Category: Information Security
HIPAA’s not just for hospitals
Most counties and behavioral health organizations aren’t compliant with the HIPAA Security rule, but don’t take my word for it. Download the HIPAA Security Rule directly from HHS and read it over the weekend. If you want to talk about it, grab a 30-minute slot in my calendar and we’ll discuss your security policies and procedures at no charge.
Read more about our HIPAA services for counties and behavioral health organizations.
For more background, read Jeff’s articles on HIPAA
- Risk assessments for local governments and SMBs. CIO.com, May 2017.
- HIPAA as an umbrella for county/municipal cybersecurity. CIO.com, April 2017.
- County and municipal cybersecurity – Part 2. CIO.com, April 2017.
- County and municipal cybersecurity – Part 1. CIO.com, March 2017.
- May I see your comprehensive security policy please? CIO.com, October 2016.
- The ACA and the death of medical privacy. CIO.com, August 2016.
- Why should county commissioners and executives care about HIPAA? Careers in Government, February 2018.
© Copyright Jeffrey Morgan, 2018
© Copyright Jeffrey Morgan, 2018
Failure of boards and mangers to address information security is expensive and the preventable, poorly handled Equifax breach may end up costing the company as much as $1.5 billion in direct costs by the time it all plays out (SeekingAlpha, 9/29/17). This lack of management attention was clearly demonstrated when Equifax acting CEO, Paulino do Rego Barros, Jr. told a congressional hearing “he wasn’t sure whether the company was encrypting consumer data.”
This problem is systemic and pervasive across the business landscape. In a January 10th article, the Wall Street Journal reported that “Board committees dedicated to information technology risks and strategy are still rare. Just four Fortune 100 companies operate one.” Moreover, only 37% of corporate directors “feel confident the company they serve is properly secured against a cyberattack,” In the broader arena of SMBs and local governments, board and management oversight of information security is even rarer and 37% seems grossly optimistic.
An even more disturbing revelation from that WSJ article was that some boards have “devised a response plan, including creating of a bitcoin account from which to pay ransoms.” I suppose there is a justifiable and quantifiable business case for this position from the board’s perspective, but it really sticks in my ex-military craw that any organization would negotiate with and reward criminals. Prevention and resilience are better policies.
What’s the role of the board and management?
There is no mystery about what boards and executives should be doing to ensure their organizations are paying attention to information security. Section 5 of ISO/IEC 27001 describes 18 requirements for “top management” with respect to developing an organizational information security management system (ISMS). These requirements include policy development, resource allocation, continual improvement, documentation, reporting, and a great deal more.
NACD (National Association of Corporate Directors) offers a 16-hour cyber-risk certificate course for directors. Upon completion of the course and an exam, participants receive a certificate from Carnegie Mellon University. NACD also publishes a free, informative, 44-page Cyber-Risk Oversight Handbook that describes “five principles for effective cyber-risk oversight,” along with a wealth of other information that includes an appendix with 48 questions boards should be asking management about Cybersecurity.
For local governments, ICMA publishes Local Government Cyber Security: Getting Started as well as other information. This guide has some useful information, but it doesn’t begin to approach the depth and quality of the NACD handbook. I would recommend that school board members, county commissioners. and city council members download and read the NACD handbook as well as the Growing Impact of Cybercrime in Local Government. The public sector doesn’t take cybersecurity seriously and local governments are in possession of huge deposits of PII and PHI.
My problem with the discussions of “the cyber” from both of these organizations is that they fail to address the broader discipline of “information security.” This isn’t simply a matter of semantics and cyber-risk has to be understood in the broader context of an overarching information security (InfoSec) program to be truly effective.
To put it simply, if senior leadership isn’t an integral part of your information security program, you don’t really have a program. Boards and executives should routinely devote CPU cycles to the issue, just as they would to any other critical business issue.
Making the case
The argument for comprehensive information security programs for even very small enterprises is simple, powerful, and backed by a constantly growing body of evidence. Failure to secure information costs money – and lots of it. The Anthem breach, in which the company was found to be neither negligent nor liable, cost them roughly $414 million and the Target breach cost $230 million (SeekingAlpha).
While the fiscal argument may make the best case for a security program, it sometimes takes a while to get traction because executives in smaller organizations may not immediately see how these gigantic breaches relate to their business. Consequently, one of my preferred techniques for making the case is to get the corporation counsel or municipal attorney involved from the start.
Bring lawyers and money
Lawyers begin making the connections faster than the rest of the team, especially if regulatory compliance issues are involved. They quickly connect the dots between stupid mistakes, negligence, breach, forensic and regulatory investigations, fines, public embarrassment and the inevitable litigation. In most organizations, the lawyers tend to be highly regarded and they can see the whole movie playing in their head. They instinctively know that they won’t be playing the part of the hero unless they get the show going so they do a pretty good job of rallying the troops.
In one organization for which I developed a comprehensive policy, the process took several months of collaborative work with a large committee of stakeholders that included board members, management, HR, attorneys and staff. The discussions sometimes became contentious, but the team approach was worth the effort because everyone was invested in the final product. It took the organization two years to fully implement the policy and when the first periodic risk assessment came due, one of the Director’s said “you mean to tell me that this is going to cost money?”
Yeah, it costs money; but it costs a hell of a lot less money than a breach.
You might appreciate my video on Equifax breach:
© Copyright Jeffrey Morgan, 2018by
NIST Cybersecurity Framework
Version 1.0 of the NIST Framework for Improving Critical Infrastructure Cybersecurity (CSF) celebrated its fourth birthday in February. The CSF is a “risk-based approach to managing cybersecurity risk… designed to complement existing business and cybersecurity operations.” I recently spoke with Matthew Barrett, NIST program manager for the CSF, and he provided me with a great deal of insight into using the framework.
NIST (National Institute of Standards and Technology) is a division of the U.S. Department of Commerce, and they have been involved in information security since the 1970s. On May 11, 2017, President Trump signed Executive Order 13800 requiring all federal agencies to use the CSF, so if you conduct business with these entities, you are likely to hear a great deal more about it in the near future.
Current State of Cybersecurity
To begin the conversation, I asked Matthew what he thought about the current state of cybersecurity in business and government.
“I think there is a bit of an awakening going on to the true importance of just how foundational cybersecurity is,” he says. “It used to be that businesses were based on trust, and it is still the case. Increasingly, we’ve built out our technological infrastructure and more and more important over time is digital trust. I’m not sure whether all parties understood when they were implementing those technologies just how much that pendulum was going to swing from traditional trust models to the digital representations of those trust models. It’s not an overnight thing. There’s a cascade. I see a ripple that has started that hasn’t completed its way across the pond.”
The CSF in a Nutshell
If you have worked with other security standards or frameworks based on best practices or compliance approaches, the CSF provides a different viewpoint. It is not intended to be used as a standalone framework for developing an information security program. Rather, the CSF is designed to be paired with other frameworks or standards such as ISO/IEC 27000, COBIT 5, ANSI/ISA 62443, and NIST SP 800-53. It is also meant to be customized rather than being used as a process or activity checklist. The CSF has three components – the core, tiers and profiles.
The core of the framework has five functions – identify, protect, detect, respond and recover. These functions can be thought of as outcomes and aligned with them are 22 categories, 98 subcategories, 125 outcomes and 287 informative references (controls). The core, with all the informative references, is also available in Excel format which can make a handy template to add to your cybersecurity policy and control toolkit. According to Matthew, becoming comfortable with these five functions and the associated concepts at the leadership level tends to be the first stage of the adoption curve.
Determining the organization’s tier is often the second step in adoption. The tiers are a useful tool and they “provide context on how an organization views cybersecurity risk and the processes in place to manage that risk.” There are four tiers: partial, risk-informed, repeatable and adaptive. Although the tiers don’t officially function as a maturity model, it is difficult for me not to see them as such.
However, Matthew explained the CSF’s position on maturity models: “We take exception to the way maturity models are applied where everyone has to get the highest mark on the maturity scale. That’s a great ambition. Rooted in the real world of things, we know that people have budgets, and those budgets are finite. More so than the way people tend to implement maturity models, we’re trying to highlight that you can pick and choose.”
“In my mind’s eye,” Matthew continued, “I picture a tier that isn’t even on the map. A tier zero. There’s a group of people who have managed to short-list high-impact items, and that’s about all they do relative to cybersecurity. For most people, that’s a temporary stopping point. Some people stop there and never get to dynamic, iterative cybersecurity risk management.”
Based on my own personal observations in the field, most SMBs, local governments and even many larger entities probably fall into Tier 1, and the only way to realistically get to Tier 2 is for management to become risk informed. However, getting executives and boards interested in information and cybersecurity is a formidable hurdle.
If an organization is truly a part of national critical infrastructure, remaining at Tier 2 would be troubling. Tier 3 is the first tier that defines organization-wide policy as a requirement, and I would personally see Tier 3 as the minimally acceptable target for most organizations, but this is my opinion rather than NIST’s or Matthew’s.
The tiers do provide a solid tool for organizational management to realistically evaluate their cybersecurity program and make rational, pragmatic, informed business decisions for program improvements going forward. Taking the leap from Tier 1 to Tier 2 is probably the most difficult step for most organizations. Once an organization gets to Tier 2, management has accountability and consequently more motivation to move forward.
NIST recommends that the framework be “customized in a way that maximizes business value,” and that customization is referred to as a “Profile.”
Matthew believes that all cybersecurity programs have three things to do and three things only:
- Support mission/business objectives;
- Fulfill cybersecurity requirements; and
- Manage the vulnerability and threat associated with the technical environment.
The CSF provides a seven-step process for creating or improving a cybersecurity program using a continuous improvement loop:
- Prioritize and scope
- Create a current profile
- Conduct a risk assessment
- Create a target profile
- Determine, analyze, and prioritize gaps
- Implement action plan
Profiles can be used as a tool to provide a basis for prioritization, budgeting and gap analysis.
One of my personal rants is on the disinterest so many executives show toward information security. I am always irritated when I see IT and security managers unilaterally commit an organization to cyber risk without obtaining informed consent from senior management. Often, these staff members make decisions that are far outside the scope of their roles and authority, and I think some executives prefer their own blissful state of ignorance. This leaves too much room for managers to claim “I never knew. Mistakes were made.” Like both ISO 27001 and COBIT 5, the CSF clearly defines management’s role in information security processes, so the CSF can be used as a powerful tool to engage boards and managers and hold them accountable for risk and budgeting decisions.
Matthew’s response to my rant was diplomatic. “I wonder whether the very nature of cybersecurity professionals makes us hold on to risk decisions rather than distribute them portfolio style. Smaller, less impactful risk decisions that are distributed. Distribute decisions, empower folks, and there is accountability around that empowerment, as well.” The CSF provides tools to distribute this risk.
Adoption and Implementation Trends
Results from a 2015 Gartner poll claim that about 30% of organizations have adopted the CSF and by 2020, 50% of organizations will have adopted it. I am skeptical of this assessment. Based on personal observation of the SMB and local government sectors, I would be astonished to find that even 25% of them have formal information security programs based on any framework or standard, let alone the CSF.
However, CSF has been used and customized by a diverse group of organizations such as the Italian government, the American Water Works Association, Intel, the Texas Department of Information Resources, and many others. Case studies can be found on the NIST CSF website.
It’s always good to look at information security programs from multiple viewpoints and the NIST CSF provides many excellent tools to do just that. NIST provides many additional materials on using the framework and they can be found on the CSF Homepage. The site also has an excellent 30-minute video presentation of Matthew providing an overview of the framework.
This article first appeared in Security Magazine.
© Copyright Jeffrey Morgan, 2018
Information security and cybersecurity are huge problem areas in county and municipal governments. In this six-page article on the subject, I cover the information every county and municipal leader should know including a summary of problems, barriers, specific solutions, and resources. The free document is available here. The intended audience is CEO, CAO, CFO, COO, County or city manager, county commissioner, city council member, or other senior management personnel in the public sector. This is a reprint of my two-part article published in CIO.com last year.
Click below to download.
Want to talk about information security in your organization? Click on the link below to e-mail me and schedule a time to talk.
Don’t hesitate to e-mail me. Initial consultation are free.
© Copyright Jeffrey Morgan, 2018by
J.S. Bach’s sublime “Fugue in C-sharp-minor,” from Book One of Das Wohltemperierte Klavier (BWV 849) was published in 1722. It has five voices and three subjects, so it is a triple fugue. Let’s take a look at what Bach and his excellent work can teach us about building a rock-solid information security program.
1. Keep it simple
The slow and stately four-note subject is simple but pregnant with possibility. Through each iteration and each addition of a new component, the piece becomes a lovely, dense mesh of darkness and light. Ultimately, the thrilling climax can send emotional waves through your body leaving you weeping, emotionally drained and forever changed. Each element is simple in itself, but when combined, an extraordinarily complex web of sound is created.
If your perimeter firewall has 5000 rules, you’re probably doing something wrong, especially if you are a relatively small organization. Likewise, if your policy documents are incomprehensible to the average end user, there is a problem. One IT staff on which I was doing an assessment claimed their policy was secret, and when I finally got hold of it, it turned out it wasn’t a policy at all – it was simply a copy of a federal agency’s policy framework written in govspeak. There was nothing there that would communicate performance and behavioral expectations to management, end users or the IT staff.
Printed music, a score, is simply a set of instructions for a performer. It’s not music until a performer brings it to life. Bach’s scores provide the minimal amount of information required to do just that and they leave a great deal of the interpretation to the performer (assuming good taste and common sense, of course).
Your information security plans and documents are similar; they’re just documents until you bring them to life and put them into practice. In many enterprises, these documents exist only on a shelf and are never used. Dust off those documents if you have them and make sure they have been implemented, followed and enforced. If you don’t have the documents, you had better get to work. Follow Bach’s lead and keep it all as simple as possible. Don’t count on common sense, though.
Bach chose a five-layer framework for this fugue. How many layers does your security program have? Comprehensive policy, procedures, guidelines, technical controls, administrative controls, physical controls, awareness and training are all part of the mix.
The common mistake I have seen in audits is that organizations often depend on only one layer – technical controls. Many security programs, probably in the majority of enterprises, consist of a firewall and some antivirus software but policy, procedure, guidelines and training are often non-existent. If you depend on technical controls alone, your score is 80-90% incomplete.
Musicians learn resilience, often the hard way, as soon as they begin doing recitals. The only way to be prepared for anything is to over-practice and over-rehearse so that no matter what happens, your fingers keep going even if your brain shuts down. You have a great amount of time to prepare, but only one chance to get it right when it actually counts.
Practicing and planning for the inevitable information disaster is the only way to survive it. If you’ve done this well, you can keep performing without anyone but an expert noticing the glitch. If you do it badly, the show is interrupted and you may never get a second chance.
4. Continuous improvement
A good music teacher shows you how to practice using mindfulness rather than rote repetition. Each iteration should be made better than the last by analyzing every aspect of what you’re doing. Walter Giesking wrote about this sort of approach in his book and he might be considered music’s version of W. Edwards Deming.
What sort of program for continuous improvement do you have in place? It doesn’t happen by itself unless you had a great teacher, coach or mentor. Great performers analyze every aspect of every performance and do a root cause analysis so they don’t make the same mistakes again. Well run organizations and great managers do the same, but the majority keeps making the same mistakes over and over again. Public humiliation in front of colleagues and coworkers doesn’t often seem to be a motivating factor in the business world, but it definitely is in the world of musical performance.
Listen to the voice of your network and your end users and pay attention to logs and metrics. Too many IT directors are tone deaf to the voices of their customers and I have seen many organizations that pay no attention to security logs and metrics at all. They can’t distinguish between the sound of a perfectly tuned network and an out-of-tune one. Don’t be that patronizing, know-it-all ass of a CIO – listen to everything and everyone.
If you are unfamiliar Bach’s c-sharp-minor masterwork, you can listen to Hélène Grimaud’s performance in which the fugue begins at about 3:15. For a different approach, Sir András Schiff’s version begins at about 2:40. There is no accounting for taste and everyone has their favorite.
If you are fascinated by the music and want to learn more, my favorite recording of the entire set is Angela Hewitt’s, which is part of my car mix for long trips. If you are new to Bach, it can be a life-changing experience.
If you want to improve your information security program, there are numerous resources from which to choose. IS0/IEC 27000, NIST, and COBIT 5 for Information Security all provide great starting points. Which is your favorite?
© Copyright Jeffrey Morgan, 2017
This article was first published on CIO.com at https://www.cio.com/article/3240972/data-protection/5-things-js-bach-can-teach-you-about-information-security.html
Security Policy Checkup Service
For county and municipal government.
Is your security policy up to current standards? Here’s how we can help for a low fixed rate:
This fixed-fee service is designed for counties and municipalities and includes:
- Initial web workshop with management and key stakeholders.
- Completion of a survey to identify your organization’s procedures, practices and specific security requirements.
- Review of your security policy and acceptable use policy against best practices and your organization’s requirements.
- Web workshop to discuss results.
- Written report with specific recommendations for improving your policies.
How to get started
- e-mail us for a quote/SOW.
- We’ll send you a Statement of Work with an NDA (Non disclosure agreement). Sign it and return with a purchase order.
- We will promptly schedule a web workshop to gather information.
- We will discuss your concerns and complete a brief survey in order to understand your organization’s requirements.
Who should be involved?
We can perform this study for an authorized executive. However, we believe that working with a cross-functional workgroup consisting of Legal, HR, IT and executive management, and possibly other departments will help build a foundation for a more solid information security program in the long term.
Don’t have a security policy?
We can help. e-mail us to schedule a time to discuss the development of a custom security policy tailored to fit your organization.
Read more about this service at: http://www.e-volvellc.com/security-policy-checkup/
© Copyright Jeffrey Morgan, 2016
Next week, I am scheduled for a semi-annual risk assessment with my dentist. He performs a very specific, highly focused type of risk assessment that is totally worth the $125 it will cost. In addition to performing specialized maintenance (hypersonic cleaning), he will provide a threat assessment (for oral cancer, cavities, periodontal disease and other anomalies). I’ll leave his office confident that my mouth is in a low-risk situation for the next six months as long as I continue to follow best practices and perform daily maintenance procedures. I am only vulnerable to these threats if I fail to follow a daily program of brushing and flossing.
I could always choose to save the small fee for these risk assessments and wait for a major dental disaster to occur. The problem with this approach is that a single incident may cost thousands of dollars if I need a root canal or some other type of procedure. Ten years of checkups are less costly than even a single disaster.
Enterprise IT risk assessments
Unfortunately, in the world of local government and SMBs, the most common approach to risk management is to allow a major catastrophe to occur before realizing the value of an enterprise risk management program.
I am at a loss to explain it. Incidents or problems involving your information and IT infrastructure are far more costly than risk management programs. Data loss, breaches, major downtime, malware, lawsuits and fines for compliance violations may cost hundreds of thousands or millions of dollars. They can permanently shut down your small business or really irritate your board of directors in a corporate environment. In the public sector, constituents pay for major screw-ups through increased taxes while the events are often covered up and the culprits skirt the blame and keep their jobs.
When was your organization’s last risk assessment? Can you put your hands on the report? If you haven’t had a risk assessment recently, it’s a safe bet that your policies are sorely lacking. Defining an organizational policy for risk assessment is an essential component of any comprehensive suite of security policies. Both HIPAA and GLBA require periodic risk assessments, but it is a sound practice for all types and sizes of organizations.
Where to start?
If you haven’t previously conducted an enterprise IT risk assessment you should carefully consider your starting point. For example, if you have few or no security policies, it may be wise to form an IG (information governance) committee and begin by developing of a comprehensive set of policies, procedures, standards and guidelines. On the other hand, your management team may benefit from the kind of wake-up call that a devastatingly thorough risk assessment can produce. A 100-page report that says you suck at security and risk management on every page may be just what you need to get everyone’s attention.
The results of a risk assessment should be used to reduce your organization’s risk exposure, improve CIA (confidentiality, integrity and availability), initiate positive change, and begin building a security culture. While using risk assessments as a punitive device isn’t the best approach, such reports often expose malfeasance and incompetence of proportions so vast that appropriate consequences are in order. In other words, if you have been paying a CIO $200,000 and the assessment uncovers gaping policy, security and privacy holes, you should certainly replace the CIO with one who has the required skill set.
Scope the project carefully
Risk assessments come in a lot of flavors and the specific purpose and scope must be worked out with the auditors in advance. A few years ago, a client of mine released an RFP for a risk assessment after we worked extensively on the development of their information security policies. The proposals ranged from $15,000 to well over $150,000. This can happen even with a pretty clear scope. Big 4 firms, for instance, have hourly rates that may be several times what a local, independent practitioners may charge. NIST SP 800-30 provides valuable information on how to perform risk assessments, including some information on scoping.
Risk assessments may be qualitative or quantitative. You may be able to do some of the quantitative work in-house by gathering cost data for all your assets in advance of the assessment. Regardless of the scope and approach, the auditors will ask to see lots of documentation.
One positive outcome of a risk assessment is that it may force your management team to rethink EVERYTHING – in-house application development, infrastructure support, IT staffing & responsibilities, LOB (line of business) staffing & responsibilities, budgets, and just about everything else related to the manner in which your organization is run.
Risk assessments are way cheaper than disasters, so go schedule your checkup.
© Copyright Jeffrey Morgan, 2017by
Free Whitepaper download for County/Municipal executives.by
Are you a covered entity?
Basing a county/municipal information security (infosec) and cybersecurity framework on HIPAA is a logical choice, especially if you have one or more covered entities (CE) in your organization.
How do you know if you have or are a CE? If some department or division within your organization is a healthcare provider, a health plan or a healthcare clearinghouse, they are a CE. If you have clinics, doctors, psychologists, clinical social workers, chiropractors, nursing homes or pharmacies, you are a CE [i]. Moreover, many counties have divisions or departments that function as accountable care organizations (ACO), managed care organizations (MCO), healthcare clearinghouses or health maintenance organizations (HMO). These are all common functions, especially within large county governments.
Are you in compliance?
If anything described above applies to your county or municipal organization, one or more divisions of your organization is a CE and is required to be in compliance with both the HIPAA Security Rule and the HIPAA Privacy Rule.
In my experience, most county governments that have covered entities are out of compliance. Where does your organization stand?
I suspect what often happens is that executives look at something like information security policy requirements and say:
This has tech words in it. IT handles tech stuff. Therefore, I’ll turn it over to IT to handle.
What a huge mistake. An organizational policy dealing with the manner in which information is handled, regardless of whether or not HIPAA regulations apply, requires communication and coordination with legal, HR, IT, information security, risk management, archives, county clerks and other divisions within your organization. It’s not a tech issue; it’s a high-level, interdisciplinary executive function. It is an information governance (IG) issue, and it shouldn’t be handed off to your IT director or CIO to address unilaterally.
Trust but verify
There are a number of reasons why IT should not be delegated sole responsibility for organizational information security. For one, a successful information security program requires checks, balances and oversight. Trust but verify! A successful program also requires expert knowledge of departmental business processes that often exceeds the knowledge of the IT staff. Moreover, if your department heads have equivalent status within the organization, it is not appropriate for a CIO or IT director to unilaterally dictate policy to his or her colleagues of equal status. There are far too many IT departments that have adversarial relations with their end users because of their autocratic and often illogical decrees. Information security requires a team approach with executive and board oversight.
Extend HIPAA to your enterprise
If you have covered entities in your organization and have limited or nonexistent enterprise security policies, I would recommend that you consider building your entire enterprise information security policy on the HIPAA Security Rule in order to raise the entire organization up to that that level while also getting compliant with federal law.
Why? It is highly probable that your organization uses shared facilities, shared IT infrastructure and shared services. Multiple information security levels create a significant management challenge and are certain to cause chaos and confusion. Multiple security stances will lead to security gaps and ultimately to breaches. Keep it simple and operate at the highest standard using generally accepted, good practices.
Develop your policy with the HIPAA Security Rule
There are two major components to HIPAA, the Privacy Rule and the Security Rule. For the purpose of this discussion, only the Security Rule matters, but we’ll definitely discuss privacy another day.
The original HIPAA Security Rule document, 45 CFR Parts 160, 162 and 164 Health Insurance Reform: Security Standards; Final Rule, is 49 pages of small print. However, the meat of the document is contained within the final six pages and includes a handy matrix on page 48 (8380 of the federal register).
The security standards in HIPAA are broken down into three sections, each of which has multiple layers and sub components:
- Administrative Safeguards (9 components)
- Physical Safeguards (4 components)
- Technical Safeguards (5 components)
These three major areas break down into at least 43 separate policy areas where your organization must build safeguards, including risk analysis, contingency planning, backup, passwords, HR sanctions and terminations, disaster recovery, encryption and many more.
Using the components in the matrix should enable you and your IG committee to quickly generate a suite of security policies and procedures that, when implemented and enforced, will vastly improve your current information security stance.
These are all policy areas that must be addressed as a matter of good practice whether or not you are a covered entity. This is why HIPAA is an excellent starting point for municipal governments that are infosec policy deficient.
1. Find out where your organization stands in terms of information security policies and procedures.
2. Find out whether or not you have covered entities in your organization. Must you comply with HIPAA? Are you compliant?
3. Meet with your IG committee to discuss your findings.
4. If you don’t have an IG committee — start one!
5. Download and review the HIPAA Security Rule. Use it to build your organization’s information security policies.
6. Use either the PDCA (Plan, Do, Check, Act) approach or the DMAIC (Define, Measure, Analyze, Improve, Control) approach to maintain continuous improvement.
7. Begin building a culture of security in your organization.
We’ll continue the discussion next week, so check back then.
This article first appeared in cio.com at http://www.cio.com/article/3188667/governance/hipaa-as-an-umbrella-for-countymunicipal-cybersecurity.html
© Copyright Jeffrey Morgan, 2017by
The cybersecurity risk to local government
Weak or nonexistent cybersecurity programs represent a massive organizational risk to county and municipal government agencies in the United States. County and municipal executives are often unaware of these risks because they assume that their IT Director, CIO, or an external vendor is managing security and addressing the risks. It is rare that such an assumption is correct.
While the Ponemon Institute[i] found that “federal organizations have a stronger cybersecurity posture than state and local organizations,” the Brookings Institute[ii] concluded that “the vast majority of public agencies lack a clear cybersecurity plan.” Much of the available research is based on small samples and I believe that these studies may understate the scope of the problem. Based on my 23 years of working with public sector organizations, I can state with confidence that most lack any cybersecurity plans at all.
Your job as a municipal executive is to provide leadership and management in order to get the big picture right throughout your organization. What follows is advice on how to ensure that an appropriate cybersecurity program is established and functional in your organization. I recommend that you, the municipal executive, assume high-level responsibility for cybersecurity oversight. You don’t need to know the technical details, but you must know whether or not the appropriate frameworks, infrastructure, policies and procedures are in place and working correctly.
The need for information security is as old as civilization and possibly as old as life on earth. Information Security (Infosec) was invented to protect the first secret – whenever and whatever that was. Infosec is not solely a human artifact — my Great Dane always felt the need to maintain security concerning the location of his favorite bones and dead woodchucks. Techniques, methods and models for protecting information haven’t changed all that much and the methods of cybersecurity are largely based on models for protecting physical information.
Information Security refers to the discipline and processes to protect the confidentiality, integrity and availability of all your information regardless of form. Cybersecurity is a subset of information security and applies to digital data. In this article, I may use them interchangeably even though they are not, but counties and municipalities need an Infosec plan that includes cybersecurity.
Municipal data – a pot of gold
County and municipal networks are treasure chests overflowing with priceless gems. Mortgage documents, deeds, births, deaths, ugly divorces, medical records, social security numbers, and military discharge documents are among the many types of publicly accessible documents that may contain PII (Personally Identifiable Information), PHI (Protected Health Information), or other sensitive information. Constituents turn over all this information naively assuming that you are doing everything in your power to protect it from theft and misuse. Are you a worthy steward of this treasure?
Root causes and obstacles
Let’s discuss eight of many root causes of failure to establish appropriate information security programs in local government organizations. Subsequently, we’ll move on to a methodical, practical approach you can initiate immediately to improve your cybersecurity posture.
“A lack of skilled personnel is a challenge at both federal and state and local organizations.”[iii] One problem is that many public sector IT Directors and CIO’s don’t have the knowledge, training and background to plan and deliver acceptable, standard’s based comprehensive information security programs. They are often unaware of widely accepted standards, guidelines and frameworks that are readily available, so cybersecurity planning is often amateur and homebrewed. Moreover, HR and hiring managers often don’t understand the required skills[iv] and look for the wrong people.
The largest municipal agencies may employ a CISO (Chief Information Security Officer) but the vast majority of public sector organizations do not have a dedicated information security executive and staff, nor should they necessarily require one.
IT staff members are rarely trained in or even familiar with relevant statutory compliance requirements. I have come to expect a deer in the headlights look from public sector CIO’s and IT staff when inquiring about security policies, privacy policies and other matters of security and compliance. Questions about HIPAA Security Rule compliance, for instance, are almost always met with “What’s that?”
A jumble of regulations
Municipal organizations may have dozens of departments, divisions, or lines of business with varying regulatory requirements from numerous federal and state agencies. Municipal governments do a lot. They may be involved in building bridges, managing traffic signals, providing water, waste, electric and sewer services, supervising elections and recording deeds while providing physical and mental health services and dental care.
A typical County government may have to comply with regulations like HIPAA[v] (Health Insurance Portability and Accountability Act) and 42 CFR[vi] while also complying with policies from CJIS[vii] (Criminal Justice Information Systems) in addition to compliance with state regulations from organizations such as an Office of Mental Health, or Department of Health. Additional requirements for records management from State Archives agencies add to those complexities and often contradict other regulatory requirements.
Departments with vastly different information security and regulatory compliance requirements often coexist on a shared network where the security posture is designed for the lowest common denominator rather than for the highest. Often, municipal IT staff members don’t have clearly defined policies and procedures for reviewing information such as security logs and system events. Even if they do record these events, their stance is usually reactive rather than proactive.
Silos and turf wars
Counties and municipalities may have highly distributed management structures which function as silos rather than as a cohesive team. In some states, the silos may be a “feature” of constitutional government where elected officials manage some departments and may not be accountable to central executives. One result of this is that a county executive, and consequently County IT, may not have global control of IT and information security because other elected officials choose not to cooperate. Some real world examples I have seen include:
- County Judges and their staff members refuse to sign and abide by acceptable use policies.
- County Sheriffs refusing to cooperate with an IT security audit claiming their security policy and processes are “secret.”
- Social Services commissioners unilaterally declaring that HIPAA regulations don’t apply to their operations.
Silos in organizations create massive gaps in security management. When multiple parties are responsible for security, no one is responsible.
Most security problems are internal
90% of breaches occur because of an internal mistake[viii] and 60% of breaches are a result of internal attacks[ix]. Unfortunately, county and municipal information security programs often treat outside threats as 100% of the problem rather than focusing on more probable internal threats.
Insufficient budget is often used as an excuse for low quality IT services and lack of security in public sector organizations. It’s usually a red herring. In my experience, there is no correlation between budget and quality in the public sector. I have seen small, low-budget organizations build excellent security programs and have also seen large organizations with eight-figure tech budgets fail to establish even the most elementary components of an information security program. A cybersecurity program will cost money, but it doesn’t have to bust your budget.
In local government, critical management positions are often filled based on political considerations rather than quality of candidates. Expertise in information security should be a major component in your CIO’s toolkit.
Tech versus strategic thinking
If you think in terms of technology, stop it! I am always a little suspicious of industry professionals who fall in love with a particular technology. Technology is rapidly replaced or superseded so think strategically instead. There is no such thing as a technology problem; there are only business problems. Identify and solve for the business problem and the appropriate technical solution will reveal itself.
Start with Information Governance (IG)
What’s the first step in establishing your cybersecurity program? It has nothing to do with cybersecurity.
Information Security and cybersecurity must be components of your overarching Information Governance (IG) Program, overseen by an interdisciplinary team with executive support. Treating cybersecurity as a standalone program outside of the context of your organization’s information universe will produce a narrow approach. Do you currently have an IG program?
I can hear some grumbling right now. “Jeff, when do we get to the important stuff?”
IG is the important stuff. There are no silver bullets. There are no miracle pills that will address your information security requirements. No miraculous hardware or software will magically keep your information safe unless you have the right policies in place. There is some real work to do here and the P-things are the most effective tools to pack for your InfoSec journey. You will develop these from your IG Program:
Policies Processes Procedures
What is information governance?
I like Robert Smallwood’s succinct definition of Information Governance: “security, control and optimization of information.“[x] In order to develop sound InfoSec and cybersecurity programs, you must know what you are protecting and why you are protecting it. The purpose of the IG program is to map, understand and manage your entire information universe. The map you create will serve as the foundation for your information security programs.
In a municipal government organization, an IG committee may include legal, HR, records management, IT, finance, and auditors, as well as other departments. Let’s say your municipality has a public health clinic, recorder of deeds, personnel/payroll and a sheriff. This means you have medical records, prisoner health records, recorded 911 calls, police reports, mortgage documents, confidential personnel records, payroll records, social security numbers and a lot more. The people with special knowledge about the nature and disposition of all this information must be on your committee.
In some organizations, information and security policy is developed at the whim of the CIO or IT Director. Is that IT Director expert in statutory requirements and industry best practices for all the areas mentioned above? I doubt it. This is why you need a cross-functional team to map the universe and make a comprehensive plan.
Establishing a comprehensive information security program
Once you have begun building your IG foundation and framework, your Infosec and cybersecurity requirements will be much clearer. Also, IG, Infosec, and Cybersecurity are not one-time activities. They require a process for continuous improvement like PDCA (Plan, Do, Check, Act) or DMAIC (Define, Measure, Analyze, Improve, Control). Get something in place first, and then continue to improve it. Attempting to get it perfect from the start will only result in implementation delays. This job never ends but it gets much easier once a solid foundation has been built.
Information Security Management Systems (ISMS), Frameworks and Standards
Once you have a comprehensive understanding of your information universe, develop security policies and programs for implementation and enforcement of those policies.
Use an existing framework. Designing comprehensive information security programs is more complicated than installing firewalls and anti-virus software and there is a great deal to think about.
There are many freely available information security tools in addition to standards and frameworks that require payment or membership in an organization. You can build a successful security program using only free tools, but my crystal ball is on the fritz today so I can’t see which tool is best for your organization. I wish I could tell you there is a one-stop shop, but there isn’t. You will have to evaluate your situation, do the research and make informed decisions about the best approach for your organization. Following is a brief discussion of some of them.
The National Institute of Standards and Technology (NIST) provides an enormous quantity of information and the gateway to it is available here. NIST’s Framework for Improving Critical Infrastructure Cybersecurity is available here and a new draft was release in January of 2017. Their Cybersecurity Framework Workshop starts on May 16, 2017 in Gaithersburg, MD if you would like to attend and learn more about it. You can also view a webcast with an overview of the Framework. In their words, “The core of the framework was designed to cover the entire breadth of cybersecurity . . . across cyber, physical, and personnel.“[xi]
NIST also provides three Special Publication (SP) series: SP800 deals with Computer Security, SP1800 contains Cybersecurity Practice Guides, and SP500 covers Computer Systems Technology.
SP800-53, Security and Privacy Controls for Federal Information Systems and Organizations will likely be an essential part of your planning process if you are building upon NIST.
If a division of your public sector organization provides clinical services, it might fit the definition of a covered entity (CE). If so, that division is required to comply with applicable federal regulations including the HIPAA Security Rule. The regulation provides a clear, jargon-free framework for developing information security policies and programs. While it won’t address all the requirements for a municipal cybersecurity program, it can help you build a solid foundation for your security programs. I don’t have any official data on HIPAA Security Rule compliance in municipal organizations, but my personal experience is that it is extremely low. Is your CE compliant? If not, why not bring your entire organization up to HIPAA standards?
I have worked extensively with HIPAA regulations and NIST products for nearly 2 decades and I like them a lot. If they are not a good fit for your organization, there are other resources, including the following three.
The Information Security Forum (ISF) publishes the Standard of Good Practice for Information Security, available free to ISF members.
The International Organization for Standardization (ISO) publishes the ISO/IEC 27000 family of standards for Information security management systems. ISO products are not inexpensive, but in the overall scheme of things you might find them to be a reasonable investment. Organizations can certify through accredited registrars, which can also be an expensive process.
ISACA publishes COBIT5, “the leading framework for the governance and management of enterprise IT” which provides an integrated information security framework as part of a larger IT governance framework. According to Joseph Granneman, “It is the most commonly used framework to achieve compliance with Sarbanes-Oxley rules.”[xii]
The role of vendors
Trusted vendors can be helpful in building your programs, but overreliance on vendors for security advice is a suboptimal approach. While they may be knowledgeable about many aspects of your industry, only you and your cross-functional IG team truly understand your business requirements. Their job is to “sell you stuff” but they will generally draw the line at writing policy and taking responsibility for overall information security in your organization. If there is a major breach or some other catastrophic security event in your organization that becomes public, you are the one whose picture will be in the paper.
Summary – one step at a time
Take a few simple steps to improving your cybersecurity infrastructure:
- Establish an IG committee and program.
- Discover and map your information universe.
- Establish an information security framework and security policy.
- Develop and implement your cybersecurity plan, based on the above.
- Use a cycle of continuous improvement.
This article first appeared in two parts in my CIO.COM column at:
A continuation of the subject appeared in:
References, Resources and Further Reading
Four critical challenges to state and local government cybersecurity efforts. Government Technology. July 17, 2015.
The need for greater focus on the cybersecurity challenges facing small and midsize businesses. Commissioner Luis A. Aguilar, October 19, 2015. US Securities and Exchange Commission.
How state governments are addressing cybersecurity. Brookings Institution. Gregory Dawson and Kevin C. Desouza. March 2015.
Four critical challenges to state and local government cybersecurity efforts. Government Technology. July 17, 2015.
Human error is to blame for most breaches. Cybersecuritytrend.com.
[i] The state of cybersecurity in local, state and federal government. Ponemon Institute. October 2015.
[ii] The vast majority of the government lacks clear cybersecurity plans. Brookings Institution. February 3, 2015. Kevin C. Desouza and Kena Fedorschak.
[ix] The biggest cybersecurity threats are inside your company. Harvard Business Review. Marc van Zadelhoff. September 19, 2016.
[xii] IT security frameworks and standards: Choosing the right one. Joseph Granneman, Techtarget.com. September 2013.
If you found this information useful, or would like to discuss cybersecurity in your organization in more detail, please feel free to e-mail me at email@example.com. I would be glad to discuss your situation.
This article first appeared in cio.com at http://www.cio.com/article/3184618/government-use-of-it/county-and-municipal-cybersecurity-part-1.html
© Copyright Jeffrey Morgan, 2017by