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
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
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 firstname.lastname@example.org. 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
Free Download – County and Municipal Cybersecurity Whitepaper:
May I see your comprehensive security policy please?
Huh? What’s that?
Lack of compliance with the HIPAA security standards is common in county and municipal government agencies even though many of these organizations have covered entities (CE) under their umbrellas. For some reason, almost everyone got the memo on required compliance with HIPAA privacy rules in 2003, but many organizations missed the subsequent memo on required compliance with security rules by April of 2005.
Nearly 14 years have passed since the security rule was published, and I have no explanation for the compliance lacuna that exists today. If you are an executive, manager or provide IT services for a CE, your security policy should be as well-worn as your kids’ Harry Potter books.
If someone (i.e. an auditor) asks about your compliance program, you should be able to succinctly summarize it and immediately provide documentation of your compliance activities. If this doesn’t describe your organization, you are not alone and there is no time like to present to begin the process.
Compliance isn’t a one-time, passive event and there are routine steps you must take ensure the CIA (confidentiality, integrity and availability) of your clients’ protected health information (PHI).
Denial and disbelief
Denial and disbelief are the first two stumbling blocks I encounter when informing managers in government agencies that they are not in compliance with HIPAA. Sickening yellow clouds of realization dawn over a period of several weeks while I continue to email copies of the Code of Federal Regulations (CFR) to the relevant parties. The attorney is generally the first to comprehend the magnitude of the situation.
Holistic information security
I talk about security policies rather than HIPAA policies. Something that is also common in municipal government is a lack of information security policies based on some generally accepted standard or framework for information security. You can and should address HIPAA security requirements and your overarching organizational information security requirements together.
Form a governance committee
Developing your security policy isn’t an IT project; it is part of an Information Governance program. A cross-functional team including representation from several organizational entities must be part of the process for developing your information security policies. Here are the roles I generally request to be part of the policy development team:
1. Executive owner
4. Information technology
5. Line of business units
6. Records management
7. Risk management, privacy and information security officer roles (Many municipal governments do not employ these functional roles, but they will once they have developed their policy).
Read the regulations!
I am a big believer in always working from primary sources. I encourage you to embark upon your HIPAA journey by reading the full text of the regulations. In the table below, I have hyperlinked them for your convenience. When I write policies for clients, I work directly from the regulation with their policy or governance committee so that everyone understands the process and the final result. Even so, clients will often argue about something that is projected on the wall right in front of them. I link every client policy to the corresponding HIPAA requirement.
Primary sources for compliance – educate yourself
|HIPAA Privacy Rule||45 CFR Parts 160 and 164 Standards for Privacy of Individually Identifiable Health Information.||Final Rule – December 28, 2000|
|HIPAA Security Rule||45 CFR Parts 160, 162, 164.||Final Rule – February 2003|
|HIPAA Combined Regulation Text||HIPAA Administrative Simplification.||Unofficial version amended through March 2013 combining the privacy and security rules.|
|HITECH Act Enforcement||HITECH Act interim final rule includes penalties for non-compliance.||October 30, 2009|
|NIST Special Publication 800-53||Security and Privacy Controls for Federal Information Systems and Organizations||Revision 4, April 2013|
|Privacy Rule Resources||HHS.GOV resources|
|Guide to Privacy and Security of Electronic Health Information||Office of National Coordinator for Health Information Technology||Version 2.0 April 2015|
|NIST HIPAA Security Rule Toolkit||Downloads and tools from NIST for assessment, etc.|
|NIST Special Publication 800-66||An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule||October 2008|
|Security Risk Assessment Tool||HealthIT.Gov||Executable tool – paper copy available too.|
In a previous article on the subject, I provided a sample, high-level compliance matrix for a security policy aligned with HIPAA.
Vendors often market products as being “HIPAA compliant.” If you have read the regulations above, you now know that there is no such thing. The HIPAA security rule is technology-neutral, and any reference to compliance would be to your organization’s policy rather than to the rule itself.
Get to work!
If you are now nauseous because you realize that you are not even remotely in compliance, that’s a good thing. Use that feeling to quickly get to work to protect your organizational information assets.
© Copyright Jeffrey Morgan, 2016
This article firs appeared on CIO.COM at http://www.cio.com/article/3134484/government/may-i-see-your-comprehensive-security-policy-please.htmlby
Is your information secure?
Are your organization’s information assets absolutely secure? Do your staff and contractors assure you that everything is safe? How do they know? And how about all those paper files? Is confidential data appropriately labeled and stored in a secure, locked and monitored facility? How do you know? How would anyone even know if there was a breach?
The role of IT Staff
I have sat in meetings with IT Staff who have sworn up and down that the network is secure without any facts or data to support that assertion. What are your IT staff and contractors doing every day to ensure that your information is secure? And what about staff that maintain other types of physical instruments and records?
The role of vendors
I have also sat in many meetings with security vendors who have made outrageous and patently false statements, like “our product is HIPAA compliant.” (There is no such thing. The HIPAA Security Rule is a federal regulation that describes the framework for developing a security policy for certain types of information and organizations. HIPAA is purposely technology and vendor-neutral). Every security vendor wants you to believe that they are selling a magical product that will keep your organization secure from all the evils that result from being connected to the entire world through the Internet.
There are no magic products
The truth of the matter is that there are no products or services that will inherently ensure and maintain the confidentiality, integrity and availability (CIA) of your information. Information Security is about process, policy, procedure, and training rather than about installing products. A successful security program comes as a result of looking closely at both the macro view and the micro details and taking appropriate, thoughtful actions using a cycle of continuous improvement. Security products might be a part of your overall security strategy, but without sensible policies. procedures, and training the products themselves are unlikely to produce the desired, advertised result.
Do you have a Comprehensive Information Security Policy?
If you are larger than a Mom and Pop operation, you should have a Comprehensive Information Security Policy. If you are running a municipality or corporation with dozens or hundreds of employees, the lack of such a policy probably constitutes organizational malpractice or malfeasance at some level. Moreover, your policy shouldn’t be just a dusty book on the shelf – all your employees should have had training on and understand the policy.
You can wait for a catastrophic security event to wake your organization up, or you can take action now to prevent an embarrassing and costly revelation. For instance, if your organization is required to comply with HIPAA, the wake up call could come in the form of a multi-million dollar fine from HHS or civil litigation. Or you might end up paying ransom to buy back your data from data pirates. These risks are real and well documented.
How do I get started with a Security Policy?
There are many options for developing a comprehensive information security policy. You can purchase kits, buy books, hire consultants, etc. You can do it yourself, or contract it out, but the process will be largely the same either way. I will give you a 40,000 foot view and you can decide how to proceed. Other than time, the initial costs should not be high, but securing your information infrastructure will definitely have some impact on your budget, albeit less than the eventual cost of not addressing security. Even if this is a DIY project, outsourcing some aspects is probably appropriate unless you have staff members who have been extensively trained in information security domains and disciplines.
Make sure the right people are at the table!
This is NOT an Information Technology project. It is a critical enterprise business, policy and security project, so you want to make sure you have the appropriate stakeholders at the table. Establish a multi-disciplinary committee to participate in the process. Managers and Department Heads from different departments may provide illuminating perspectives and the group must also include rank and file members of your staff who actually do the work (AKA the minions). Staff members with security and military backgrounds may have much to contribute. People who may have had experience in highly regulated industries, such as Pharmaceutical, Insurance, Medical, Public and Mental Health, and Law Enforcement may also have much to contribute to the process. HR and Legal must be at the table. I am certain that your organization has untapped, expert resources, so find them and use them.
Inventory your Assets
Once your Information Security Committee is assembled, its time to get to work. The first step is going to be a Risk Assessment. Since you have already established your Information Security committee, begin the Risk Assessment process by cataloging and categorizing all your information resources. Information in this catalog may include paper files, network and computer files including backups, archival and historical records, microfilm, tax records, specifications, etc. There are payroll records, health insurance records, possibly protected medical information, HR information, meeting records, AR and AP records. All of these records may contain information protected by local, state or federal statute. There may be proprietary information related to manufacturing or other information such as videos, films, sound recordings that you may want or need to protect in some way. Use an interrogative process to identify, catalog, and categorize all this information. The output of this process should be a detailed document that clearly identifies all of these assets.
It may be appropriate to contract a qualified consultant for the Risk Assessment process. Why? Regardless of how intelligent and qualified the members of your staff are, they are probably immersed in your organizational culture. They may have biases and make assumptions because “we have always done it this way.” Outsiders may be able to see past the assumptions and biases that your staff members can’t
Once you have completed this process, you will almost certainly have found information that you didn’t even know you had. If you found sensitive information without any plan for protecting it, you might have trouble sleeping until your committee comes up with a plan.
Once you know what types of information for which you are responsible, ask yourself and the Subject Matter Experts on your committee what statutes apply. There are at least a handful of regulations that always apply, and there may be dozens of regulations dealing with information-specific data you have to consider. You probably also found information not protected by statute that needs to be addressed. Do your current policies cover all the information in your catalog? In a subsequent article, I will continue with the next steps for securing your information.
Thinking of your staff will not change overnight.
If you want to discuss Information Security in your organization, send me an e-mail at email@example.com.
Copyright © Jeffrey Morgan 2015by