose customers’ account information is breached also may incur costs for remedial steps such as canceling existing accounts or replacing affected customers’ credit or debit cards—although such steps may not be required by the applicable breach notification requirements.

Entities experiencing a breach also often provide affected individuals with free credit monitoring services. For example, a representative of a large financial management company noted that offering free credit monitoring services after a breach has become standard industry practice, and costs, on average, between $20 and $40 per customer.

Challenges Exist in Complying with and Developing Breach Notification Requirements

Officials of companies and other entities we interviewed identified challenges such as interpreting ambiguous statutory language, identifying and locating affected consumers, and developing effective notification letters. In addition, policymakers face challenges in developing breach notification requirements, particularly in setting the appropriate standard to establish the circumstances under which consumers should be notified.

Complying with Notification Requirements

Companies and other entities we interviewed said they can face a number of challenges related to complying with the breach notification requirements in state laws or federal banking guidance. These include the following: Interpreting ambiguous provisions. Entities subject to breach notification requirements sometimes face challenges interpreting certain terms or provisions of notification laws. For example, an information security expert told us that some laws do not adequately define encryption, which could refer to anything from simple password protection to complex coding. Similarly, federal banking regulators acknowledged that their institutions sometimes face difficulty determining whether misuse of breached information is “reasonably possible,” such as when little information exists about the location of the data, the intent of a criminal who stole data, or the effectiveness of security features designed to render data inaccessible.

Addressing who is responsible. Notification requirements do not always fully address who should bear the cost of and responsibility for notification, particularly in cases where a third party is responsible for the breach. For example, representatives of some federal banking regulators and industry associations cited particular challenges associated with breaches of credit and debit card information by retailers. Banks that issue credit and debit cards compromised by a merchant that is not the bank’s service provider are generally not required by the banking regulators’ guidance to notify their customers, but nevertheless in some cases, they feel obliged to do so. Bank representatives with whom we spoke expressed concern that breaches of credit card information by third parties can adversely affect a bank’s reputation and result in costs related to notifying customers and reissuing cards.

Identifying affected consumers. Some entities we interviewed said that it can be difficult to identify which consumers may have been affected by a breach and obtain their contact information. For example, one representative at a state agency involved in a breach told us officials were unsure what data had been downloaded among records that may have been accessed on 600,000 people. Obtaining accurate and current mailing addresses for affected parties also can be difficult and costly, many entities told us. This can be a particular problem for entities, such as merchants, that have breached credit card numbers but do not themselves possess the mailing addresses associated with those numbers.

Developing clear and effective notification letters. We have noted in the past that public notices should be useful and easy to understand if they are to be effective. However, the 2005 study conducted by the Ponemon Institute found that 52 percent of survey respondents who received a notification letter said the letter was not easy to understand. In addition, consumers might be confused by other mail solicitations that may resemble notification letters. For example, officials at one large national bank noted that marketing solicitations for credit monitoring services often are made to resemble breach notification letters, potentially desensitizing or confusing consumers when a true notification letter arrives.

Complying with multiple state laws. Officials of companies with customers in multiple states and their trade associations noted that they face the challenge of complying with breach notification requirements that vary among the states, including who must be notified, the level of risk that triggers a notice, the nature of the notification, and exceptions to the requirement. Officials of companies we contacted noted that it is challenging to comply with these multiple requirements since most breaches involve customers in many states.

Setting an Appropriate Notification Standard

Existing state laws vary in terms of the notification standard—that is, the event or circumstance that triggers a required notification. For example, California has an expansive standard that requires notification in nearly all cases where unencrypted sensitive personal data “is reasonably believed to have been acquired by an unauthorized individual.” Other states employ a risk-based approach that incorporates into the standard the extent to which the data are likely to be misused. The standards vary in terms of what is required in cases where the risk of harm is unknown. For example, Vermont requires notification unless an entity can demonstrate that misuse of the breached data “is not reasonably possible.” In contrast, North Carolina requires notification only when it has been determined that the breach has resulted, or is reasonably likely to result, in illegal use of the data or creates a material risk of harm to a consumer. As shown in figure 1, whether or not a breach is subject to notification can depend on the specific notification standard.

Because of the difficulty of complying with multiple state requirements, many companies and industry representatives have argued for a consistent federal standard for breach notification that would preempt state notification laws. However, the National Association of Attorneys General, as well as some consumer and privacy groups, have expressed concern that a federal breach notification law could weaken consumer protections if it were to preempt stronger state laws. These groups have advocated a strong notification standard because, they say, the link between breaches and identity theft is not always clear and entities are not well equipped to assess the risk of harm resulting from a given breach. As a result, too narrow a notification standard may prevent consumers from taking action in cases that do in fact present some risk. Also, as noted earlier, some privacy groups and others believe that consumers have basic rights to be notified when their personal information has been breached, no matter what the circumstances. Moreover, they say that fears of “overnotification”—where consumers are inundated by frequent notifications—are unfounded, given that they are aware of no evidence of this occurring in states that currently have strict notification requirements.

By contrast, some representatives of the federal banking regulatory agencies, FTC, private companies, and other experts have expressed concern about overly expansive breach notification standards. They say that such standards may require businesses to notify consumers about minor and insignificant breaches. This in turn could eventually lead to overnotification and cause consumers to spend time and money taking proactive steps that are not necessary or, alternatively, to ignore notices when action is warranted. In addition, businesses and federal banking regulators have expressed concern about the financial burden that overnotification could cause. Overly broad notification standards could also have the effect of limiting entities’ reputational incentives for improving data security, if nearly all entities regularly issue notifications as a result of minor breaches. Representatives of the federal banking regulatory agencies have noted that they sought to strike an appropriate balance with their notification standard. Their guidance provides that, when a financial institution becomes aware of an incident of unauthorized access to sensitive customer information, the institution should conduct a reasonable investigation to promptly determine the likelihood that the information has been or will be misused. If the institution determines that misuse of the information has occurred or is reasonably possible, it should notify affected customers as soon as possible. The guidance is intended to provide notice to customers only when there is a reasonable expectation of misuse.

Similarly, the guidance for federal agencies developed by the President’s Identity Theft Task Force recommended that if an agency experiences a breach, it should analyze the risk of identity theft and tailor its response— which may include notifying individuals—to the nature and scope of the risk presented. The guidance noted that such a risk assessment can minimize the potentially significant costs of notification where little risk exists. The task force’s April 2007 strategic plan recommended the development of a national standard requiring all entities that maintain sensitive consumer information, in both the public and private sectors, to provide notice to consumers and law enforcement in the event of a breach. As with its guidance to federal agencies, the task force recommended that the standard be risk based to provide notice when consumers face a significant risk of identity theft but to avoid excessive notification.

As we have noted in the past, care is needed in defining appropriate criteria for data breaches that merit notification. The frequency of data breaches identified in this report suggests that a national breach notification requirement may be beneficial, in large part because of its role in further encouraging entities to improve their data security practices. However, because breaches vary in the risk they present, and because most breaches have not resulted in detected incidents of identity theft, a notification that is risk based appears appropriate. Should Congress choose to enact a federal breach notification requirement, use of the risk- based approaches that the federal banking regulators and the President’s Identity Theft Task Force advocate could avoid undue burden on organizations and unnecessary and counterproductive notifications to consumers.

Agency Comments

We provided a draft of this report to FTC, which provided technical comments that were incorporated in this report as appropriate. In addition, we provided selected portions of the draft to the Board of Governors of the Federal Reserve System, the Department of Justice, DHS, FDIC, the National Credit Union Administration, the Office of the Comptroller of the Currency, the Office of Thrift Supervision, the Social Security Administration, and USPIS, and also incorporated their technical comments as appropriate.

As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution of it until 30 days from the date of this letter. We will then send copies of this report to the Chairman, House Committee on Financial Services; the Chairman and Ranking Member, Senate Committee on Banking, Housing, and Urban Affairs; the Chairman and Ranking Member, Senate Committee on the Judiciary; the Chairman and Ranking Member, House Committee on the Judiciary; the Chairman and Vice Chairman, Senate Committee on Commerce, Science, and Transportation; and the Chairman and Ranking Member, House Committee on Energy and Commerce. We will also send copies to the Chairman of the Board of Governors of the Federal Reserve System, the Attorney General, the Secretary of the Department of Homeland Security, the Chairman of the Federal Deposit Insurance Corporation, the Chairman of the Federal Trade Commission, the Chairman of the National Credit Union Administration, the Comptroller of the Currency, the Director of the Office of Thrift Supervision, the Commissioner of the Social Security Administration, and the Postmaster General and Chief Executive Officer of the U.S. Postal Service. We will also make copies available to others upon request. In addition, the report will be available at no charge on GAO’s Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-8678 or woodd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II.

Appendix I: Scope and Methodology

Our report objectives were to examine (1) what is known about the incidence and circumstances of breaches of sensitive personal information; (2) what information exists on the extent to which breaches of sensitive personal information have resulted in identity theft; and (3) the potential benefits, costs, and challenges associated with breach notification requirements. We use the term “data breach” to refer to the unauthorized or unintentional exposure, disclosure, or loss of sensitive personal information by a company, government agency, university, or other public or private entity. Our scope was limited to breaches involving personal data, including financial data, that could be used to commit identity theft or other related harm, and we excluded breaches involving other types of sensitive data, such as medical records or proprietary business information. For the purposes of this report, the term “identity theft” is used broadly to refer to both fraud on existing accounts and the unauthorized creation of new accounts.

To address all three objectives, we conducted a literature search of relevant articles, reports, and studies. We also collected and analyzed documents from, and interviewed, officials of government agencies that investigate and track data breaches, including the Federal Trade Commission, the Department of Homeland Security, the Department of Justice, the U.S. Postal Inspection Service, and the Social Security Administration. We also interviewed staff at the five federal banking regulators—the Board of Governors of the Federal Reserve System, the Federal Deposit Insurance Corporation, the Office of the Comptroller of the Currency, the Office of Thrift Supervision, and the National Credit Union Administration. In addition, we spoke with representatives of the National Association of Attorneys General and organizations that address consumer protection and privacy issues, including Consumers Union, Electronic Privacy Information Center, Privacy Rights Clearinghouse, Attrition, and the Identity Theft Resource Center. We also spoke with three academic researchers who study issues related to data breaches and notification and an attorney who helps companies address data privacy and security issues. In addition, we reviewed studies on data breaches conducted by private and nonprofit research organizations, including the Ponemon Institute, ID Analytics, and Javelin Strategy and Research. We interviewed the studies’ authors and took other steps to ensure that the data and methodologies were sufficiently reliable for our purposes. We also spoke with representatives of the California Office of Privacy Protection and its advisory group and reviewed the office’s recommended practices for notification.

To address the first objective on the incidence and circumstances of data breaches, we reviewed lists of news media-reported data breaches that are compiled and maintained by three private research and advocacy organizations—Privacy Rights Clearinghouse, Attrition, and the Identity Theft Resource Center. We analyzed the three independent lists to create a single, nonduplicative list of data breaches that had been reported in the news media from January 2005 through December 2006. We took measures to ensure the lists were of sufficient quality for our purposes, including spot checking selected data and interviewing representatives of the three organizations on their methodologies. The Privacy Rights Clearinghouse, Attrition, and Identity Theft Resource Center lists contained 436, 453, and 462 breaches, respectively, for the time period we analyzed. Of the 572 breaches they collectively compiled, 59 percent appeared on all three lists, 19 percent appeared on two, and 22 percent appeared on one. Our analysis was based on the lists as they stood on February 15, 2007; these data may have changed because the lists are occasionally updated when the compilers learn of new breaches that may have occurred in the past.

We also collected available data from federal law enforcement agencies on the breaches they have investigated in recent years. In addition, the five federal banking regulators provided, at our request, data on the breaches of which they have been notified by the institutions they supervise. These data varied in usefulness and comprehensiveness because of the regulators’ differing methods of counting and tracking breaches and maintaining data on them. We also gathered data from two states, New York and North Carolina, which were selected because they were two large states that maintain centralized information on breaches. Further, we obtained available data from industry and trade associations representing key sectors—such as financial services, retail sales, higher education, hospitals, and information services—that have experienced data breaches. We also collected information on breaches experienced by federal agencies compiled by the House Government Reform Committee and the U.S. Computer Emergency Readiness Team, a component of the Department of Homeland Security.

To address the second objective, we selected for more detailed examination the 24 largest (in terms of number of records breached) data breaches reported in the news media from January 2000 through June 2005. We selected these breaches in August 2006 using the lists maintained by Privacy Rights Clearinghouse and Identity Theft Resource Center, as well as a similar compilation of breaches collected by the Congressional Research Service. We were not aware of the Attrition list at the time we made our selection. For each of these breaches, we reviewed news reports as well as publicly available documents such as testimonies and criminal indictments. We also conducted interviews, where possible, with representatives of the entities that experienced the breach and law enforcement agencies that investigated the breach. We identified those cases where this information collectively indicated that the breach appeared to have resulted in some form of identity theft. Ultimately, the determination of whether particular conduct violated a law prohibiting identity theft would be a matter of law for the courts. We did not directly contact individuals whose data had been affected by the breaches because of privacy concerns and because we did not have a systematic means of identifying them. We also reviewed five breaches that reportedly involved federal agencies—the Navy; the Internal Revenue Service; the Federal Deposit Insurance Corporation; the National Park Service; and the Department of Justice. These were selected to represent breaches that included different causes, types of data, and involvement by third-party vendors.

To examine the potential benefits, costs, and challenges associated with breach notification requirements, we reviewed the federal banking regulators’ proposed and final guidance related to breach notification, and interviewed representatives of each agency regarding their consideration of potential costs, benefits, and challenges during development of the guidance. Further, we reviewed the strategic plan and other documents issued by the President’s Identity Theft Task Force. In addition, we conducted a review of the effects of California’s breach notification law. We interviewed representatives of, and gathered information from, seven organizations to learn about their experiences complying with California’s breach notification law. These organizations were selected to represent a range of organization sizes and industry sectors. We also interviewed representatives of the California State Information Security Office, California State Assembly, California Office of Privacy Protection, and California Bankers Association.

We conducted our review from August 2006 through April 2007 in accordance with generally accepted government auditing standards.

Appendix II: GAO Contact and Staff Acknowledgments

Staff Acknowledgments

In addition to the contact named above, Jason Bromberg, Assistant Director; Randy Fasnacht; Marc Molino; Kathryn O’Dea; Carl Ramirez; Linda Rego; Barbara Roesmann; and Winnie Tsen made key contributions to this report.