Risk Management – RISC Management and Consulting

Critical to Enterprises With Sensitive or Confidential Information

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

Are in possession or use of data that is regulated, confidential, sensitive, or otherwise limited from public access;
Are large enough to have more than a single, structured data repository such as only one server and dumb terminals (hardly the case anymore);
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:

Regulated
Confidential
Non-public
Public

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

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

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

In the most recent disciplinary action by the Office for Civil Rights regarding a HIPAA Data Breach, the OCR has set a new record for cost per affected individual and total fine amount. A breach affecting 6,800 individuals resulted in $4.8 Million in fines, or almost $706 per affected individual, in addition to the intense, and costly, corrective action plan.

Two health care organizations have agreed to settle charges that they potentially violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules by failing to secure thousands of patients’ electronic protected health information (ePHI) held on their network. The monetary payments of $4,800,000 include the largest HIPAA settlement to date.

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) initiated its investigation of New York and Presbyterian Hospital (NYP) and Columbia University (CU) following their submission of a joint breach report, dated September 27, 2010, regarding the disclosure of the ePHI of 6,800 individuals, including patient status, vital signs, medications, and laboratory results.

NYP and CU are separate covered entities that participate in a joint arrangement in which CU faculty members serve as attending physicians at NYP. The entities generally refer to their affiliation as “New York Presbyterian Hospital/Columbia University Medical Center.” NYP and CU operate a shared data network and a shared network firewall that is administered by employees of both entities. The shared network links to NYP patient information systems containing ePHI.

The investigation revealed that the breach was caused when a physician employed by CU who developed applications for both NYP and CU attempted to deactivate a personally-owned computer server on the network containing NYP patient ePHI. Because of a lack of technical safeguards, deactivation of the server resulted in ePHI being accessible on internet search engines. The entities learned of the breach after receiving a complaint by an individual who found the ePHI of the individual’s deceased partner, a former patient of NYP, on the internet.

In addition to the impermissible disclosure of ePHI on the internet, OCR’s investigation found that neither NYP nor CU made efforts prior to the breach to assure that the server was secure and that it contained appropriate software protections. Moreover, OCR determined that neither entity had conducted an accurate and thorough risk analysis that identified all systems that access NYP ePHI. As a result, neither entity had developed an adequate risk management plan that addressed the potential threats and hazards to the security of ePHI. Lastly, NYP failed to implement appropriate policies and procedures for authorizing access to its databases and failed to comply with its own policies on information access management.

NYP has paid OCR a monetary settlement of $3,300,000 and CU $1,500,000, with both entities agreeing to a substantive corrective action plan, which includes undertaking a risk analysis, developing a risk management plan, revising policies and procedures, training staff, and providing progress reports.

For information about the basics of HIPAA Security Risk Analysis and Risk Management, as well as other compliance tips, visit: http://www.hhs.gov/ocr/privacy/hipaa/understanding/training

The New York and Presbyterian Hospital Resolution Agreement may be found at: http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/ny-and-presbyterian-hospital-settlement-agreement.pdf

The Columbia University Resolution Agreement may be found at: http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/columbia-university-resolution-agreement.pdf