Category: Information Security
PHI Breach detection in county government
The Office of Civil Rights (OCR) maintains a list of HIPAA breach investigations which currently lists over 400 open breach investigations.
One interesting breach is Adams County, Wisconsin which was leaking information undetected for over five years from 2013 and it highlights the lack of controls counties have in place for detection of security anomalies.
It’s pretty easy to determine whether or not counties have appropriate controls in place. The first question to ask is do they have a risk assessment? If your local government organization doesn’t conduct ongoing periodic risk assessments, you aren’t compliant with the HIPAA Security Rule. So, if you don’t have a risk assessment, get one so you can identify potential problems.
There are roughly 40 policy requirements for the HIPAA Security Rule and HIPAA sets a low bar in comparison to ISO/IEC 27001 and NIST CSF. If your county security policy doesn’t have these 40 policies in place, with corresponding processes and procedures you aren’t compliant with HIPAA.
We offer a low-cost 90 minute HIPAA workshop to help you assess your level of HIPAA compliance. The worst time to find out that you aren’t compliant is after a breach!
© Copyright Jeffrey Morgan, 2018
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