Final Exam Case Study        ITT-1021-01 Principles of Information Security                 Instructor: Scott Simenson  Ka...
Table of Contents1. Introduction2. Job Description and Qualifications3. Policies Descriptions4. Risk Assessment5. Adequate...
IntroductionThe purpose of the security architecture blueprint is to bring focus to the key areas of concern for RLKProduc...
RLK Products                                     Office of the Chief Information Officer                                  ...
Compliance and EnforcementServe as the company compliance officer with respect to RLK, state and federal information secur...
Excellent documentation skills       Ability to weigh business risks and enforce appropriate information security measures...
· Abide by and be aware of all policies and laws (local, state, federal, and international) applicable to computersystem u...
Who’s responsible?Risk and Contingency Manager is responsible for administering and managing the facility’s risk managemen...
System Owner serves as the process owner for all ongoing activities related to the availability, integrity, andconfidentia...
understands the platform on which database runs, and adds new users to the system. They plan and coordinate securitymeasur...
units to ensure timely development and implementation of corrective action plans in response to monitoringdeficiencies and...
TABLE 1: SECURITY CONTROL CLASSES,              FAMILY                        CLASS  FAMILIES, AND IDENTIFIERS IDENTIFIER ...
Assist in safeguarding the companys assets -- people, data, property and reputationHealth Insurance Portability and Accoun...
Figure 1The steps listed in the NIST RMF create an effective information security program and can be applied to bothnew an...
Document the agreed-upon set of security controls in the system security plan including theorganization’s rationale for an...
• Vulnerabilities are a flaw or weakness in a system security procedure, design, implementation, or controlthat could be i...
The scope of a risk assessment should include both the physical boundaries of a covered entity’s location aswell as a logi...
4. Identify Potential Vulnerabilities.Often performed simultaneously with step 3, Identify Realistic Threats, the goal of ...
Some tangible impacts can be measured quantitatively in terms of lost revenue, the cost of repairing thesystem, or the lev...
assigning a risk level based on the average of the assigned likelihood and impact levels. A risk-level matrix,such as the ...
The risk assessment provides important inputs to determine the sufficiency of the security control baseline.The risk asses...
damage to organizational assets; (iii) result in major financial loss; or (iv) result in severe or catastrophic harmto ind...
along with the control baselines.The following specific example shows the criteria for determining control baselines:     ...
Implementing and Documentation of the SystemPertinent system information such as system boundaries, information types, con...
who, if satisfied with the documentation and the results of certification, accredits the system by issuing anauthorization...
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Final Exam Case Study (3)

  1. 1. Final Exam Case Study ITT-1021-01 Principles of Information Security Instructor: Scott Simenson Kathy Cotterman and Lisa Neuttila December 8, 2010
  2. 2. Table of Contents1. Introduction2. Job Description and Qualifications3. Policies Descriptions4. Risk Assessment5. Adequate Procedural and Activity Detail6. Information, Assurance and Security Ongoing Maintenance7. Employee Annual Evaluation Criteria8. Overall Solution to Problem 2|Page
  3. 3. IntroductionThe purpose of the security architecture blueprint is to bring focus to the key areas of concern for RLKProducts, highlighting decision criteria and context for each domain. Since security is a system property it canbe difficult for Enterprise Security groups to separate the disparate concerns that exist at different systemlayers and to understand their role in the system as a whole. This blueprint provides a framework forunderstanding disparate design and process considerations; to organize architecture and actions towardimproving enterprise security.The security architecture blueprint in Figure 1 depicts an approach to map the system’s stakeholders’conceptual goals to a logical view for security, which is set of security policy and standards, securityarchitecture, and risk management domains. The decisions in the logical layer drive the security processes,defense in depth services and security metrics through design time to run time.Figure 1 3|Page
  4. 4. RLK Products Office of the Chief Information Officer (CIO) Job DescriptionDEPARTMENT: Office of the CIOJOB TITLE: Information Assurance/Security Officer (IA/SO)POSITION RELATIONSHIPS: Reports to: Chief Information Officer Works with: Risk and Contingency Manager, System Owner, Security Operations Manager External Relationships: IT suppliers/vendors, law enforcementPOSITION SUMMARY:Under the general direction of the CIO, the Information Assurance/Security Officer (IA/SO) is responsible forthe development and delivery of a comprehensive information security and privacy program for RLKProducts. The scope of this program is company-wide, and includes information in electronic, print andother formats. The purposes of this program include: to assure that information created, acquired ormaintained by RLK and its authorized users, is used in accordance with its intended purpose; to protect RLKinformation and its infrastructure from external or internal threats; and to assure that RLK complies withstatutory and regulatory requirements regarding information access, security and privacy.POSITION DUTIES, RESPONSIBILITIES AND COMPETENCIESPolicyCoordinate the development of RLK information security policies, standards and procedures. Work with key IToffices, data custodians and governance groups in the development of such policies. Ensure that companypolicies support compliance with external requirements. Oversee the dissemination of policies, standards andprocedures to the company.Education and TrainingCoordinate the development and delivery of an education and training program on information security andprivacy matters for employees, other authorized users. 4|Page
  5. 5. Compliance and EnforcementServe as the company compliance officer with respect to RLK, state and federal information securitypolicies and regulations 1 . Work with the company-designated Records Access and HIPAA-privacy Officerson compliance issues as necessary. Prepare and submit required reports to external agencies.Incident ResponseDevelop and implement an Incident Reporting and Response System to address RLK security incidents(breaches), respond to alleged policy violations, or complaints from external parties. Serve as the officialcompany contact point for information security, privacy and copyright infringement incidents, includingrelationships with law enforcement entities.Risk Assessment and Incident PreventionDevelop and implement an ongoing risk assessment program targeting information security and privacymatters; recommend methods for vulnerability detection and remediation, and oversee vulnerabilitytesting.Official ContactAct as the CIO’s designee representing RLK on Information Security matters; serve as the company contactpoint for external auditors and agencies, survey requests, etc on security/privacy matters.Maintain KnowledgebaseKeep abreast of latest security and privacy legislation, regulations, advisories, alerts and vulnerabilitiespertaining to the RLK and its mission.Emergency PreparednessTake part in Disaster Recovery Planning.QUALIFICATIONS:The emphasis of this position is on policy development, program administration and compliance/incidentresponse activities. While technical knowledge of information technology and security issues is highlydesirable, technical expertise and resources will be available from units such as Systems Management &Operations, and the Office of Telecommunications to support the information security and privacy program.1 For example, HIPAA, NIST and FIPS Publications, Minnesota Laws and Statutes, USA Patriot Act, et al.Education: Bachelors degree required. Advanced degree preferred.General Skills and Experience Requirements: Experienced in the management of both physical and logical information security systems Strong technical skills (application and operating system hardening, vulnerability assessments, security audits, TCP/IP, intrusion detection systems, firewalls, etc.) Outstanding interpersonal and communication skills Must possess a high degree of integrity and trust along with the ability to work independently
  6. 6. Excellent documentation skills Ability to weigh business risks and enforce appropriate information security measures In-depth knowledge of the HIPAA Security Rule and other government technology laws CISSP (Certified Information Systems Security Professional) certification preferredPreambleIn compliance with HIPAA, NIST, and FIPS standards, and generally accepted industry best practices, RLKProducts provides for the security and privacy of the data stored on, redirected through, or processed by itstechnology resources. RLK Products encourages the use of these technology resources; however they remainthe property of RLK Products and are offered on a privilege basis only.Throughout this policy, the term “staff” identifies full- and part-time employees, contractors, consultants,temporaries, student assistants, volunteers, retired annuitants, vendors and other users including thoseaffiliated with third parties who access RLK Products technology resources due to their job responsibilities.Management expects staff to comply with this and other applicable RLK Products policies, procedures, andlocal, state, federal, and international laws. Failure to abide by these conditions may result in forfeiture of theprivilege to use technology resources, disciplinary action, and/or legal action.The IT Policy Review Team regularly modifies this and other IT security related policies to reflect changes inindustry standards, legislation, technology and/or products, services, and processes at RLK Products.PrivacyRLK Products reserves the right to monitor, duplicate, record and/or log all staff use of RLK Productstechnology resources with or without notice. This includes but is not limited to e-mail, Internet access,keystrokes, file access, logins, and/or changes to access levels. Staff shall have no expectation of privacy inthe use of these technology resources.LiabilityRLK Products makes no warranties of any kind, whether expressed or implied for the services in this policy. Inaddition, RLK Products is not responsible for any damages which staff may suffer or cause arising from orrelated to their use of RLK Products technology resources. Staff must recognize that RLK Products technologyresource usage is a privilege and that the policies implementing said usage are requirements that mandateadherence.Staff Responsibilities and AccountabilityEffective information security requires staff involvement as it relates to their jobs. Staff is accountable for theiractions and therefore they own any events occurring under their user identification code(s). It is staff’sresponsibility to abide by policies and procedures of all networks and systems with which they communicate.Access of personal or private Internet Service Providers while using RLK Products provided informationtechnology resources or using non-RLK Products provided information technology resources to conduct RLKProducts business does not indemnify any entity from the responsibilities, accountability and/or compliancewith this or other RLK Products policies. Staff responsibilities include but are not limited to:· Access and release only the data for which you have authorized privileges and a need to know (includingmisdirected e-mail) 6|Page
  7. 7. · Abide by and be aware of all policies and laws (local, state, federal, and international) applicable to computersystem use· Report information security violations to the Information Security Officer or designee and cooperate fullywith all investigations regarding the abuse or misuse of state owned information technology resources· Protect assigned user IDs, passwords, and other access keys from disclosure· Secure and maintain confidential printed information, magnetic media or electronic storage mechanisms inapproved storage containers when not in use and dispose of these items in accordance with RLK Productspolicy· Log off of systems (or initiate a password protected screensaver) before leaving a workstation unattended· Use only RLK Products acquired and licensed software· Attend periodic information security training provided by RLK Products IT Security Branch· Follow all applicable procedures and policies© SANS Institute 2001, Author retains full rightsKey fingerprint = AF19 FA27 2F94 998D FDB5 DE3D F8B5 06E4 A169 4E46Key fingerprint = AF19 FA27 2F94 998D FDB5 DE3D F8B5 06E4 A169 4E46 7|Page
  8. 8. Who’s responsible?Risk and Contingency Manager is responsible for administering and managing the facility’s risk management program.They develop and implement the organization’s risk management program in a manner that fulfills the mission andstrategic goals of the organization while complying with state and federal laws and accreditation standards related tosafety and risk management. They develop and implement systems, policies, and procedures for the identification,collection and analysis of risk related information. They educate and train the leadership, staff and business associatesas to the risk management program, and their respective responsibilities in carrying out the risk management program.They lead, facilitate, and advise departments in designing risk management programs within their own departments.They collect, evaluate, and maintain data concerning patient injuries, claims, worker’s compensation, and other risk-related data. They help investigate and analyze root causes, patterns, or trends that could result in compensatory orsentinel events. They help to identify and implement corrective action where appropriate. They provide a quarterlysummary to the Board on incidents, claims, and claim payments. They serve as the organization’s liaison to theorganization’s insurance carrier. They assist in processing summonses and claims against the facility by working withlegal counsel to coordinate the investigation, processing, and defense of claims against the organization. They activelyparticipate in or facilitate committees related to risk management, safety, and quality improvement. 8|Page
  9. 9. System Owner serves as the process owner for all ongoing activities related to the availability, integrity, andconfidentiality of patient, provider, employee and business information in compliance with the healthcare organizationsinformation security policies and procedures. Documents for information security policies and procedures instituted bythe organizations Information Security Committee. Implements the organization’s information security policies andprocedures. Provides direct information security training to all employees, contractors, alliances, and other third-parties.Monitors compliance with the organization’s information security policies and procedures among employees,contractors, alliances, and other third parties and refers problems to appropriate department managers oradministrators. Monitors internal control systems to ensure that appropriate information access levels and securityclearances are maintained. Performs information security risk assessment and serves as the internal auditor forinformation security processes. Prepares the organization’s disaster recovery and business continuity plans forinformation systems. Serves as an internal information security consultant to the organization. Monitors advancementin information security technologies. Monitors changes in legislation and accreditation standards that affect informationsecurity. Initiates, facilitates, and promotes activities to foster information security awareness within the organization.Serves as the information security liaison for users of clinical, administrative, and behavioral systems. Reviews allsystem- related information security plans throughout the organizations network.Security Operations Manager provide supervisory oversight for day to day security operations of the site. Ensures allrequired reporting and contract compliance requirements are met by conducting regular performance reviews.Prepares reports or metrics as assigned to track data. Maintains daily contact with patients to solicit feedback regardingperformance, operational requirements, and other issues pertaining to site operations. Building, improving andmaintaining effective relationships with patients, employees and third-parties. Maintains administrative oversight forsite operations including procedural changes, contact information, and works instructions. Assists in operationalplanning, emergency response, and other security related matters. Handles security issues in emergency situations inaccordance with regulations, company policies and contract requirements.Computer Security Specialist plan, Coordinate and maintain an organizations information security. They educate usersabout computer security, install security software, monitor network for security breaches, respond to cyber-attacks and,in some cases, gather data and evidence to be used in prosecuting cyber-crime.Telecommunications Specialist focus on the interaction between computer and communities communicationsequipment. They designed voice, video and data communication systems, supervise the installation of the systems, andprovide maintenance and other services after the systems are installed. They also test lines, oversees equipment repair,and may compile and maintain system records.Web Administrators are responsible for maintaining website. They oversee issues such as availability to users and speedof access, and are responsible for approving the content of the site. Web Administrators also collect and analyze data onweb activity, traffic patterns and other metrics, as well as monitor in respond to user feedback. They are alsoresponsible for the technical aspects of website creation. They use software languages and tools and create applicationsfor the web. They identify the site’s users and oversee its product production and implementation. They determine theinformation that the site will contain and how it will be organized, and may use web development software to integratedatabases and other information systems. Database Administrators work with data base management software and determine ways to store, organize, analyze,use and present data. They identify user needs and set up new computer databases. In many cases, databaseadministrators must integrate data from old systems into a new system. They also test and coordinate modifications tothe system when needed, and troubleshoot problems when they occur. They ensure performance of the system, 9|Page
  10. 10. understands the platform on which database runs, and adds new users to the system. They plan and coordinate securitymeasures with network administrators.Systems Architects are the designers of computer networks. They set up, test, and evaluate systems such as local areanetworks (LANs), wide area networks (WANs), the internet, intranets, and other data communications systems.Systems are configured in many ways and can range from a connection between two offices in the same building toglobally distributed networks, voice mail and e-mail systems of a multinational organization. Network architects andengineers perform network modeling, analysis and planning, which often require both hardware and software solutions.For example, setting up a network may involve installation of several pieces of hardware, such as routers and hubs,wireless adapters and cables, as well as the installation and configuration of software, such as network drivers. Theseworkers may also research related products and make necessary hardware and software recommendations, as well asthe address information security issues.System Administrators are responsible for LANs, WANs, network segments, and Internet and intranet systems. They arealso responsible for maintaining system efficiency. They ensure that the design of an organizations computer systemallows all the components, including computers, the network, and software, to work properly together. Administratorsalso troubleshoot problems reported by users in by automated network monitoring systems and makerecommendations for future system upgrades. They maintain network and system security, maintain network hardwareand software, analyze problems, and monitor networks to ensure their availability to users. They gather data toevaluate the systems performance, identify user needs, and determine system and network requirements.Computer Security Specialist oversee all ongoing activities related to development, implementation, maintenance of,and adherence to policies and procedures covering security of and access to protected health information (PH I) incompliance to federal and state laws and health system security practices. The Computer Security Specialist ensures thatperiodic risk assessments and ongoing monitoring of key elements of the security program are monitored. They lead inthe development and enforcement of information security policies and procedures, measures and mechanisms toensure the prevention, detection, containment and correction of security incidents. They ensure that security standardscomply with statutory and regulatory requirements regarding health information. Ensures that security policies aremaintained that include: administrative security, personnel security, physical safeguards, technical security andtransmission security. They provide assurance that appropriate documentation exists of response of the institution ofthe addressable portion of the security rule. Ensures that security procedures are maintained that include: evaluation ofcompliance with security measures; contingency plans for emergency and disaster recovery; security incident responseprocess and protocols; testing of security procedures, measures and mechanisms, and continuous improvement; andsecurity incident reporting mechanisms and sanction policy. Ensures that appropriate security measures andmechanisms are in place to guard against unauthorized access to electronically stored and/or transmitted patient dataand protect against reasonably anticipated threats and hazards, including, when appropriate: integrity controls,authentication controls, access controls, encryption, and abnormal condition alarms, audit trails, entity authenticationand events reporting. They oversee ongoing security monitoring of information systems, including: periodic informationsecurity risk assessment; functionality and gap analyses to determine the extent to which key business areas andinfrastructure comply with statutory and regulatory requirements; and review of new information security technologiesand counter- measures against threats to information or privacy. They oversee training programs, periodic securityawareness reminders, and periodic security audits. This position serves as an instrumental resource regarding mattersof informational security. Works with administration, legal counsel and other related parties to represent theorganization information security interests with external parties (state or local government bodies) who undertake toadopt or amend security legislation, regulation, or standard. They coordinate with the appropriate departments and 10 | P a g e
  11. 11. units to ensure timely development and implementation of corrective action plans in response to monitoringdeficiencies and complaints. 11 | P a g e
  12. 12. TABLE 1: SECURITY CONTROL CLASSES, FAMILY CLASS FAMILIES, AND IDENTIFIERS IDENTIFIER AC Access Control Technical AT Awareness and Training Operational AU Audit and Accountability Technical CA Certification, Management Accreditation, and Security Assessments CM Configuration Operational Management CP Contingency Planning Operational IA Identification and Technical Authentication IR Incident Response Operational MA Maintenance Operational MP Media Protection Operational PE Physical and Operational Environmental Protection PL Planning Management PS Personnel Security Operational RA Risk Assessment Management SA System and Services Management Acquisition SC System and Technical Communications Protection SI System and Information Operational Integrity NIST SP 800-53Risk Assessment FrameworkRisk Assessment Framework introduces a structured, flexible, extensible, and repeatable process for managingorganizational risk and achieving risk-based protection related to the operation and use of information. RLKEnterprises is an electronic medical records storage company and is subject to HIPPA Security Rule. TheNational Institute of Standards and Technology has created structure, guidelines and procedures that arerequired to be followed by Federal Agencies when dealing with electronic health information. They havemade these available to commercial enterprises and actually recommend their use by the private sector. Sowe have decided to adopt most if not all of their recommended Risk Assessment Framework, with somescoping and customizing to the specific needs of RLK Enterprises.A Risk Management Policy has been created to: Protect RLK Enterprises from those risks of significant likelihood and consequence in the pursuit of the company’s stated strategic goals and objectives Provide a consistent risk management framework in which the risks concerning business processes and functions of the company will be identified, considered and addressed in key approval, review and control processes Provide assistance to and improve the quality of decision making throughout the company Meet legal or statutory requirements Encourage pro-active rather than re-active management 12 | P a g e
  13. 13. Assist in safeguarding the companys assets -- people, data, property and reputationHealth Insurance Portability and Accountability Act (HIPAA)HIPAA Security RuleThe HIPAA Security Rule specifically focuses on the safeguarding of electronic protected health information(EPHI). All HIPAA covered entities, which includes some federal agencies, must comply with the Security Rule.The Security Rule specifically focuses on protecting the confidentiality, integrity, and availability of EPHI, asdefined in the Security Rule. The EPHI that a covered entity creates, receives, maintains, or transmits must beprotected against reasonably anticipated threats, hazards, and impermissible uses and/or disclosures. Ingeneral, the requirements, standards, and implementation specifications of the Security Rule apply to anyprovider of medical or other health services, or supplies, who transmits any health information in electronicform in connection with a transaction for which HHS has adopted a standard.Security Rule Goals and ObjectivesAs required by the “Security standards: General rules” section of the HIPAA Security Rule, each covered entitymust:• Ensure the confidentiality, integrity, and availability of EPHI that it creates, receives, maintains, or transmits;• Protect against any reasonably anticipated threats and hazards to the security or integrity of EPHI; and• Protect against reasonably anticipated uses or disclosures of such information that are not permitted by thePrivacy Rule.In complying with this section of the Security Rule, covered entities must be aware of the definitions providedfor confidentiality, integrity, and availability as given by § 164.304:• Confidentiality is “the property that data or information is not made available or disclosed to unauthorizedpersons or processes.”• Integrity is “the property that data or information have not been altered or destroyed in an unauthorizedmanner.”• Availability is “the property that data or information is accessible and useable upon demand by anauthorized person.”NIST Risk Management Framework (RMF)The NIST RMF, illustrated in Figure 1, provides a disciplined, structured, extensible, and repeatable process forachieving risk-based protection related to the operation and use of information systems and the protection ofEPHI. It represents an information security life cycle that facilitates continuous monitoring and improvementin the security state of the information systems within the organization. 13 | P a g e
  14. 14. Figure 1The steps listed in the NIST RMF create an effective information security program and can be applied to bothnew and legacy information systems within the context of a system development life cycle. A risk-basedapproach to security control selection and specification considers effectiveness, efficiency, and constraintsdue to applicable laws, policies, standards, or regulations. The flexible nature of the NIST RMF allows othercommunities of interest, such as private sector entities, to use the framework voluntarily either with the NISTsecurity standards and guidelines or with industry-specific standards and guidelines. The RMF providesorganizations with the flexibility needed to apply the right security controls to the right information systems atthe right time to adequately protect the critical and sensitive information, missions, and business functions ofthe organization. Categorize the information system and the information resident within that system based on a FIPS199 impact analysis. Select an initial set of security controls (i.e., security control baseline from Appendix D) for theinformation system based on the FIPS 199 security categorization and the minimum security requirementsdefined in FIPS 200; apply tailoring guidance from Section 3.3 as appropriate, to obtain the control set used asthe starting point for the assessment of risk associated with the use of the system. Supplement the initial set of tailored security controls based on an assessment of risk and localconditions including organization-specific security requirements, specific threat information, cost-benefitanalyses, or special circumstances. 14 | P a g e
  15. 15. Document the agreed-upon set of security controls in the system security plan including theorganization’s rationale for any refinements or adjustments to the initial set of controls. Implement the security controls in the information system. For legacy systems, some or all of thesecurity controls selected may already be in place. Assess the security controls using appropriate methods and procedures to determine the extent towhich the controls are implemented correctly, operating as intended, and producing the desired outcomewith respect to meeting the security requirements for the system. Authorize information system operation based upon a determination of the risk to organizationaloperations, organizational assets, or to individuals resulting from the operation of the information system andthe decision that this risk is acceptable. Monitor and assess selected security controls in the information system on a continuous basisincluding documenting changes to the system, conducting security impact analyses of the associated changes,and reporting the security status of the system to appropriate organizational officials on a regular basis.Risk Assessment GuidelinesThis appendix incorporates risk assessment concepts and processes described in NIST SP 800-30 Revision 1,Effective Use of Risk Assessments in Managing Enterprise Risk, the NIST Risk Management Framework, and theHIPAA Security Series: Basics of Risk Analysis and Risk Management. It is intended to assist covered entities inidentifying and mitigating risks to acceptable levels.The purpose of a risk assessment is to identify conditions where EPHI could be disclosed without properauthorization, improperly modified, or made unavailable when needed. This information is then used to makerisk management decisions on whether the HIPAA-required implementation specifications are sufficient orwhat additional addressable implementation specifications are needed to reduce risk to an acceptable level.Key Terms DefinedWhen talking about risk, it is important that terminology be defined and clearly understood. This sectiondefines important terms associated with risk assessment and management.• Risk is the potential impact that a threat can have on the confidentiality, integrity, and availability on EPHI byexploiting a vulnerability.• Threats are anything that can have a negative impact on EPHI. Threats are: Intentional (e.g., malicious intent); or Unintentional (e.g., misconfigured server, data entry error).• Threat sources are: Natural (e.g., floods, earthquakes, storms, tornados); Human (e.g., intentional such as identity thieves, hackers, spyware authors; unintentional such as data entry error, accidental deletions); or Environmental (e.g., power surges and spikes, hazmat contamination, environmental pollution). 15 | P a g e
  16. 16. • Vulnerabilities are a flaw or weakness in a system security procedure, design, implementation, or controlthat could be intentionally or unintentionally exercised by a threat.• Impact is a negative quantitative and/or qualitative assessment of a vulnerability being exercised on theconfidentiality, integrity, and availability of EPHI.It can be easy to confuse vulnerabilities and threats. An organization may be vulnerable to damage frompower spikes. The threats that could exploit this vulnerability may be overloaded circuits, faulty buildingwiring, dirty street power, or too much load on the local grid. It is important to separate these two terms inorder to assist in proper security control selection. In this example, security controls could range frominstalling UPS systems, additional fuse boxes, or standby generators, or rewiring the office. These additionalsecurity controls may help to mitigate the vulnerability but not necessarily for each threat.HIPAA Risk Assessment RequirementsStandard 164.308(a)(1)(i), Security Management Process, requires covered entities to: Implement policies andprocedures to prevent, detect, contain, and correct security violations. The Security Management Processstandard includes four required implementation specifications. Two of these specifications deal directly withrisk analysis and risk management.1. Risk Analysis (R123) – 164.308(a)(1)(ii)(A): Conduct an accurate and thorough assessment of the potentialrisks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected healthinformation held by the covered entity.2. Risk Management (R) – 163.308(a)(1)(ii)(B): Implement security measures sufficient to reduce risks andvulnerabilities to a reasonable and appropriate level to comply with Section 164.306(a).How to Conduct the Risk Assessment:Risk assessments can be conducted using many different methodologies. There is no single methodology thatwill work for all organizations and all situations. The following steps represent key elements in acomprehensive risk assessment program, and provide an example of the risk assessment methodologydescribed in NIST SP 800-30. It is expected that these steps will be customized to most effectively identify riskfor an organization based on its own uniqueness. Even though these items are listed as steps, they are notprescriptive in the order that they should be conducted. Some steps can be conducted simultaneously ratherthan sequentially.1. Scope the Assessment.The first step in assessing risk is to define the scope of the effort, resulting in a general characterization of theinformation system, its operating environment, and its boundary. To do this, it is necessary to identify whereEPHI is created, received, maintained, processed, or transmitted. 16 | P a g e
  17. 17. The scope of a risk assessment should include both the physical boundaries of a covered entity’s location aswell as a logical boundary covering the media containing EPHI, regardless of its location. Ensure that the riskassessment scope takes into consideration the remote work force and telecommuters, and removable mediaand portable computing devices (e.g., laptops, removable media, and backup media).2. Gather Information.During this step, the covered entity should identify:• The conditions under which EPHI is created, received, maintained, processed, or transmitted by the coveredentity; and• The security controls currently being used to protect the EPHI.This step is essential to ensure that vulnerabilities and threats are correctly identified. For example, aninvalidated belief that a policy is being followed can miss a potential vulnerability, and not knowing aboutportable media containing EPHI can miss a threat to that environment. The level of effort needed to gatherthe necessary information depends heavily on the scope of the assessment and the size of the covered entity.3. Identify Realistic Threats.Often performed simultaneously with step 4, Identify Potential Vulnerabilities, the goal of this step is toidentify the potential threat sources and compile a threat statement listing potential threat-sources that areapplicable to the covered entity and its operating environment. The listing of threat sources should includerealistic and probable human and natural incidents that can have a negative impact on an organizations abilityto protect EPHI.Threats can be easily identified by examining the environments where EPHI is being used. Many externalsources can be used for threat identification. Internet searches, vendor information, insurance data, andcrime statistics are all viable sources of threat data. Examples of some common threat sources are listed inTable 5 below.Table 5. Common Threat Sources 17 | P a g e
  18. 18. 4. Identify Potential Vulnerabilities.Often performed simultaneously with step 3, Identify Realistic Threats, the goal of this step is to develop a listof vulnerabilities (flaws or weaknesses) that could be exploited by potential threat sources. This list shouldfocus on realistic technical and nontechnical areas where EPHI can be disclosed without proper authorization,improperly modified, or made unavailable when needed.Covered entities should use internal and external sources to identify potential vulnerabilities. Internal sourcesmay include previous risk assessments, vulnerability scan and system security test results, and audit reports.External sources may include Internet searches, vendor information, insurance data, and vulnerabilitydatabases such as the National Vulnerability Database (http://nvd.nist.gov).5. Assess Current Security Controls.Often performed simultaneously with step 2, Gather Information, the purpose of this step is to determine ifthe implemented or planned security controls will minimize or eliminate risks to EPHI. A thoroughunderstanding of the actual security controls in place for a covered entity will reduce the list of vulnerabilities,as well as the realistic probability, of a threat attacking (intentionally or unintentionally) EPHI. Covered entitiesshould evaluate technical and nontechnical security controls at all places where EPHI is created, received,maintained, processed, or transmitted. This evaluation should determine whether the security measuresimplemented or planned are adequate to protect EPHI, and whether those measures required by the SecurityRule are in place, configured, and used properly. The appropriateness and adequacy of security measures mayvary depending on the structure, size, and geographical dispersion of the covered entity.6. Determine the Likelihood and the Impact of a Threat Exercising a Vulnerability.The next major step in measuring the level of risk is to determine the likelihood and the adverse impactresulting from a threat successfully exploiting a vulnerability. This information can be obtained from existingorganizational documentation, such as business impact and asset criticality assessments. A business impactassessment prioritizes the impact levels associated with the compromise of an organization’s informationassets based on a qualitative or quantitative assessment of the sensitivity and criticality of those assets. Anasset criticality assessment identifies and prioritizes the sensitive and critical organization information assets(e.g., hardware, software, systems, services, and related technology assets) that support the organization’scritical missions. If these organizational documents do not exist, the system and data sensitivity can bedetermined based on the level of protection required to maintain the EPHI’s confidentiality, integrity, andavailability. The adverse impact of a security event can be described in terms of loss or degradation of any, ora combination of any, of the following three security objectives: integrity, availability, and confidentiality.Table 6 provides a brief description of each security objective and the consequence (or impact) of its not beingmet.Table 6. Security Objectives and Impacts 18 | P a g e
  19. 19. Some tangible impacts can be measured quantitatively in terms of lost revenue, the cost of repairing thesystem, or the level of effort required to correct problems caused by a successful threat action. Otherimpacts, such as the loss of public confidence, the loss of credibility, or damage to an organization’s interest,cannot be measured in specific units but can be qualified or described in terms of high, medium, and lowimpacts. Qualitative and quantitative methods can be used to measure the impact of a threat occurring7. Determine the Level of Risk. The purpose of this step is to assess the level of risk to the IT system.The determination of risk takes into account the information gathered and determinations made during theprevious steps. The level of risk is determined by analyzing the values assigned to the likelihood of threatoccurrence and resulting impact of threat occurrence. The risk-level determination may be performed by 19 | P a g e
  20. 20. assigning a risk level based on the average of the assigned likelihood and impact levels. A risk-level matrix,such as the sample depicted in Table 7, can be used to assist in determining risk levels.Table 7. Sample Risk-Level Matrix8. Recommend Security Controls. During this step, security controls that could mitigate the identifiedrisks, as appropriate to the organization’s operations, are recommended. The goal of the recommendedcontrols is to reduce the level of risk to the IT system and its data to an acceptable level. Security controlrecommendations provide input to the risk mitigation process, during which the recommended securitycontrols are evaluated, prioritized, and implemented.It should be noted that not all possible recommended security controls can be implemented to reduce loss.To determine which ones are required and appropriate for a specific organization, a cost-benefit analysisshould be conducted for the proposed recommended controls, to demonstrate that the costs of implementingthe controls can be justified by the reduction in the level of risk.In addition to cost, organizations should consider the operational impact and feasibility of introducing therecommended security controls into the operating environment.9. Document the Risk Assessment Results. Once the risk assessment has been completed (threatsources and vulnerabilities identified, risks assessed, and security controls recommended), the results of eachstep in the risk assessment should be documented. NIST SP 800-30 provides a sample risk assessment reportoutline that may prove useful to covered entities.Risk Assessment Results Affect Risk ManagementThe results of a risk assessment play a significant role in executing an organization’s risk management strategy.In the context of the HIPAA Security Rule, the security control baseline, which consists of the standards andrequired implementation specifications, should be viewed as the foundation or starting point in the selectionof adequate security controls necessary to protect EPHI. In many cases, additional security controls or controlenhancements will be needed to protect EPHI or to satisfy the requirements of applicable laws, policies,standards, or regulations. 20 | P a g e
  21. 21. The risk assessment provides important inputs to determine the sufficiency of the security control baseline.The risk assessment results, coupled with the security control baseline, should be used to identify whichaddressable implementation specifications should be implemented to adequately mitigate identified risks.Identification and Categorization of Information Types in RLK SystemWe have identified the information types and assigned a category number on a scale of 1 to 5 according to themagnitude of harm resulting were the system to suffer a compromise of Confidentiality, Integrity, orAvailability. NIST SP 800-60 provides a catalog of information types, and FIPS-199 provides a ratingmethodology and a definition of the three criteria. The overall FIPS-199 system categorization is the highwater mark of the impact rating of all the criteria of all information types resident in the system.Category 0-1 -- The potential impact is LOW if—− The loss of confidentiality, integrity, or availability could be expected to have a limited adverse effect onorganizational operations, organizational assets, or individuals.AMPLIFICATION: A limited adverse effect means that, for example, the loss of confidentiality, integrity, oravailability might: (i) cause a degradation in mission capability to an extent and duration that the organizationis able to perform its primary functions, but the effectiveness of the functions is noticeably reduced; (ii) resultin minor damage to organizational assets; (iii) result in minor financial loss; or (iv) result in minor harm toindividuals.Category 2-3 -- The potential impact is MODERATE if—− The loss of confidentiality, integrity, or availability could be expected to have a serious adverse effect onorganizational operations, organizational assets, or individuals.AMPLIFICATION: A serious adverse effect means that, for example, the loss of confidentiality, integrity, oravailability might: (i) cause a significant degradation in mission capability to an extent and duration that theorganization is able to perform its primary functions, but the effectiveness of the functions is significantlyreduced; (ii) result in significant damage to organizational assets; (iii) result in significant financial loss; or (iv)result in significant harm to individuals that does not involve loss of life or serious life threatening injuries.Adverse effects on individuals may include, but are not limited to, loss of the privacy to which individuals areentitled under law.FIPS Publication 199 Standards for Security Categorization of Federal Information and Information SystemsCategory 4-5 -- The potential impact is HIGH if—− The loss of confidentiality, integrity, or availability could be expected to have a severe or catastrophicadverse effect on organizational operations, organizational assets, or individuals.AMPLIFICATION: A severe or catastrophic adverse effect means that, for example, the loss of confidentiality,integrity, or availability might: (i) cause a severe degradation in or loss of mission capability to an extent andduration that the organization is not able to perform one or more of its primary functions; (ii) result in major 21 | P a g e
  22. 22. damage to organizational assets; (iii) result in major financial loss; or (iv) result in severe or catastrophic harmto individuals involving loss of life or serious life threatening injuries.Selection of Security Controls for SystemDuring the design and implementation life-cycle phase, a set of security controls must be selected andincorporated into the system implementation. NIST SP 800-53 provides a catalog of security controls in SpecialPublication 800-53, Revision 2 the following chart is a small sample of the security controls recommended, 22 | P a g e
  23. 23. along with the control baselines.The following specific example shows the criteria for determining control baselines: 23 | P a g e
  24. 24. Implementing and Documentation of the SystemPertinent system information such as system boundaries, information types, constituent components,responsible individuals, description of user communities, interconnections with other systems andimplementation details for each security control need to be documented in the system security plan. NIST SP800-18 Rev 1 gives guidance on documentation standards. Additional documentation such as a contingencyplan for the system also needs to be prepared at this stage. Guidance on contingency planning can be found inNIST SP 800-34.Performing Risk AssessmentOnce the controls implementation are documented, a risk assessment can be performed. A risk assessmentsstarts by identifying potential threats and vulnerabilities, and maps implemented controls to individualvulnerabilities. One then determines risk by calculating the likelihood and impact of any given vulnerabilitybeing exploited, taking into account existing controls. The culmination of the risk assessment shows thecalculated risk for all vulnerabilities, and describes whether the risk is to accepted or mitigated. If mitigated,one needs to describe what additional SP 800-53 controls will be added to the system. NIST SP 800-30provides guidance on the risk assessment process.Certification of SystemOnce the system documentation and risk assessment is complete, the system needs to have its controlsassessed and certified to be functioning appropriately. For systems with a FIPS-199 categorization of Low, aself-assessment is sufficient for certification. For systems categorized at higher FIPS-199 levels, a certificationperformed by an independent 3rd party is required. NIST SP 800-26 provides guidance on the self-assessmentprocess. NIST SP 800-53A provides guidance on the assessment methods applicable to individual controls.Accreditation (Authorization) of SystemOnce a system has been certified, the security documentation package is reviewed by an accrediting official, 24 | P a g e
  25. 25. who, if satisfied with the documentation and the results of certification, accredits the system by issuing anauthorization to operate. This authorization is usually for a 3 year period, and may be contingent on additionalcontrols or processes being implemented. NIST SP 800-37 provides guidance on the certification andaccreditation of systems.Continuous MonitoringAll accredited systems are required to monitor a selected set of security controls for efficacy, and the systemdocumentation is updated to reflect changes and modifications to the system. Significant changes to thesecurity profile of the system should trigger an updated risk assessment, and controls that are significantlymodified may need to be re-certified. Guidance on continuous monitoring can be found in NIST SP 800-37 andSP 800-53A.Future Review of the IA/SO positionThe future review of the IA/SO position will take place every 6 months to evaluate if the processes put in placeby the IA/SO are still relevant.Proposed SolutionThe above Framework of risk identification, security controls and mitigation procedures, when scoped to theparticular needs and applied to the specific operation of RLK Enterprises, is designed to provide an acceptablelevel of data assurance as well as meeting Federal Government requirements and guidelines. 25 | P a g e
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