Data Breach, News Events, Risk Analysis/Risk Management

Sutter Health Breach Update

This past week, Sutter Health released a statement stating that they are notifying 2,582 patients that personal information was included in billing documents a former employee emailed to their personal account without authorization. For all but two of the affected patients, no Social Security numbers, financial information or driver’s license data were included.

Despite the incident occurring on April 23, 2013, the breach was only discovered “during a thorough review of the former employee’s email activity and computer access.” The internal investigation began on August 27, 2015, more than two years after the incident. What stands out in this instance was the inability for Sutter Health to discover, mitigate, and remediate this incident within a reasonable timeframe. When it comes to HIPAA, breaches must be reported to HHS and the individuals affected without unreasonable delay and in no case later than 60 days following discovery of a breach or when it reasonably should have been known that a breach occurred.

The last point is key and clearly indicates the need for tools that allow organizations to better understand when PHI or other types of sensitive data leave their network. The best option to track and stop data from leaving your network is a Data Loss Prevention (DLP) solution. In this incident, the third large data breach involving Sutter Health, they have found “no evidence that any of the patient information was used or disclosed to others.” Since the data was sent to a personal email account, it is unlikely, truly impossible, that Sutter Health can determine with 100% certainty that the patient information was not disclosed inappropriately and this is reflected in their offering affected individuals one year of free credit monitoring.

In some other breach cases, however, data is available to forensically determine with certainty what happened after a breach occurred, and sometimes long after a breach occurred. If this is the case, then the information existed when the breach actually occurred. The takeaway in those instances is that logs or other forensic data were not reviewed proactively to catch the breach sooner.  In a digital information world with bigger and bigger data hurtling down the road faster and faster, no one seems to be watching the gauges for trouble!

With the many tools available and the ease with which an employee can move data outside of an organization, a DLP solution is a necessity. Not only would your organization be able to watch sensitive information flowing into, throughout, and out of your network without impacting performance, you can lock down many of those outlets for data leakage. In addition to performing a HIPAA Risk Analysis and publishing policies and procedures, DLP can help your organization maintain compliance with regulations such as HIPAA, Red Flags Rule, PCI, and other state and Federal privacy regulations. As the costs for remediating a breach rise, DLP becomes a more prudent decision that can offer real value as well as peace of mind.

If you are interested in learning more about DLP or other related services, contact RISC Management and Consulting, LLC at 800.648.4358 or visit www.RISCsecurity.com.

 

References

http://news.sutterhealth.org/2015/09/11/sutter-health-informs-patients-of-unauthorized-document-handling-by-former-billing-unit-employee/

http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/

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Business Continuity, Cyber Security, Data Breach, Education, HIPAA / HITECH Enforcement, Risk Analysis/Risk Management, Tip of the Week, Vulnerability Testing & Management

Data Loss Prevention Solutions

Critical to Enterprises With Sensitive or Confidential Information

Data Loss Prevention, often abbreviated DLP, is no longer an optional solution for organizations that:

  1. Are in possession or use of data that is regulated, confidential, sensitive, or otherwise limited from public access;
  2. Are large enough to have more than a single, structured data repository such as only one server and dumb terminals (hardly the case anymore);
  3. Need to be able to prove to management, auditors, or regulatory bodies that they know where their data is, and how it is being protected.

Business owners should consult with security professionals according to Siciliano (Entrepreneur, 2014), CEO of IDTheftSecurity.com, Inc. Siciliano reported the importance of installing data-loss prevention software and performing a risk assessment, “it’s possible to monitor the entire network’s activities to detect events that could lead to a data breach and detect trespassers before it occurs” (p. 3).

Part of the Guide to Privacy and Security of Health Information explains the HIPAA Security Rule requirement that a covered entity must conduct a Risk Analysis [§ 164.308(a) (1) (ii) (A)] to identify risks and vulnerabilities to electronic protected health information. Performing a “risk analysis is the first step in an organization’s Security Rule compliance efforts” (Office of the National Coordinator for Health Information Technology, 2014, p. 10) in identifying and implementing safeguards that comply with and carry out the standards and implementation specifications in the Security Rule. In addition, organizations must perform an Application and Data Criticality Analysis [§ 164.308(a) (7) (ii) (E)] to, “Assess the relative criticality of specific applications and data…”

The first step in any information security and compliance program is understanding what data your organization has, where it is located, and who is using it; authorized or unauthorized. Complete and accurate knowledge is necessary in order to understand what laws or requirements apply to your organization, and which members of your workforce may require training or monitoring.

Data Classification

Classifying your data into categories such as a Data Classification Matrix makes it easier to apply controls based upon the data type, rather than in a discretionary manner, or simply guessing. Most organizations know that they should protect credit card information differently than public marketing materials. But can they explain the differences in controls applied to ePHI versus Social Security Numbers? What are the requirements for this data? Who enforces them? How much trouble are we in if we have an unauthorized breach of this data?

Every organization should determine the classes that their data types fall into, not the data repositories. For example, classify your data as “Regulated” as opposed to “ePHI” or “Confidential” as opposed to “Payroll Records”. Remember, for data privacy and security regulations and industry requirements, the purpose of the data is irrelevant, it’s the existence of the data that matters.

An example of a data classification matrix that RISC has assisted its clients in successfully deploying is:

  1. Regulated
  2. Confidential
  3. Non-public
  4. Public

Once your data is classified, control mechanisms can be assigned to that classification as a whole, rather than piecemeal.

Roads

Now, your DLP solution is ready to find that data, and let you know where it is, at high speed, with pretty good accuracy. A DLP solution, or even a DLP assessment, can perform a year’s worth of human analysis in a week or two of close to pure automation!

RISC Management’s DLP solution

  • Can assist you in finding the sensitive information that is created, collected, stored, processed, transmitted, disclosed, or archived by your organization;
  • Will deliver Data Loss Prevention (DLP) solutions that protect regulated, sensitive, or confidential employee, customer, or company information and safeguard intellectual property across all electronic communications channels;
  • Can help you watch the sensitive information flowing into, throughout, and out of your network without impacting performance or requiring infrastructure modifications.

Key Benefits

  1. Compliance with regulations such as HIPAA, Red Flags Rule, PCI, and state/federal privacy regulations
  2. Automated email encryption utilizing policy-driven healthcare data classification and filtering
  3. Unobtrusive enforcement of data loss prevention policies across all popular Internet communication channels
  4. Healthcare code sets (e.g. HCPCS, ICD-9, LOINC, and NDC) as built-in dictionaries
  5. Inclusive data logs of confidential data copied, sent, or downloaded

An important definition to understand is the term Vulnerability and Technical vulnerability. Vulnerability is defined in NIST (2012) Special Publication (SP) 800-30 as “[a] flaw or weakness in system security procedures, design, implementation, or internal controls that could be exercised (accidentally triggered or intentionally exploited) and result in a security breach or a violation of the system’s security policy.” Technical vulnerabilities may include: holes, flaws or weaknesses in the development of information systems; or incorrectly implemented and/or configured information systems. The NIST (SP) 800-30 guide is a 95 page document published and developed by the National Institute of Standards and Technology (NIST) under the Federal Information Security Management Act (FISMA), Public Law 107-347.

Vulnerability Testing

Included in the risks that should be identified by an organization regularly are technical vulnerabilities. These vulnerabilities may include missing patches on computing devices, misconfigurations accidentally performed by staff members or consultants, or insecure network architecture. While the reasons are many, the result is the same, elevated risk to the confidentiality, integrity, and availability of your organization’s sensitive information.

RISC Management & Consulting can assist your organization in performing comprehensive technical vulnerability testing. The Security Engineers at RISC use numerous best in class tools to establish a thorough view of your security posture. The output of these tools is used in a number of ways including:

  •  Comparing security controls and system configuration to organizational policy.
  • Comparing the state of security to compliance requirements such as HIPAA, PCI-DSS, and ISO 27002.
  • Comparing the actual network architecture to the organization’s understanding of the network architecture.
  • Developing a technical vulnerability assessment report that provides a compliance, business, and technical review of the state of information security.

Contact RISC Management and Consulting today to discover how we can help you! www.RISCsecurity.com or 630-270-9336

References

Entrepreneur.(2014). 11 Ways to protect your business from cyber criminals. Retrieved from http://www.entrepreneur.com/article/238369

National Institute of Standards & Technology. (2012). Guide for conducting risk assessments: Information security. Retrieved from http://csrc.nist.gov/publications/nistpubs/800-30-rev1/sp800_30_r1.pdf