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Ensuring Security, Privacy, and Compliance in Healthcare IT - Redspin Information Security

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A step by step approach to meeting security, …

A step by step approach to meeting security,
privacy, and compliance goals through a focus
on value creation.

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  • 1. Ensuring security, privacy, and compliance while creating value with healthcare IT A step by step approach 6450 Via Real, Suite 3 Carpinteria,CA 93013 800-721-9177 805-684-6858 www.redspin.com White Paper
  • 2. Ensuring security, privacy, and compliance while creating value with healthcare IT From electronic health record adoption to clinical A step by step approach to meeting security, workflow automation, healthcare increasingly runs privacy, and compliance goals through a focus on information. Yet, healthcare has traditionally on value creation. lagged other industry segments in terms of IT spending. As a percent of revenue, IT spending Spiraling costs and a lack of global competitive- represents just over 5% for the healthcare industry ness are often cited as major problems with the segment versus 11% for financial services (For- U.S. healthcare system. Information technology rester Research). More importantly IT spending can be a significant part of the solution to these in healthcare has not been aligned with achieving problems. In fact, industry leaders and the gov- objectives. Given the rising demands for overall ernment sector have begun to focus resources, transformation of the healthcare industry and the management attention, and funding towards IT competitive pressures on U.S. provider organiza- investments. Yet historically, IT has been viewed tions, healthcare urgently needs the improvements as a cost center rather than as an investment. As IT can enable. Information security must play a an element of that cost center, spending on IT central role in this transformation both in terms of security, privacy, and compliance has been typi- ensuring patient trust through proper use of their cally budgeted at the minimum level necessary to data and protecting the business from threats rang- meet regulatory requirements. A new perspective ing from cyber crime to brand damage associated is required, where investing in IT is understood to with data breaches. create value by increasing competiveness, lowering costs, and increasing the quality of patient care. IT Value Oriented, Performance Driven thus becomes a large part of the solution to the Fortunately, this transition to value-oriented, per- problems facing the healthcare industry. formance driven healthcare is underway in several leading providers such as Kaiser Permanente, Part- This paper examines a general process for manag- ners Healthcare System and Geisinger. A common ing healthcare IT investments and specifically out- denominator among these companies is that IT lines a step by step approach to meeting security, and the information security program are viewed privacy, and compliance goals through a focus on as creating value rather than cost centers. From a value creation and risk management. Information process perspective these leaders have also devel- security programs in the healthcare sector have of- oped similar methods for aligning IT investments ten been driven by reactive approaches and ad hoc with value to the business. This involves defining a compliance oriented processes. These approaches set of observable, quantifiable operational metrics. view “success” as avoiding security incidents and Broad categories include benefits to patient safety, passing compliance audits with the minimum quality of care, staff productivity, employee satis- amount of investment. We will examine why this faction, revenue enhancement, and cost optimiza- approach is unsustainable and show how it be- tion. In this manner IT investments are evaluated lies widely-accepted risk management principles. in terms of how well they help the organization Instead, we will offer a results-oriented alterna- meet business objectives. Another critical common tive that ensures security, compliance, and privacy factor in these organizations is a system of risk programs that support the overall healthcare IT management for continuously optimizing security, mission of creating value and meeting business privacy, and compliance initiatives. Throughout the objectives. rest of this paper we will discuss the step by step Page 1 l www.redspin.com
  • 3. process of deploying a successful information risk Organizing For Performance (Figure 1) management program. The major steps associated with a successful infor- mation risk management program are as follows: 1. Organizing for performance 2. Assessing risk 3. Decision analysis 4. Policy implementation 5. Measuring program effectiveness 6. Repeat steps 2-5, adjust the organization defined in step 1 to evolving business re- quirements The objective of the information risk management The first step in the process involves organizing program is to minimize risk to information that for performance. There are two critical compo- is critical to the business while enabling business nents for success. The first component is execu- goals. The primary interactions in this area are tive sponsorship. Executive sponsorship is not with the line of business, finance, and legal teams. a passive role. The executive sponsor is typically The security team must codify the net results in the CIO or CISO and is responsible for funding, terms of policy that will drive operational as well authority, and support of the information risk as quality and performance management decisions. management program. This role also serves as Information security management is owned by the the final escalation point to define acceptable risk security team but interacts and primarily leverages to the business. The second critical component operations, IT, and HR. Information generated for success is integration of the information risk at this point contributes to the overall picture of management program with the rest of the orga- situational awareness that guides both the business nization. A program that does not leverage other and the information risk management program. functional units will have difficultly aligning with The security relevant aspects of quality and perfor- business goals and ultimately fail. mance management for the business are owned by the security team but must work with the audit, de- A successful organizational structure for carrying velopment, and QA teams. This function generates out the step by step information risk management the reporting metrics (e.g. compliance to internal plan outlined above is shown in Figure 1. policies and regulatory requirements) that drive decisions for the business and the security team as well as contributing to the overall situational awareness picture. The overall output of this cycle is not simply to protect information but to allow better decisions to be made that drive the business forward. Page 2 l www.redspin.com
  • 4. With this organization in place the information PHI/PII Risk Indication (Figure 2) risk management program can be set in motion. Before describing the process in detail it is useful to consider alternative approaches. With pressure to meet the more stringent regulatory requirements imposed by the HITECH act, urgent deadlines to meet meaningful use requirements, and the need to react to day to day incidents, it is easy for a program to become derailed. Let’s consider the re- quirements required to comply with the HITECH act. Organizations must do the following: • Implement a data classification policy that describes the processes used to identify, classify, store, secure, and monitor access to PHI data. • Implement a process to detect a potential data breach and carry out an incident response plan. • Implement a notification process to inform Developing a broader view of risk to the business affected parties after a discovery of a breach allows the information risk management team to of security to PHI without unrea-sonable delay. avoid acting narrowly. For example, rather than a siloed effort to develop policies and implement • Implement policies, processes, and procedures controls to comply with the HITECH Act, a pro- for security awareness and training. gram can be put in place that addresses the unified regulatory requirements associated with PHI/PII • Encrypt PHI data – at rest and in transit. data. Immediately launching an effort to address these Now let’s examine each of the steps to carry out requirements is tempting, but fraught with peril. the information risk management program. The Many HIPAA security programs focused on creat- continuous nature of this process is illustrated in ing policies and procedures as a starting point. Figure 3. Frequently, there was a disconnection between policies and actual technical and procedural safe- Risk Management Process (Figure 3) guards. Further, there is not a clear understanding of the broader risk picture and integration with the business context. A more informed view is shown in Figure 2. Page 3 l www.redspin.com
  • 5. Step 1. Assess Risk a. Ensure that policy specifications are enforce- The first step in the process involves identification able. and prioritization of risks to the business. b. Apply a comprehensive approach that inte- a. Plan data gathering. Identify key success grates process automation, people, and tech- factors and preparation guidance. nology in the mitigation solution. b. Gather risk data. Outline the data collection c. Focus on defense in depth by coordinating process and analysis. application, system, data, and network controls to meet business objectives. c. Prioritize risks. Use qualitative and quantitative risk analysis to drive prioritization. d. Communicate policies and control responsibili- ties throughout the organization. Step 2. Decision Analysis The second step covers the processes for evaluat- Step 4. Measure Effectiveness ing requirements, understanding possible solutions, The fourth step consists of developing and dis- selecting controls, estimating costs, and choosing seminating reports as well as providing managment the most effective mitigation strategy. a dashboard to understand program effectiveness. a. Define functional requirements to mitigate a. Develop and continuously update a manage risks. ment dashboard that summarizes the organiza- tion’s risk profile. b. Outline possible control solutions. Keep in mind that these include not only technical con- b. Report on changes under consideration and trols but people-driven processes (e.g., separa- summarize changes that are underway. tion of duties) and service level agreements. c. Communicate the effectiveness of the control c. Estimate risk reduction. Understand the solutions in mitigating risk. probability of risks and the impact of reduced exposure. d. Report on the existing environment in terms of threats, vulnerabilities and risk profile. d. Estimate solution cost. Reflect direct and indirect costs associated with mitigation Key Success Factors solutions. As noted earlier a major element contributing to the success of an information risk manage- e. Choose mitigation strategy. Complete a cost- ment program is involvement of functional units benefit analysis to identify the most effective throughout the organization. The information risk mitigation solution. management team needs to take responsibility for educating the organization on the process and de- Step 3. Policy Implementation veloping the thorough understanding of risk that The third step addresses policy implementation will allow the business to take specific action when and the acquisition and deployment of controls to managing it. carry out the policy. Page 4 l www.redspin.com
  • 6. An effective method to get this process underway • Critical - Corrective measures are required im- is to view risk across four simple categories. This mediately. provides a straightforward way to clarify trad- eoffs and make decisions. These categories can be • High - Strong need for corrective measures. thought of as the four A’s: An action plan must be put in place as soon as possible. Availability: This means keeping the systems run- • Medium - Corrective actions are needed ning. IT needs to communicate regularly to execu- and a plan must be developed to incorporate tive staff on the availability risk to major business these actions within a reasonable period of time. processes and ensure there is a business continuity plan in case of failure. • Low - Management must determine whether corrective actions are required, or decide to ac- Access: This is defined as ensuring access to cept the risk. systems and data. IT is responsible for provid- ing the right people with the access they need and • Informational - The issue does not indicate ensuring that sensitive information is not misused. a material policy violation but is something The IT organization must regularly discuss risks for management to consider for enhancing the associated with data loss, privacy violations, and overall security posture. inappropriate use. Drive these definitions into risk mitigation pro- Accuracy: This means providing complete, timely grams, policy specifications and controls. and correct information that meets the require- ments of customers, suppliers, regulators and Next, everyone in the organization needs a clear management. Compliance with HIPAA/HITECH and consistent definition of risk. In this context, and Sarbanes-Oxley are common sources of ac- risk is the probability of a vulnerability being ex- curacy risk for enterprises in the United States. ploited in the current environment, leading to a IT should review with management the sources of degree of loss of confidentiality, integrity or avail- accuracy risk (and risk mitigation programs) such ability of an asset. The diagram shown in Figure as the inability to get an accurate, consistent view 4 illustrates the relationships of each element of of patient records or clinical workflow effective- risk. ness. Component of Risk (Figure 4) Agility: This is defined as the ability to make the necessary business changes with appropriate cost and speed. A specific example of agil- ity risk would be the delay or cancellation of a merger because of the risk of integrating IT systems. The IT organization needs to dis- cuss these risks so that management can make informed decisions and not hedge their bets be- cause they don’t believe IT can deliver on time. Another area to look at is consistent usage of risk severity levels and the associated actions. At Redspin we use five levels: Page 5 l www.redspin.com
  • 7. To illustrate the usage of a risk statement in prac- strongly with management. However, such a pro- tice let’s look at an example focusing on risk to cess is resource intensive and thus more expensive PHI data. so broad based coverage is challenging. Therefore, focusing on high impact areas with quantitative The assets (what you are trying to protect is PHI) methods and driving coverage with qualitative approaches tends to produce the best results. • You need to know where it is, how it is used, and how it is transported over the network. A final consideration in terms of key success factors is the timing for repeating the process. The threats (what are you afraid of happening) Each cycle starts with a new risk assessment. The frequency will vary from organization to organiza- • Sophisticated cybercriminals stealing account tion. Many companies find that annual recurren- credentials, credit card records, or medical ceis sufficient so long as the information security history to file false claims. team is proactively monitoring for new threats, vulnerabilities, and assets. • Hackers using application attacks to gain access to database records. In summary, you can expect investment in an information risk management program to bring • Insiders gathering inappropriate data through important business benefits. Some of these include misconfigured access control. the following: The vulnerabilities (how could the threat occur) • Risk reduction allows deployment of new busi- ness processes that were not previously possible. • Targeted social engineering attacks; malware exploiting Adobe .pdf and MS office .doc vul- • Confidence in brand protection can result in nerabilities new revenue generating programs. • Application vulnerabilities (e.g., SQL injection, command injection) • Trust in service availability means that existing programs can generate more revenue and more • Misconfigured database access controls profitably. Current mitigation (what is currently reducing • Confidence in risk mitigation efforts ranging the risk) from technical controls to effective service level agreements decrease program launch time. • Staff • Clear guidance on security requirements associ- • Technology ated with new business unit projects accelerates time to revenue. • Processes Another key success factor is development of an effective methodology for risk assessment. There are many different approaches but most are quali- tative or quantitative methods or a combination of the two. A quantitative approach allows risk to be expressed with financial values and thus resonates Page 6 l www.redspin.com
  • 8. How Redspin Can Help Redspin has invested heavily in the healthcare in- dustry segment for several years and has built deep understanding of security, privacy, and compliance issues. Specific service offerings include: • HIPAA security risk assessment • HIE security assessment • Infrastructure assessment • Application security assessment Given our healthcare domain expertise and experi- ence with security assessments, we can serve as an effective partner in getting your information risk management program started or optimizing an existing program. About Redspin Redspin delivers the highest quality information security assessments through technical expertise, business acumen, and objectivity. Redspin cus- tomers include leading companies in healthcare, financial services, media/entertainment, retail, and technology. Some of the largest communica- tions providers and commercial banks rely upon Redspin to provide an effective managerial, op- erational and technical solution tailored to their business context, allowing them to reduce risk, maintain compliance, and increase the value of their business unit and IT portfolios. Page 7 l www.redspin.com © 2010 Redspin, Inc. All rights reserved.