Archive for September, 2010

Providers – Is HIPAA Security Risk Analysis in your plan over the next few months?

Security Risk Analysis is something that we recommend all organizations conduct periodically or before a  significant process or technology change. After all, threats, vulnerabilities and impact (three components of risk, see my other post here) often change or evolve over time which means that risk analysis results can soon become outdated.

In the context of Healthcare, Security Risk Analysis is also mandatory for two reasons.

The first reason is that it is required for compliance with HIPAA Security Rule which, by way of the HITECH Act, now applies to Business Associates in addition to Covered Entities.  It is a “Required” Implementation Specification in the “Security Management Process” standard under Administrative Safeguards of the HIPAA Security Rule, as highlighted in the table below.

The second (and more urgent) reason to conduct a Security Risk Analysis is that it is a core requirement for providers to achieve Meaningful Use certification of Electronic Health Records (EHRs) and thereby become eligible for Medicare/Medicaid incentives beginning April 2011 or risk Medicare reimbursement penalties beginning 2015 (see below).

Source: Center for Medicare & Medicaid Services (CMS)

So, it is important that providers plan on conducting a security risk analysis within the next few months unless you have conducted one recently. If you have already implemented an EHR system, you will need to ensure that the risk analysis included the EHR system and the related processes or practice workflows. If you plan to implement an EHR system in the next few months, we would recommend conducting risk analysis before the implementation so that any discovered risks can be identified and mitigated by proper design of the system and associated workflows or processes.  Any change to the system or processes after implementation is going to be hard, not to talk of the disruption to the practice and other costs.

The Final Guidance from OCR on Risk Analysis can be a useful reference in planning and conduct of risk analysis efforts.

Finally, I would like to go back to what I said right at the beginning. We recommend that organizations focus on managing all information risks, not just the risk of non-compliance with regulations such as HIPAA.  Therefore, it is critical that personnel performing the risks analysis are up-to-date on the current threat environment. Upon determination of the threats, one must be able to clearly identify the organization’s vulnerabilities to those threats and then the impact resulting from any exploits and various legal or compliance obligations including HIPAA.  Last but not the least, risk analysis must be conducted at appropriate intervals and certainly whenever there is a significant change in processes or technologies.

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Important Disclaimer

The guidance and content we provide in our blogs including this one is based on our experience and understanding of best practices. Readers must always exercise due diligence and obtain professional advice before applying the guidance within their environments.

Let’s talk some “real” insider threat numbers – How can Access Governance and SIEM be useful as effective safeguards?

If you have been following some of our posts, you probably realize that we don’t advocate security for the sake of security. Nor do we like to do compliance for the sake of compliance though you may not have much choice there if the compliance requirements are mandated by external regulations such as industry regulations (e.g. PCI DSS, NERC CIP etc.) or government regulations (e.g. HIPAA, GLBA, SOX etc.). On the other hand, we think that every investment in security projects or operations (beyond what is required for routine business support) must be justifiable in terms of the risk(s) that we are trying to mitigate or eliminate. And the allocation of IT resources and budgets must be prioritized by risk level which in turn requires every IT organization to conduct periodic risk assessments  and rank the risks by severity.  This probably sounds all too obvious but we still see a lot of security purchasing decisions being made that are not based on formal risk assessments or discernable risk-aligned  priorities. BTW, I talk about the quality of risk assessments in another post.

In this post, I would like to go over some “real” numbers on insider threats, as we know from a few recent survey reports. More importantly, I’ll cover how Access Governance and Security Information and Event Management (SIEM) can be effective safeguards in mitigating risks from insider threats.  If you are not up to speed on what Access Governance (sometimes also referred to as Access Assurance) includes, I would point you here (may need registration).  For SIEM, I would point you here.

It probably needs an explanation as to why I chose Access Governance and SIEM for this discussion. Insider threats, by definition, are caused by people  (employers, contractors, partners etc.) whose identity is known to the organization and have been provided some level of access to one or more of the organization’s information systems.  Access Governance can be both an effective detective control (through access reviews) and preventative control (through role based access provisioning and access remediation) for user access. SIEM can be an effective control for detecting anomalous, suspicious  or  unauthorized user activities. When properly integrated, Access Governance and SIEM  solutions can help achieve substantial reduction of risks from insider threats.

Below is a discussion of findings related to insider threats from recent reports. Also provided are notes on how effective implementations of Access Governance and SIEM processes or technologies can be useful safeguards against these threats. I use findings from three recent reports for the analysis – 2010 Verizon Data Breach Investigations Report (DBIR), 2010 CyberSecurity Watch Survey (CSWS)and Securosis 2010 Data Security Survey (SDSS).

Size and significance of Insider Threats

As one can infer from these findings, insider threats are the cause of at least as many security breaches as external threats. It also appears that the cost of breaches caused by internal threats could be higher than those caused by external threats.

Intentional Vs Accidental

It appears from the findings that insiders could be causing breaches intentionally more often than accidentally. Access Governance can help reduce malicious insider risk  by enforcing “least privilege” user access and "segregation of duties" through role based access provisioning, access reviews and remediation of improper access. On the other hand, a properly implemented SIEM solution can be an effective deterrent (as a detective control) to malicious insider threats by logging user activities, correlation of user activities and alerting on suspicious activities by the user. By suitable integration of SIEM and Access Governance solutions, it is possible to analyze user activities (obtained from SIEM) against a user’s role in the organization and hence what the user is authorized to do (obtained from Access Governance).

Cause and prevention

The DBIR findings clearly illustrate the need for organizations to enforce least privilege access through business need-to-know (managing user access based on a user’s role), periodic review of user access (access reviews and certification) and prompt remediation of improper user access.  Access Governance solutions can help achieve these objectives effectively as well as efficiently.

The CSWS finding seems to suggest a problem with the enforcement of organization’s policies related to user access.  As mentioned above, a properly implemented Access Governance program and solution can help with effective enforcement of user access policies.

To conclude, it is obvious that risk management of insider threats needs to be a key focus area of any Information Security  or Risk Management program. An effective Access Governance and SIEM program can help with significant mitigation of the insider risk.

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RisknCompliance Consulting Services Note

We at RisknCompliance have extensive advisory and implementation experience in the Access Governance and SIEM areas.

Please contact us here if you would like to discuss your needs. We will be glad to talk to you about how we could be of assistance.