Compliance obligations need not stand in the way of better information security and risk management
I couldn’t help write this post when I noticed this press release based on an IDC Insights Survey of Oil & Gas Companies. I don’t have access to the full report so I am basing my comments solely on the contents of the press release.
I found the following two findings (copied from the press release) to be of interest :
- Security investments are not compliance driven. Only 10% of the respondents indicated that they are using regulatory compliance as a requirement to justify budgets.
- Tough regulatory compliance and threat sophistication are the biggest barriers. Almost 25% of respondents indicated regulatory environment as a barrier to ensuring security. In addition, 20% of respondents acknowledged the increasing threat landscape.
The good news here is that only 10% of the respondents used Regulatory Compliance needs to justify budgets. What that tells me (I hope it is the case) is that the remaining 90% make budgetary decisions based solely on the information security risks that their businesses face and not on the risks of not complying with regulations or audits. I would commend them for it… and I don’t think any good auditor (regulatory or internal/external) would have a problem with it either if the organization was able to “demonstrate” that the risk of not complying with a particular regulatory requirement was very low. Agreed.. you still need to be able to “demonstrate” which isn’t easy if one hasn’t been diligent with risk assessments.
The not-so-good news to me is the 25% number (I realize it might be low enough for some people).. that of folks indicating that regulatory compliance is a barrier to ensuring security. For those folks, I say “It really doesn’t need to be a barrier”, not if you have good information risk management governance and processes. I don’t know a single regulation that would force you to implement specific controls no matter what. Even if you are faced with an all-or-nothing regulation like PCI DSS, you can resort to using compensating controls (see here and here for some coverage of PCI DSS Compensating controls) to comply with a specific mandatory requirement. To repeat my argument in the previous paragraph, an auditor would be hard-pressed to fault you if you were able to clearly articulate that you went about the compliance program methodically by performing a risk assessment and prioritizing (by risk level) the need for specific controls required by the regulation. If you did that, you would focus on ”ensuring security” and not ignoring it for the sake of compliance.
Categories: Information Risk, PCI DSS Compliance, Regulatory Compliance, Risk Assessment, Security Tags: Assessment, Compliance, PCI DSS, Risk, Security
Do we have a wake-up call in the OIG HHS Report on HIPAA Security Rule Compliance & Enforcement?
If you didn’t notice already, the Office of Inspector General (OIG) in the Department of Health and Human Services (HHS) published a report on the oversight by the Center for Medicare and Medicaid Services (CMS) in the enforcement of the HIPAA Security Rule. The report is available to the public here. As we know, CMS was responsible for enforcement of the HIPAA Security Rule until the HHS Secretary transferred that responsibility over to the Office of Civil Rights (OCR) back in 2009.
To quote from the report, the OIG conducted audits at seven covered entities (hospitals) in California, Georgia, Illinois, Massachusetts, Missouri, New York, and Texas in addition to an audit of CMS oversight and enforcement actions. These audits focused primarily on the hospitals’ implementation of the following:
- The wireless electronic communications network or security measures the security management staff implemented in its computerized information systems (technical safeguards);
- The physical access to electronic information systems and the facilities in which they are housed (physical safeguards); and,
- The policies and procedures developed and implemented for the security measures to protect the confidentiality, integrity, and availability of ePHI (administrative safeguards).
These audits were spread over three years (2008, 2009 and 2010) with the last couple of audits happening in March 2010. The report doesn’t mention the criteria by which these hospitals were selected for audit except that these hospitals were not selected because they had a breach of Protected Health Information(PHI) .
It wouldn’t necessarily be wise to extrapolate the findings in the report to the larger healthcare space in general without knowing how these hospitals were selected for audit. All one can say is that the findings would paint a worrisome picture if these hospitals were selected truly in a random manner. For example, if one were to look at ”High Impact” causing technical vulnerabilities, all 7 audited hospitals seem to have had vulnerabilities related to Access and Integrity Controls, 5 out of 7 had vulnerabilities related to Wireless and Audit Controls and 4 out 7 had vulnerabilities related to Authentication and Transmission Security Controls.
What might be particularly concerning is that the highest number of vulnerabilities were in the Access and Integrity Controls categories. These are typically the vulnerabilities that are exploited most by hackers as evidenced (for instance) by the highlight in this quote from the 2011 Verizon Data Breach Investigation Report – “The top three threat action categories were Hacking, Malware, and Social. The most common types of hacking actions used were the use of stolen login credentials, exploiting backdoors, and man-in-the-middle attacks”.
Wake-up call or not, healthcare entities should perhaps take a cue from these findings and look to implement robust security and privacy controls. A diligent effort should help protect organizations from the well publicized consequences of a potential data breach.
Categories: Access Governance, Data Breaches, HIPAA/HITECH Compliance, Regulatory Compliance Tags: Breach, Compliance, HIPAA, HITECH, Risk, Security
Next time you do a Risk Assessment or Analysis, make sure you have Risk Intelligence on board
I was prompted to write this quick post this morning when I read this article.
I think it is a good example of what some (actually many, in my experience) risk management programs may be lacking, which is a good quality of Risk Intelligence. In this particular case, I think the original article failed to emphasize that vulnerabilities by themselves may not mean much unless there is a good likelihood of them being exploited, resulting in real risk. We discussed some details regarding the quality of risk assessments in a previous post.
A good understanding of information risks and their prioritization needs to be the first and arguably the most important step in any information risk management program. Yet, we often see risk assessment initiatives not being done right or at the right quality. We think it is critical that a risk analysis or assessment is headed by someone or performed by a team that has or does the following:
- A very good understanding of your environment from people, process and technology perspectives
- A very good and up-to-date intelligence on the current threats out there (both internal and external) and is able to objectively define those threats
- Is able to clearly list and define the vulnerabilities in your environment. It will often require process or technology specialists to do a good job of defining the vulnerabilities
- Is able to make an unbiased and objective determination of the the likelihood that the vulnerabilities (from Step 3) can be exploited by one or more threats (from Step 2)
- A very good understanding of the impact to the business if each vulnerability were to be exploited by one or more threats. Impact is largely a function of the organization’s characteristics including various business and technical factors, so it is important that you involve your relevant business and technology Subject Matter Experts.
- Based on the likelihood (Step 4) and impacts (Step 5), estimate risks and then rank them by magnitude.
We just can’t stress the importance of steps 1-5 enough. We think it takes “Risk Intelligence” to do these steps well. Without good Risk Intelligence on your team, you may well be wasting precious time, money and resources on your risk assessments. More importantly, you may not be protecting your business to the extent that you should, with the same budget and resources.
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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.
Categories: Information Risk, Privacy, Regulatory Compliance, Risk Assessment, Security Tags: Assessment, Breach, Compliance, HIPAA, Risk, Security
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.
Categories: HIPAA/HITECH Compliance, Regulatory Compliance, Risk Assessment, Security Tags: Assessment, EHRs, HIPAA, HITECH, Meaningful Use, Risk, Security
You don’t know what you don’t know – Do we have a "detection" problem with the healthcare data breach numbers?
Like some of you perhaps, I have been reading a few recent articles on Healthcare data breaches, especially the one from Dark Reading and a detailed analysis of the 2010-to-date breaches from HITRUST Alliance.
What stood out for me from these articles is something that is not necessarily highlighted in the articles and that is the very low number of breaches involving technology/people/process controls as opposed to physical losses.
These articles focused on the 119 or so breaches that have been reported to Department of Health and Human Services (HHS) or made public to date in 2010. From the HITRUST Alliance analysis, it is clear that an overwhelming majority of the breaches resulted from physical loss/theft of paper or electronic media, laptops etc. Only two breaches resulted from hacking incidents.
I then went back to do a little bit of my own analysis of the 2010 data breach incidents covered in the Identity Theft Resource Center report available here. I came up with the following numbers for breaches other than those that involved physical loss, theft, burglary, improper disposal etc. :
- Malware infection -1
- Unauthorized access to file share – 1
- Database misconfiguration or vulnerability – 2
- Website vulnerability – 1
- Improper access or misuse by internal personnel – 6
As you can see, these account for less than 10% of the healthcare breaches known or reported so far this year. Contrast this with the findings in 2010 Verizon Data Breach Investigation Report which attributes 38% of breaches to malware, 40% to hacking and 48% to misuse. It is pertinent to note that the Verizon report focused on 141 confirmed breaches from 2009 covering a variety of industries, but I think it is still good for a high level comparison to determine if we may be missing something in the healthcare breach data.
The comparison seems to suggest that the healthcare industry probably has much stronger safeguards against malware, hacking, improper logical access etc. I know from my own experience working with healthcare entities that this is not necessarily the case. For further corroboration, I reviewed two Ponemon Institute survey reports – Electronic Health Information at Risk: A Study of IT Practitioners and Are You Ready for HITECH? – A benchmark study of healthcare covered entities & business associates, both from Q4 2009. Following sample numbers from these reports further validate that the state of Information Security and Privacy among HIPAA Covered Entities (CEs) and Business Associates (BAs) is far from perfect:
Electronic Health Information at Risk: A Study of IT Practitioners
|
#
|
Question
|
% of respondents saying “Yes”
|
|
1 |
My organization’s senior management does not view privacy and data security as a top priority |
70% |
|
2 |
My organization does not have ample resources to ensure privacy and data security requirements are met – 61% of respondents. |
61% |
|
3 |
My organization does not have adequate policies and procedures to protect health information |
54% |
|
4 |
My organization does not take appropriate steps to comply with the requirements of HIPAA and other related healthcare regulations |
53% |
Are You Ready for HITECH? – A benchmark study of healthcare covered entities & business associates
|
#
|
HIPAA compliance requirements that are not formally implemented
|
% of respondents saying “Yes”
|
|
1 |
Risk-based assessment of PHI handling practices |
49% |
|
2 |
Access governance a and an access management policy |
47% |
|
3 |
Staff training |
47% |
|
4 |
Detailed risk analysis |
45% |
All this leads me to think of the possibility that some HIPAA CEs and BAs may not be detecting potential breaches. If you study the healthcare breaches that have been reported so far, almost all of them have been through physical losses of computers or media (which is easy to know and detect) or through reporting by third parties (victims, law enforcement, someone finding improperly disposed PHI paper records in trash bins etc.). I don’t know of any healthcare data breach this year that was detected through proactive monitoring of information systems.
As I covered in a related post on breach reports and what they tell us, I would recommend that CEs and BAs focus on certain key controls and related activities (see table below) in order to improve their breach prevention and detection capabilities:
|
# |
Key Controls |
Recommended Activities |
|
1 |
Secure Configuration and Lockdown |
Review configuration of information systems (network devices, servers, applications, databases etc.) periodically and ensure that they are locked down from a security configuration standpoint |
|
2 |
Web Application Security |
· Scan web applications periodically for OWASP Top 10 vulnerabilities and fix any discovered vulnerabilities · For new applications under development, perform code reviews and/or vulnerability scans to fix any security vulnerabilities before the applications are put to production use (Studies show that it is far more cost effective to fix the vulnerabilities before applications are put to production use than after) · Use Web Application Firewalls as appropriate |
|
3 |
Strong Access Credentials |
· Configure PHI systems and applications to have a strong password policy (complexity of the password, periodic change of password etc.) · Implement multi-factor authentication on PHI systems and applications wherever possible
|
|
4 |
Access Assurance or Governance |
· Conduct Access Certifications periodically, preferably at least every quarter for PHI systems and applications. · Review access privileges within PHI systems and applications to ensure all access conforms to the “Least Privilege” principle. In other words, no user, application or service must have any more privileges than what is required for the job function or role · If any excess privileges are found, they must be remediated promptly · Revoke access to PHI systems and applications promptly in the event that a person leaves the organization or no longer requires access due to a change in the person’s job role within the organization |
|
5 |
Logging, Monitoring and Reporting |
· Identify “risky” events within PHI systems · Configure the systems to generate logs for the identified events · Tamper-proof the logs · Implement appropriate technologies and/or processes for monitoring of the events (Refer to our related posts here and here for examples) · High risk events must be identified and monitored through near-real-time alerts · Responsibilities for daily review of log reports and alerts must be assigned to specific personnel |
|
6 |
Encryption (Data at rest, media), Physical security of media |
· Maintain an inventory of locations and systems wherever PHI exists · Implement suitable encryption of PHI on laptops and removable media · Implement appropriate physical security safeguards to prevent theft of devices or systems containing PHI |
|
7 |
Security Incident Response |
· Implement and operationalize an effective Security Incident Response program including clear assignment of responsibilities, response steps/workflows etc. · Test Incident Response process periodically as required |
|
8 |
Security Awareness and Training |
· Implement a formal security awareness and training program so the workforce is aware of their responsibilities, security/privacy best practices and actions to take in the event of suspected incidents · Require personnel to go through the security awareness and/or training periodically as appropriate |
If you are familiar with the HIPAA Security Rule, you will notice that not all of the above controls are “Required” (as opposed to “Addressable”) under HIPAA Security Rule or in the proposed amendments to the rule under the HITECH Act. One may argue however, that the above controls must be identified as required based on “risk analysis” , which of course is a required implementation specification in the HIPAA Security Rule. In any event, CEs and BAs need to look beyond the HIPAA compliance risk and focus on the risk to their business or brand reputation if a breach were to occur.
Hope this is useful! As always, we welcome your thoughts and comments.
RisknCompliance Services Note
We at RisknCompliance maintain a up-to-date database of the current security threats and vulnerabilities at a detailed level. We are able to leverage this knowledge in providing our clients with high quality risk analysis.
Please contact us here if you would like to discuss your HIPAA security or privacy needs. We will be glad to talk to you about how we could be of assistance.
Categories: Data Breaches, HIPAA/HITECH Compliance, Information Risk, Privacy, Regulatory Compliance, Security Tags: Breach, HIPAA, HITECH, Logging, Privacy, Risk, Security
May we suggest some priority adjustments to your PCI DSS Compliance program?
It isn’t any news that achieving PCI DSS Compliance continues to be onerous for many merchants out there. PCI DSS is after all an all-or-nothing regulation meaning that not passing even one of over 200 requirements could prevent you from getting there. And then, if you do become compliant, there is really no assurance that you will have 100% security. This is something we have known all along to be true for any regulation and now we have one more statistic from the 2010 Verizon Data Breach Investigation Report to prove it … 21% of organizations facing payment card data breaches were compliant with PCI DSS at the time of the breach.
So, may be it is time to rethink our approach to PCI DSS compliance, in terms of how do we get there by way of addressing controls that carry higher breach risks before the others. That will at least help improve your organization’s security posture against potential breaches even if you are nowhere close to meeting all PCI DSS requirements. I think recent breach surveys or reports are a great source to identify such controls with an objective of prioritizing the remediation initiatives in the right order. Such prioritization should help in achieving a better security posture sooner, as we’ll see below.
I am not the first one to suggest a prioritized approach to achieving PCI DSS compliance. In fact, PCI SSC already has guidance on this, though the guidance itself is somewhat dated having been issued back in February 2009. Since then, the threat environment has probably evolved somewhat and exploitation of certain vulnerabilities isn’t quite of the same order relative to others. Therefore, I suggest leveraging the data breach findings to make necessary prioritization adjustments.
Here are some findings from three recent reports on which I am basing my recommendations:
|
#
|
Report
|
Findings
|
Relevant Controls (Our Analysis)
|
|
1 |
Verizon Data Breach Investigations Report 2010 |
· 61% of the breaches were discovered by a third party · 86% of victims had evidence of the breach in their log files |
· Technology – Monitoring, correlation, reporting and alerting off the log events · Process – Regular reviews of logs, log reports or alerts · People – Clear definition and assignment of responsibilities around log reviews and incident response |
|
2 |
Verizon Data Breach Investigations Report 2010 |
· 94% of breached records had malware as one of the causes and 96% of breached records involved hacking · 51% of malware was installed or injected remotely by the attacker (by obtaining privileged access to the system or other means such as SQL Injection) · 85% of records breached by malware involved the attacker gaining backdoor access to the system · 81% of records breached by malware involved data being sent to an external entity or site · 86% of records breached by hacking involved use of stolen login credentials · 86% of records breached by hacking involved use of stolen login credentials · 89% of records breached by hacking involved SQL Injection · 92% of records breached by hacking used web applications as the attack pathway |
· Technology – Proper configuration and lockdown of systems, strong access credentials, access controls or assurance, assessment of web applications and remediation for OWASP Top 10 vulnerabilities, deployment of Web Application Firewalls, Logging/Monitoring/Reporting/Alerting of important events on critical systems · Process – Configuration reviews, OWASP Top 10 vulnerability management, access assurance in the form of ongoing role/privilege management processes and periodic access certifications, regular reviews of logs, log reports or alerts, effective security incident response · People – Clear definition and assignment of responsibilities around configuration reviews, access certifications, log reviews and incident response
|
|
3 |
Verizon Data Breach Investigations Report 2010 |
· More than 50% of breaches remain undiscovered for months or more · 61% of the breaches were discovered by 3rd parties, and not the victim organization itself
|
· Technology – Monitoring, correlation, reporting and alerting off the log events · Process – regular reviews of logs, log reports or alerts · People – Clear definition and assignment of responsibilities around log reviews and incident response, User awareness and training |
|
4 |
Verizon Data Breach Investigations Report 2010 |
· Few breaches were caused due to exploitation of vulnerabilities for which a patch was available. · Likelihood of exploitation of an unpatched vulnerability is far less as compared to a vulnerability caused by a configuration issue. |
Lockdown (secure configuration) of systems may receive higher priority over application of vendor patches unless there is a specific reason not to do so |
|
5 |
Leaking Vault – Five years of data breaches – July 2010 |
· Drives/Media and hacking were the top two breach vectors · Documents and Fraud (Social Engineering) have been increasing in prominence as threat breach vectors recently · Of the breaches that involved hacking, SQL Injection, stolen credentials and malware accounted for most breaches |
· Technology – Disk/Tape encryption, appropriate system lockdown to prevent use of media such as USB drives , Encryption of unstructured data (documents), Refer to controls in #2 against hacking · Process – Physical Security, Encryption and Key Management · People – Awareness and Training |
|
6 |
Ponemon Institute – Annual Cost of Cybercrime study – July 2010 |
· The most costly cyber crimes are those caused by web attacks, malicious code and malicious insiders, which account for more than 90 percent of all cyber crime costs per organization on an annual basis. · The average number of days to resolve a cyber attack was 14 days with an average cost to the organization of $17,696 per day. The survey revealed that malicious insider attacks can take up to 42 days or more to resolve. |
Refer to #2 above |
Here then is a summary of the key controls in the above table, relevant PCI DSS requirements and priorities from the PCI SSC Guidance.
|
Key Control (Our Analysis) |
Relevant PCI DSS Requirement Numbers (See Notes below) |
|
Secure Configuration and Lockdown |
1.1.5 (2), 1.2 (2), 2.1 (2), 2.2.3 (3), 2.2.4 (3), 2.3 (2) |
|
Web Application Security |
6.5 (3) |
|
Strong Access Credentials including periodic changes in credentials (e.g. password) |
8 (4) |
|
Access Assurance (Least Privilege access based on users’ business or job roles, timely revocation of access privileges) |
7 (4), 12.2(6), 12.5.4(6), 12.5.5(6) |
|
Logging, Monitoring and Reporting |
10.1(4), 10.2(4), 10.3(4), 10.4(4), 10.5(4), 10.5(6), 10.7(4), 12.2(6), 12.5.2(6), |
|
Encryption (Data at rest, media), Physical security of media |
3.3(5), 3.4(5), 3.5(5), 9.5(5), 9.6(5), 9.7(5), 9.8(5), 9.9(5) |
|
Security Incident Response |
12.5.3(6), 12.9(6) |
|
Security Awareness and Training |
12.3(6), 12.3.10(6), 12.4(6), 12.6(6) |
Note: Numbers in brackets are the priority numbers from the PCI SSC guidance. Numbers in the guidance range from 1 through 6. A lower number indicates a higher priority.
As we can see from the table, there are several requirements which if addressed sooner, will actually improve an organization’s security posture against potential breaches, based on what we know from the recent breach studies. I would recommend increasing the priority of the requirements in red to at least 3 if not 2. I do realize that organizations may not be able to afford to address too many requirements at a higher priority. If that is the case, you may want to review the current priority 2 and 3 requirements against the key controls in the table above and then decide to push some of them lower down the priority order as applicable.
Hope this is useful! As always, we welcome your thoughts and comments.
RisknCompliance Services Note
We at RisknCompliance track about a dozen of such reports every year and maintain a up-to-date database of the current security threats and vulnerabilities at a detailed level. We are able to leverage this knowledge in providing our clients with a much-wanted third-party assessment of their risk management or audit methodologies and programs. After all, security risk assessments and audits form the very foundation of risk management or audit programs, so we believe it is critical that every organization fine-tunes its methodologies and knowledgebase.
Please contact us here if you would like to discuss your needs. We will be glad to talk to you with the details and how we could be of assistance to you.
Categories: Information Risk, PCI DSS Compliance, Regulatory Compliance, Security Tags: Breach, Compliance, PCI DSS, Risk, Security
Verizon 2010 Data Breach Investigations Report – Key takeaways for Security Assessors and Auditors
The Verizon 2010 Data Breach Investigations Report (DBIR) released last week has some interesting findings, just as it did last year. What makes it special this year is that Verizon partnered with the United States Secret Service in developing this report. I don’t intend to discuss all the statistics in this blog (will do so in another upcoming blog) but as you will see explained in the report, the Secret Service’s involvement has thrown new light into some of the findings.
My intention here is to highlight the significance of such a report to security and audit practitioners with the objective of improving the quality of their risk assessments or audits and more importantly, help make the right recommendations to management. From my experience as a security practitioner and an occasional auditor, I can tell that we may not always be using all the available information to help improve the quality of our risk assessments or audits. And, I think reports such as the Verizon DBIR can provide some valuable help from that standpoint.
Let me explain what I mean… Deliverables for any risk assessment or audit typically include a list of findings and for each finding, we provide an explanation of the risk, the risk severity (High, Medium, Low) and suitable recommendations for risk mitigation or remediation. The management would then proceed to remediate various gaps in priority based on our risk rankings. Considering that risk is a product of likelihood and impact (I like the OWASP risk rating methodology, so will use it here), it is important that we get the impact and likelihood right. Impact is largely a function of the organization’s characteristics including various technical and business factors seen in the methodology. On the other hand, likelihood is a function of threats and vulnerabilities. I think the DBIR can be a useful reference in estimating the likelihood.
For example, the DBIR says that external agents were responsible for about 78% of the breaches whereas about 48% were caused by insiders. These numbers can be used to arrive at a better objective estimate of the likelihood that these threat agents may cause any harm. Similarly, the DBIR also says that 48% of the breaches involved privilege misuse, 40% resulted from hacking and 38% utilized malware. These numbers can be used for objective estimation of the likelihood that associated vulnerabilities could be exploited. The OWASP methodology has an illustration for such objective risk estimation.
These are but a couple of examples. The DBIR has a wealth of information that can be useful to auditors and security practitioners alike, both in improving the quality of their work as well as in being able to defend their risk rankings. We all realize that risk rankings almost always have a level of subjectivity in them but I think reports like the DBIR can be leveraged to make them as objective as possible. A very good example is the risk level one might normally assign to a case of unpatched vulnerability versus a configuration issue. It may not be readily obvious that one might need to be assigned a higher risk level over another until you read the DBIR. The DBIR tells us that the likelihood of exploitation of an unpatched vulnerability is far less as compared to a vulnerability caused by a configuration issue. If we didn’t leverage the DBIR (and assuming both issues had equal impacts), we might assign equal risk levels to both the findings or worse, we might assign the unpatched vulnerability a higher risk level.
Over the next couple of weeks, I plan to be blogging with a detailed commentary on some of the findings in the report including a special post on how the report can be leveraged to enhance the effectiveness of PCI DSS programs.
Hope this is useful! As always, we welcome your thoughts and comments.
RisknCompliance Services Note
We at RisknCompliance track about a dozen of such reports every year and maintain a up-to-date database of the current security threats and vulnerabilities at a detailed level. We are able to leverage this knowledge in providing our clients with a much-wanted third-party assessment of their risk management or audit methodologies and programs. After all, security risk assessments and audits form the very foundation of risk management or audit programs, so we believe it is critical that every organization fine-tunes its methodologies and knowledgebase.
Please contact us here if you would like to discuss your needs. We will be glad to talk to you with the details and how we might be of assistance to you.
Categories: Information Risk, PCI DSS Compliance, Risk Assessment, Security Tags: Assessment, Audit, Breach, Risk, Security
Proposed updates to HIPAA Security and Privacy Rules – What is new?
It was good to see the Office of Civil Rights (OCR) publish the long awaited proposed updates to HIPAA Security and Privacy Rules Thursday last week. Note that OCR is the division of the Department of Health and Human Services (HHS) responsible for enforcing both the HIPAA Security and Privacy Rules.
I want to emphasize that these are proposed updates, also called Notice of Proposed Rulemaking (NPRM) in Federal Government parlance. There is a 60 days period for the public to submit comments on the NPRM after it was published yesterday in the Federal Register. The comments are due by 09/13/2010.
The NPRM includes updates to the following HIPAA rules or areas:
1. Privacy Rule
2. Security Rule
3. Rules pertaining to Compliance and Investigations
4. Imposition of Civil Money Penalties, and
5. Procedures for Hearings (Enforcement Rule)
As noted in the NPRM, these updates are being made to “implement recent statutory amendments under the Health Information Technology for Economic and Clinical Health Act (HITECH) and to strengthen the privacy and security protection of health information, and to improve the workability and effectiveness of these HIPAA Rules”.
For those who don’t have much history on HIPAA, the current Privacy Rule was issued on December 28, 2000, and amended on August 14, 2002 while the Security Rule was issued on February 20, 2003. So, the proposed updates are long overdue in any case given that Information Security and Privacy risk landscapes have changed substantially since these rules were issued.
I’ll focus on updates to just the Security and Privacy Rules in this post. I’ll have two more posts over the next week or so, one with an in-depth coverage on what to expect from proposed updates to the Security Rule and the other one with a similar coverage of the Privacy Rule.
So, here are notable proposed updates:
1. Replace “individually identifiable health information” with “protected health information” to better reflect the scope of the Privacy and Security Rules.
2. Definition of “Business Associate”(BA) being expanded to include the following new constituents:
a. Patient Safety Organizations (PSO)
b. Health Information Organizations (HIO)
c. E-Prescribing Gateways
d. Other Persons that facilitate PHI data transmissions for Covered Entities or other BAs and require routine access to such PHI
e. Vendors of Personal Health Records (like Google Health and Microsoft Healthvault)
f. Subcontractors of a Covered Entity (CE) – i.e., those persons that perform functions for or provide services to a BA, other than in the capacity as a member of the business associate’s workforce.
3. As provided in section 13401 of the HITECH Act, the Security Rule’s administrative, physical, and technical safeguards requirements in §§ 164.308, 164.310, and 164.312, as well as its policies and procedures and documentation requirements in § 164.316, shall apply to BAs in the same manner as these requirements apply to CEs.
4. BAs shall be civilly and criminally liable for penalties for violations of the provisions in #3 above.
5. Requirements of BA contracts (or other arrangements) between CEs and BAs will now apply to contracts (or other arrangements) between BAs and their subcontractors. It is important to note here that the burden of obtaining assurances (through contracts) from subcontractors regarding safety of PHI falls on the BA rather than the CE.
6. A subcontractor will be required to notify any breaches of unsecured PHI to the BA who in turn would be required to notify the CE. The CE then notifies the affected individuals, HHS, and, if applicable, the media, of the breach, unless it has delegated such responsibilities to a BA.
7. BAs, like CEs, may not use or disclose PHI except as permitted or required by the Privacy Rule or their contracts with CEs or as required by law. If a CE and its BA have failed to enter into a BA contract or other arrangement, then the BA may use or disclose PHI only as necessary to perform its obligations for the CE.
8. Other proposed changes to the Privacy Rule include:
a. Certain material changes to the Notice of Privacy Practices (NPP) issued by a CE or by a BA, if delegated so by a CE through contract
b. A number of changes to the definition of “marketing” in the Privacy Rule at § 164.501
c. Provisions for individuals to request restriction of disclosure of certain PHI to a health plan under certain circumstances
d. New restrictions on sale of PHI by CEs and BAs
e. Strengthen the right of “access” more uniformly to cover all protected health information maintained in one or more designated record sets electronically, regardless of whether the designated record set is an electronic health record
OCR has also proposed that the compliance deadline for all new and updated requirements in the Security and Privacy rules will be 180 days after the final update which I believe can be expected in Q4 this year. OCR is also proposing an additional one-year transition period to modify certain BA agreements. The NPRM further qualifies the one-year transition period as “The additional transition period would be available to a covered entity or business associate if, prior to the publication date of the modified Rules, the covered entity or business associate had an existing contract or other written arrangement with a business associate or subcontractor, respectively, that complied with the prior provisions of the HIPAA Rules and such contract or arrangement was not renewed or modified between the effective date and the compliance date of the modifications to the Rules.”
Assuming that these timelines don’t change in the final rule, all CEs and BAs need to plan for full compliance with the final rules by Q2 of 2011 and for revision of existing BA agreements no later than Q2 of 2012. I want to emphasize here that the current BAs (as defined in section § 160.103 of 45 CFR 160) must already be in compliance with the current Privacy Rule and certain provisions of the current Security Rule beginning February 18, 2010 as required by the HITECH Act. The new deadlines will apply only to the new BAs (see 2. a-f above) and for all CEs and current BAs to comply with any new or updated requirements in the final rules.
So, what are the highlights in this NPRM? We have known all along (from the HITECH Act) that the BAs need to comply with the Privacy Rule and certain provisions of the Security Rule. The real highlight to me in this NPRM is the expansion of the definition of a BA. Pretty much everyone (including all subcontractors and others) that has the custody of PHI will now have to comply with both the Security and Privacy Rules. Another highlight to me is the expected compliance deadlines as discussed in the previous paragraph.
As I mentioned earlier in this post, I’ll provide an in-depth coverage of the updates to Security and Privacy Rules in two of my upcoming posts.
As always, we welcome your thoughts and comments. We would also obviously like to hear if you need any consulting support in order to prepare for the anticipated HIPAA changes.
Categories: HIPAA/HITECH Compliance, Information Risk, Privacy, Regulatory Compliance, Security Tags: Compliance, HIPAA, HITECH, Privacy
Logging for Effective SIEM and PCI DSS Compliance …. UNIX, Network Devices and Databases
In one of my previous blogs, I covered the importance of logging the “right” events for an effective Log Management or Security Information and Event Management (SIEM) deployment … see here or here for a discussion on the two technologies. The blog also provided a suggested listing of the Windows or Active Directory events that you might want to log from a PCI DSS Compliance standpoint.
Clearly, no amount of investment in your Log Management or SIEM solution is going to do much good, unless you have been able to generate all the right logs to begin with … see a related discussion with the recognized PCI Expert and Author, Dr. Anton Chuvakin here.
I would like to extend my suggested list in the previous post to cover a few other systems here, specifically UNIX/LINUX, Network Devices and Databases. Note that this list is only a starting point so you can work with the respective System Specialists or Administrators in your organization to generate these events.
UNIX/LINUX Logging for Effective SIEM and PCI DSS Compliance
Logging of Network Devices for Effective SIEM and PCI DSS Compliance
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Database Logging for Effective SIEM and PCI DSS Compliance
Categories: HIPAA/HITECH Compliance, PCI DSS Compliance, Regulatory Compliance, Security, SIEM Tags: Compliance, HIPAA, HITECH, Logging, PCI DSS, SIEM
FTC delays enforcement of Identity Theft Red Flags Rule to 12/31/10
FTC announced earlier this morning that it is delaying enforcement of the Red Flags Rule to 12/31/10 pending expected legislation by Congress that would affect the scope of entities covered by the Rule. As I wrote in my blog just a few days ago, organizations representing physicians, lawyers and accountants have already contested that the Rule shouldn’t apply to them. I wrote that the previous deadline of 06/01/10 was probably too close for FTC to move it again. I guess it is never too close!
Let us wait and watch for next steps from the Congress now!
Categories: FTC Identity Theft Red Flags Rule, Privacy, Regulatory Compliance Tags: FTC, Identity Theft, Red Flags Rule
