information security compliance system owner training richard gadsden information security office...
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Information Security ComplianceSystem Owner Training
Richard Gadsden
Information Security Office
Office of the CIO – Information Services
Sharon Knowles
Information Assurance Compliance
MUSC Medical Center
Overview
➲ Information Security Fundamentals➲ HIPAA Security vs. HIPAA Privacy
● How the two regulations differ● MUSC's compliance strategy
➲ New Security Responsibilities● Enterprise● Covered Entities● System Owners● Other individuals
Information Security Process
➲ The goal: protection of information assets from threats to their:
● availability● integrity● confidentiality
➲ Security is a process...● not a product● not really a state either● not “set it and forget it”
Information SecurityA Risk Management Process
➲ Risk management ● the process for making security decisions
➲ Steps in the process● identify significant risks● evaluate possible controls● implement the most cost-effective set of controls that
will keep risks within acceptable levels➲ Caveat: zero risk is not attainable
MUSC's Information Security PolicySystem Owners Are Responsible For...
➲ Ensuring that accurate and thorough risk assessments are conducted
and documented at appropriate points in the lifecycle of the System,
beginning prior to the System's implementation, and that the findings
are applied to the effective management of risks over the entire life of
the System.
➲ Ensuring that appropriate System-specific policies, procedures and
safeguards are developed and implemented, to comply with all
applicable MUSC policies, any applicable Entity policies, and all
applicable laws and regulations.
Information Assurance
➲ Standard of Due Care● duty is to protect against “all reasonably
anticipated threats” by implementing
“reasonable and appropriate” safeguards➲ Reasonable and appropriate
● ideally, minimum but sufficient controls● must avoid unacceptable risks● must avoid unnecessary expense
Reasonable and Appropriate
➲ How to achieve?● the risk management process
● assessment of risk● evaluation and selection of controls● approval, funding, implementation, operation
➲ How to verify?● the compliance process
● documentation● audits and other reviews
Information AssuranceCompliance Process
➲ Document the level of assurance● Are all security responsibilities clearly defined
and understood?● Is a sound (risk-based and cost-conscious)
decision-making process being followed?● Are security procedures documented?● Are procedures being followed?● Are controls working as intended?
HIPAA: Security Rule vs. Privacy Rule
➲ Security is more than just privacy● confidentiality, integrity, availability
➲ PHI vs. ePHI● all electronic (“computerized”) PHI is subject to both
the Privacy Rule and the Security Rule● telephone and fax communications are subject to the
Privacy Rule, but not the Security Rule ➲ Covered Entities (CEs)
● responsible for compliance with both regulations
Security vs. Privacy: MUSC
➲ Overall HIPAA compliance strategy● Organizational: MUSC OHCA comprised of 4 CEs
➲ Privacy Rule strategy● policies were set by each MUSC Entity
➲ Security Rule strategy● One set of enterprise-wide security policies
● these policies apply to all MUSC Entities● not just for HIPAA/ePHI, but for all types of protected
information
● 16 new policies and 1 updated policy were issued by
the Office of the President in Feb 2005
MUSC's Security Policies
➲ Computer Use Policy (updated)➲ Information Security Policies (new)
● Information Security, Risk Management, Evaluation,
Workforce Security, Awareness and Training, Incident
Response, Contingency Plan, Workstation Use,
Device and Media Controls, Access Control, Network
Access, Audit Controls, Person or Entity
Authentication, Data Integrity, Encryption,
Documentation
New Security Responsibilities
➲ Enterprise (Office of the CIO)➲ Covered Entities (CEs)➲ System Owners and System Administrators➲ Managers and Supervisors➲ Workforce members
Responsibilities: OCIO
➲ Information Security Office (ISO) will:● Document security architecture and plans● Coordinate development of enterprise policies,
standards, guidelines● Manage Enterprise-level safeguards● Develop shared tools and services● Direct MUSC's incident response team● Conduct vulnerability assessments
Covered Entities
➲ Each Entity will designate an Information Assurance Compliance Officer (IACO), who will:
● Monitor compliance (system owners, system
administrators, managers, supervisors,
workforce members)● Report violations of policy to appropriate
enforcement authorities● Ensure access to documentation and training
System Owners
➲ Each System must have a designated System Owner, who will:
● Assess and manage security risks● Risk assessments and risk management plans must be
documented if the system contains protected information (e.g.
ePHI)
● Ensure that appropriate safeguards are
implemented● Some safeguards are required only if the System contains
protected information (e.g. ePHI)
● Also, designate a System Administrator
MUSC Risk Management Standards
➲ Standards established for managing risk at 4 stages in the System life cycle
● Initiation● Development/Procurement● Implementation● Post-Implementation
● aka “Existing Systems”
Existing Systemsi.e. “Post-Implementation Stage”
➲ Have you...● Registered your system?● Designated a System Administrator?● Conducted a System risk assessment?● Implemented appropriate safeguards?
● administrative measures● physical security measures● technical measures● document, document, document...
Step 2.0: Document Current System Environment
and Personnel
➲ Deliverable: Security Documentation, Section 2 (System Identification)
● System Name● Key System Personnel● Functional Description● Key Components● System Boundaries● Relationships with other systems
● interfaces, interdependencies
Step 3.0: Document Current System-Specific
Security Procedures and Other Controls
➲ Deliverable: Security Documentation, Section 3 (Current System Procedures)
➲ Use the MUSC Information Security Policy Compliance Checklist for System Owners as a guide
➲ http://www.musc.edu/security/tools
Step 4.0: Identify and Analyze Potential Issues
➲ Deliverable: Risk Analysis Worksheet➲ http://www.musc.edu/security/tools➲ Priorities
● Address policy compliance gaps identified using
the Policy Checklist, or any other assessments● Decide how to address other risks identified
through formal risk analysis process
Step 5.0: Develop Security Plan
➲ Deliverable: Security Plan Summary➲ http://www.musc.edu/security/tools➲ Document your plan for resolving all known
compliance gaps● who● what● when
Step 6.0: Execute Security Plan
➲ Deliverables● Document changes made to system procedures
and other controls (Section 3, Current System
Procedures)● Progress and status reports as required by your
Entity's IACO
Are We There Yet?
➲ Security is never finished➲ Repeat the risk management cycle as
warranted by conditions● respond to environmental, operational, policy,
and/or regulatory changes➲ Evaluate the effectiveness of your System's
security measures● until your System is retired
➲ Set it and forget it? Not an option!