Sisa Information Security Inc., founded in 2003, specializes in risk analysis with a focus on HIPAA compliance, leveraging its widely-used tool, Sisa Assistant. The document highlights the importance of formal risk assessment in protecting organizational information security, addressing misconceptions, and outlining processes for risk identification, estimation, and treatment. It emphasizes that effective risk management is vital for safeguarding sensitive information and ensuring ongoing compliance across various sectors, including healthcare and finance.

1. © 2013 SISA Information Security Inc.
About SISA:
SISA Information Security was founded in 2003 and has over 300 customers
ranging from healthcare, insurance, banks, hospitality and information technology.
SISA is a leader in Risk Analysis and its tool SISA Assistant is widely used for
HIPAA compliance.
HIPAA Risk Analysis
www.sisainfosec.com
© 2013 SISA Information Security Inc.

2. © 2013 SISA Information Security Inc.© 2013 SISA Information Security Inc.
Dharshan Shanthamurthy,
CISA, CISSP, GWAPT, PCI QSA, OCTAVE Authorized
Trainer/Advisor, FCA, ISA, CEH, P2PE QSA, PA QSA
• CEO of SISA Information Security Inc
• Two decades of information security experience and specialist on formal
risk assessment methodologies.
• Conducted around 120 workshops in over 13 countries on topics
ranging from Risk Assessment, HIPAA, PCI and ISO.
• Trained at CERT Coordination Center on Risk Assessment and
recognized as authorized trainer/advisor for SEI in 2003.
• Author of the Certified Information Security Risk Assessor Program
(training dedicated towards formal methodologies)
• PCI DSS Special Interest Group Proposer and Lead for Risk
Assessment.
LinkedIn: http://www.linkedin.com/in/dharshanshanthamurthy

3. © 2013 SISA Information Security Inc.
Agenda
• Definition
• Background
• Current environment
• Common Risk Analysis Process
• Questions
Objective: Step-by-step approach to HIPAA Risk Analysis

4. © 2013 SISA Information Security Inc.
Risk Assessment
Risk assessment is the cornerstone of any
information security program, and it is the fastest
way to gain a complete understanding of an
organization's security profile – its strengths and
weaknesses, its vulnerabilities and exposures.
“IF YOU CAN’T MEASURE IT
…YOU CAN’T MANAGE IT!”

5. © 2013 SISA Information Security Inc.
• Formal risk analysis (or risk assessment)
- Essential component of HIPAA compliance
- Can help organizations identify their most critical
exposures vulnerabilities and — more importantly —
safeguard overall privacy and security
- Forms a basis for determining how risks should be
managed
• Add value by ensuring that resources are directed at the
areas that are most important to management and
governance.
Background

6. © 2013 SISA Information Security Inc.
HIPAA and Risk Analysis
Administrative Safeguard
Security Management Process
• “Conduct an accurate and thorough assessment of the
potential risks and vulnerabilities to the confidentiality,
integrity, and availability of EPHI held by the covered entity.”
• “Implement security measures sufficient to reduce risks and
vulnerabilities to a reasonable and appropriate level to
comply with §164.306(a). “

7. © 2013 SISA Information Security Inc.
Risk Analysis: Why is it so critical?
• Control optimization: Protect everything or do RISK Analysis to
know what need to be protected
• Treat helps to prioritize the mitigation process
• Be secure, not just compliant: Effective and Efficient control
deployment
• Was secure yesterday but is it true today? Analyze the
effectiveness of existing control on ongoing basis
• Helps organization to take right decision at the right time

8. © 2013 SISA Information Security Inc.
Current Environment
• 80% of the organizations don’t have a consistent manner in
assessing risk.
• 4/5 of the organizations have no formal risk appetite defined.
• 47/49 providers, 20/35 health plans and 2/7 of clearing houses
did not have basic formal risk assessment
Source: NIST-OCR 2013
Source: 2013 KPMG Survey

9. © 2013 SISA Information Security Inc.
Common misconceptions
• Vulnerability Assessment = Risk Analysis
• Risk Analysis = Audit
• Risk Analysis does not require any specific skill
• Risk Analysis is black or white.
• We already know the risk so why conduct formal Risk
Analysis?
• Risk Analysis has no business value and is required only
for compliance purposes just before the audit
• Risk Analysis does not require formal approach. Let me
devise my own.

10. © 2013 SISA Information Security Inc.
Common Risk Analysis Flow
Risk Treatment
Risk Analysis: Risk
Identification
Risk Analysis: Risk
Estimation and
Evaluation
General Description
of ISRA
SISA Assistant
Risk Profiling
Threat
Vulnerabilities
Scope
Asset
Results Documentation
Risk Treatment Plan

11. © 2013 SISA Information Security Inc.
1. General Description of ISRA
• Basic Criteria
• Scope and
Boundaries
• Organization for
ISRM
Identify, Describe
(quantitatively or
qualitatively) and
Prioritize Risks
Assessed risks
prioritized according
to Risk Evaluation
Criteria.
Risk Evaluation
Risk Analysis:
Risk Identification
Risk Analysis:
Risk Estimation
General
Description
of ISRA

12. © 2013 SISA Information Security Inc.
2. Risk Analysis: Risk Identification
Identification of Assets
Scope and
Boundaries
Asset owners
Asset Location
Asset function
Assets are defined
List of Assets.
List of associated
business processes.
Risk Evaluation
Risk Analysis:
Risk Estimation
Risk
Analysis:
Risk
Identification
General
Description of
ISRA

13. © 2013 SISA Information Security Inc.
2. Risk Analysis: Risk Identification
Identification of Threats
Threat Information
from
• Review of
Incidents
• Asset Owners
• Asset Users, etc.
Threats are defined
• Threats
• Threat source
• Threat type
Risk Evaluation
Risk Analysis:
Risk Estimation
Risk
Analysis:
Risk
Identification
General
Description of
ISRA

14. © 2013 SISA Information Security Inc.
2. Risk Analysis: Risk Identification
Identification of Existing
Controls
• Documentation of
controls
• RTP
Existing and planned
controls are defined
• Existing and
planned controls
• Implementation
status
• Usage status
Risk Evaluation
Risk Analysis:
Risk Estimation
Risk
Analysis:
Risk
Identification
General
Description of
ISRA

15. © 2013 SISA Information Security Inc.
2. Risk Analysis: Risk Identification
Identification of Vulnerabilities
• Identified Assets
• Identified Threats
• Identified Existing
Controls
Vulnerabilities are
identified
• Vulnerabilities
related to assets,
threats, controls.
• Vulnerabilities not
related to any
threat.
Risk Evaluation
Risk Analysis:
Risk Estimation
Risk
Analysis:
Risk
Identification
General
Description of
ISRA

16. © 2013 SISA Information Security Inc.
2. Risk Analysis: Risk Identification
Identification of Consequences
• Assets and
business
processes
• Threats and
vulnerabilities
The impact of the
loss of CIA is
identified
• Incident scenarios
with their
consequences
related to assets
and business
processes
Risk Evaluation
Risk Analysis:
Risk Estimation
Risk
Analysis:
Risk
Identification
General
Description of
ISRA

17. © 2013 SISA Information Security Inc.
3. Risk Analysis: Risk Estimation
Risk Estimation Methodologies
(a) Qualitative Estimation: High, Medium, Low
(b) Quantitative Estimation: $, hours, etc.
Risk Evaluation
Risk
Analysis:
Risk
Estimation
General
Description of
ISRA
Risk Analysis:
Risk Identification

18. © 2013 SISA Information Security Inc.
3. Risk Analysis: Risk Estimation
Assessment of consequences
Risk Evaluation
Risk
Analysis:
Risk
Estimation
General
Description of
ISRA
Risk Analysis:
Risk Identification
• Assets and
business
processes
• Threats and
vulnerabilities
• Incident scenarios
The business impact
from information
security incidents is
assessed.
Assessed
consequences of an
incident scenario
expressed in terms of
assets and impact
criteria.

19. © 2013 SISA Information Security Inc.
3. Risk Analysis: Risk Estimation
Level of Risk Estimation
Risk Evaluation
Risk
Analysis:
Risk
Estimation
General
Description of
ISRA
Risk Analysis:
Risk Identification
• Incident scenarios
with their
consequences
• Their likelihood
(quantitative or
qualitative).
Level of risk is
estimated for all
relevant incident
scenarios
List of risks with value
levels assigned.

20. © 2013 SISA Information Security Inc.
4. Risk Analysis: Risk Estimation
Level of Risk Estimation
General Description
of ISRA
Risk Analysis:
Risk Identification
• Risks with value
levels assigned and
risk evaluation
criteria.
Level of risk is
compared against
risk evaluation
criteria and risk
acceptance criteria
Risks prioritized
according to risk
evaluation criteria in
relation to the incident
scenarios.
Risk
Evaluation
Risk Analysis:
Risk Estimation

21. © 2013 SISA Information Security Inc.
Scope
Physical Location – building,
room, etc.
Data Center
Business Process
Business Division
Risk Profiling
Threat
Vulnerabilities
Scope
Asset
Results Documentation
Risk Treatment Plan

22. © 2013 SISA Information Security Inc.
Asset Review
 Admin Processes
 Clinical Processes
 Electronic Health
Records System
Risk Profiling
Vulnerabilities
Scope
Results Documentation
Risk Treatment Plan
Threat
Asset

23. © 2013 SISA Information Security Inc.
Threat Review
smart-ra.com
Hacker exploits insecure
communication channels
Theft /destruction of
media or documents
Corruption of data
CSRF Attack
Risk Profiling
Vulnerabilities
Scope
Results Documentation
Risk Treatment Plan
Asset
Threat

24. © 2013 SISA Information Security Inc.
Vulnerability Review
Employee Disclosure
EPHI is stored unencrypted
No quarterly review of firewall
rules
XSS Vulnerability
Risk Profiling
Threat
Scope
Results Documentation
Risk Treatment Plan
Asset
Vulnerabilities

25. © 2013 SISA Information Security Inc.
Risk Profiling
Risk Score = f( Asset Value, LHOT,
LOV)
•Calculated after taking Risk
Evaluation and Risk Acceptance
Criteria into account
Revised Risk Score = Risk Score
after
•Evaluating Existing Controls
•Applying New Controls
Vulnerabilities
Threat
Scope
Results Documentation
Risk Treatment Plan
Asset
Risk Profiling

26. © 2013 SISA Information Security Inc.
Risk Treatment Plan
Vulnerabilities
Threat
Scope
Results Documentation
Risk Profiling
Asset
Risk Treatment Plan
Treat/Tolerate/Terminate/Transfer
Take Action if Treat/Transfer
 Take Approval if Tolerate/Terminate

27. © 2013 SISA Information Security Inc.
Results Documentation
smart-ra.com

Vulnerabilities
Threat
Scope
Risk Profiling
Risk Treatment Plan
Asset
Results Documentation
 Document A-T-V Combination with the
associated Risk
 Calculation of Risk
 RTP
 Action Taken

28. © 2013 SISA Information Security Inc.
Scenario – Threat Profiling
We have had people moving from one
department to another and it seems like
some of them continue to have their
previous access rights both to the network
and to the lab area. Consequently PHI is
accessible to more people than required.

29. © 2013 SISA Information Security Inc.
Questions
Email: dbs@sisainfosec.com
About SISA:
SISA Information Security was founded in 2003 and has over 300 customers
ranging from healthcare, insurance, banks, hospitality and information technology.
SISA is a leader in Risk Analysis and its tool SISA Assistant is widely used for
HIPAA compliance. Sign up on our website to get a FREE 30 day trial.
www.sisainfosec.com
LinkedIn: http://www.linkedin.com/in/dharshanshanthamurthy