AUDIT USING CERTIFIED KNOWLEDGE TOM ZIMMERMAN SENIOR DIRECTOR, IT AUDITING CLEVELAND CLINIC

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1 1 PREPARING FOR AN IT AUDIT USING CERTIFIED KNOWLEDGE TOM ZIMMERMAN SENIOR DIRECTOR, IT AUDITING CLEVELAND CLINIC AHIA 32 nd Annual Conference August 25-28, 2013 Chicago, Illinois

2 Biography Cleveland Clinic, Senior Director, Office of Internal Audit Certified in information security, enterprise IT governance, information technology infrastructure Master s degree in health science Experience: health care IT, security consulting, mergers and acquisitions, and shared services management Developing a forensic auditing department focusing on improvement of controls governing electronic data

3 Cleveland Clinic 3 Nonprofit Group Practice Main Campus Located in Cleveland, Ohio - 1,300 Bed Hospital Top 4 Hospital 16 Family Health Centers 9 Community Hospitals 3 Ambulatory Surgery Centers 2012 Statistics 5 Million Out-Patient Visits 69,900 Out-Patient Surgeries 54,000 In-Patient Admissions 26,000 In-Patient Surgeries 43,000 Employees

4 From There to Here Public Pharmaceutical Company, Sales 2 Private Steel Fabricating Company, Estimating 11 NFP Health Care, Network Administration i ti 6 Public Financial Services Co., Shared Services 2 Pbli Public Software Sft Co., Principal Pi i Security Consultant t 5 Cleveland Clinic, Internal Audit 8 BS, MS, NCNA, MSPS, CISSP, ITIL, CGEIT, AAGG

5 Acronym Reference ID Identification IP Internet Protocol DR Disaster Recovery HR Human Resources IT Information Technology BC Business Continuity IDS Intrusion Detection System O/S Operating System CBK Common Body of Knowledge BIA Business Impact Analysis CIA Confidentiality, Integrity, Availability SDLC Systems/Software development life cycle ITIL Information Technology Infrastructure Library CGEIT Certified in the Governance of Enterprise IT CISSP Certified Information Systems Security Professional COBIT Control Objectives for Information & Related Technologies

6 Presentation Objectives Develop business tools using technical checklists Consider certified information professionals as trusted advisors Expand IT control perspectives to an enterprise level Forensic Auditing (time permitting)

7 Applying CBK s and Control Objectives IT audits should focus on controls that effectively: Satisfy business objectives Mitigate risks Many managers: Understand the business risks for which they are responsible Lack an understanding of the technical issues affecting current process The business manager & IT auditor can find common ground Apply a Common Body of Knowledge (CBK) in their respective processes CBK s can be applied by business & technical professionals not possessing a certification Use to realize benefits in improving and reviewing existing controls

8 Auditor Explain the Audit from a business person s perspective Risk of not accepting recommendations Demonstrate noncompliance of current state Business Manager needs to recognize how recommendations will improve their business Certified Professionals Create awareness of your Certified Knowledge

9 Business Manager Ask audit professional what certifications they hold Search certification Common Body of Knowledge Keep as personal reference Discuss certification with your trusted IT advisor Relate CBK to the audit or ask auditor to explain Create Checklists you both understand and use

10 CISSP (ISC)² CBK s Certified Information Systems Security Professional (CISSP) International Information Systems Security Certification Consortium (ISC)² Access Control Protects the assets of the information system Monitoring for effectiveness Telecommunications and Network Security Provide CIA Network components and attacks IT Governance and Risk Management Policies, standards, procedures and guidelines for information assets Information ownership Certification and accreditation

11 CISSP (ISC)² CBK s s, continued Software Development Security Controls within applications and development steps Systems development life cycle (SDLC) Security Architecture and Design Design, implement, monitor, and secure, operating systems, equipment, networks, and applications Vulnerabilities and threats (e.g., cloud, data flow control) Operations Security Controls over privileged access to hardware and media Patch and vulnerability management Incident prevention and response

12 CISSP (ISC)² CBK s s, continued Business Continuity and Disaster Recovery Planning Business impact analysis Legal, Regulations, Investigations and Compliance Computer crime laws and regulations Investigations, compliance requirements, forensic procedures Physical Security Threats, vulnerabilities, and countermeasures for physically protecting the environment and restricted information Internal security, perimeter security

13 CGEIT (ISACA) CBK s Certified in the Governance of Enterprise IT (CGEIT) Information Systems Audit and Control Association (ISACA) IT Governance Framework Strategic Alignment Vl Value Delivery Dli Risk Management Resource Management Performance Measurement

14 CGEIT (ISACA), continued Advance from Divisional IT to Enterprise IT IT governance that reflects the values, philosophy, management style, objectives, standards, and policies Compliance with applicable regulatory requirements and Enterprise IT standards, policies, and procedures Integrate unique expertise within sectors such as badge management, operations, HR, and revenue cycle Develop a service centric, comprehensive, and repeatable v p v, p v, p IT process and control model

15 CGEIT (ISACA), continued Needs, investment, e strategy, and steering committees, technology council, and architecture review board Ensure that appropriate roles, responsibilities, i and accountabilities are established Enforce information requirements, data and system ownership, and IT processes; knowledge transfer Communications plan to continuously promote, demonstrate, and reinforce the need and value of IT

16 ITIL (The IT Service Management Forum) Information Technology Infrastructure Library (ITIL) Set of practices for IT service management: Incident Management Problem Management Configuration Management Change Management Release Management Service Desk Service Level Management Financial Management Capacity Management Availability Management Security Management

17 COBIT* Business Professionals should understand d the Control Objectives for Information and Related Technologies COBIT Domains Plan & Organize Acquire & Implement,.Deliver & Support Monitor & Evaluate Processes Responsibility/areas of concept, build, run, and manage *Information Systems Audit and Control Association (ISACA)

18 Policies and Procedures Starting point for creating a Security Checklist Do you have an Access Control policy and procedure Do you have a Change Management policy and procedure Do you have an Application Development procedure Checklists Understand Current Controls (for reducing threats) Likelihood of Compromise (vulnerability) Determine Risk Tolerance (needs, next steps, urgency)

19 Tying Certifications to Business Ui Using a CBK Perspective Access Control Change Management Application Development

20 Access Control* CISSP Need unique identification to avoid a compromise of system and data confidentiality, integrity, and availability Procedure for requesting and managing g account access should be documented and maintained current Access control based on an individual s need-to-know Establishing, issuing, suspending, and closing user accounts User and system access rights monitored and adequately controlled Identification and access rights centrally managed and consistent Account and system activity information stored in operations logs *Reference Shon Harris All In One CISSP Certification, 2002

21 Access Control COBIT Access controls to systems, data and programs are restricted to authorized users: User identification and strong authorization Need-to-have and need-to-know Incident handling, reporting, and follow-up Virus prevention and detection Firewalls Centralized security administration Tools for monitoring compliance, intrusion testing, and Tools for monitoring compliance, intrusion testing, and reporting

22 Access Control COBIT, continued Non-Repudiation Transactions cannot be denied d and controls provide origin, i proof of submission, and receipt Trusted Path Sensitive transaction details only exchanged over a trusted path Protection of Security Functions All security hardware and software is protected against tampering; integrity assurance Malicious Software Prevention, Detection, and Correction Framework of preventative, detective, corrective, response, and reporting controls Firewall Architectures t & Connections with Public Networks Firewalls operating to protect against denial of services and any unauthorized access in and out

23 Checklist: Access Control Policy and Procedure 1. Annual certification that all accounts (O/S, user, and application) are appropriate 2. Set a defined period of inactivity for deactivating accounts 3. Rationale for accessing servers and workstations 4. Are more than one naming conventions for account ID s and passwords in use 5. Application & network passwords should change frequently and according to policy 6. Annually confirm/approve procedures for granting, changing and deleting rights 7. Requests for user access are approved by appropriate supervisor 8. Types and levels l of physical access control to every server 9. Identify by name all persons authorized to access critical components of the network 10. Independent audit of access control policy, procedure, and practice

24 Change Management ITIL (The IT Service Management Forum) All changes should be traceable Ability to explain what changed Objective: Ensure that t standard d methods & procedures are used Changes can be dealt with quickly With the lowest possible impact on service quality

25 Change Management ITIL, continued Drivers of Change Incident management Problem management Service level management Availability management and Capacity management Customer requests Activities Submission Acceptance filtering Classification sorting Planning consolidating Coordination build, test, implement Evaluation determine success and drawing conclusions

26 Change Management COBIT Minimize the likelihood of disruption, unauthorized alterations, and errors Take into consideration: Identification of changes Categorization, prioritization Emergency procedures Impact assessment Change authorization Release management Software distribution Use of automated tools Configuration management Business process re-design Change Request Initiation and Control All requests for changes, system maintenance, and supplier maintenance are standardized Keep change requestors informed about the status of their request

27 Change Management COBIT, continued Emergency Changes Procedures to control these changes when they circumvent the normal process of technical, operational, and management assessment prior to implementation Documentation and Procedures Whenever system changes are implemented, the associated documentation and procedures are updated Authorized Maintenance Ensure that maintenance personnel have specific assignments and that their work is properly monitored Software Release Policy Release of software is governed by formal procedures ensuring sign-off, packaging, regression testing, handover, etc. Internal control measures ensure distribution of the correct software element to the right place, with integrity, in a timely manner, with adequate audit trails

28 Checklist: Change Management Policy & Procedure 1. Understand the request, review, approval, testing, and timing process 2. Self assessments vs. independent assessments 3. Inform all levels of IT support personnel when implementing a change 4. Steps in place that validate authenticity of person requesting password change 5. All applied service & security settings/patches are documented and justified 6. Change team awareness of IP address and primary function of every server 7. Documented & approved BIA s, BC, and DR plans tested as acceptable 8. Violation reports frequently reviewed 9. Monitoring tools for detecting and preventing an attack 10. Authorized and scheduled server downtime

29 Application and System Development* CISSP Input, processing, & interfacing with other programs, access control &output Security: Device (IDS) vs. Software (back doors) Central repository of data elements and their relationships Data warehouse / Data mining / Data dictionary System development (SDLC): Functional design analysis and planning System design specifications Disposal Separation of Duties Integrity Installation/implementation Change control Software development Operational/maintenance Project initiation (risk analysis, contingency plans, motivation to fraud) Documentation on all of the above *Reference Shon Harris All In One CISSP Certification, 2002

30 Application and System Development COBIT Design Specification Approval File Requirements Definition and Documentation Functional Specifications Input Requirements Definition and Documentation Definition of Interfaces Processing Requirements Definition and Documentation Output Requirements Definition and Documentation Testing before approved by the user Unit Application Integration System Stress

31 Checklist: Application Development Policy and Procedure 1. Test and confirm code is safe from known vulnerabilities 2. Users involved in writing design specifications 3. Written design specifications verified against user requirements 4. Modification projects receive approval of change management control team 5. Modifications agree with approved design specifications 6. External & internal interfaces are specified, approved, designed & documented 7. Output requirements defined and documented 8. Service levels formalized, agreed, and approved 9. Unit testing, application testing, integration testing, system testing, load & stress 10. Security of sensitive information in test and production

32 Common Controls and Themes Access Control - Is there a formal documented procedure for requesting and authorizing new user accounts or changes to an existing user s access privileges Authentication - How are users authenticated. Passwords associated with a user ID that t is assigned to a single person, token and/or biometric i Auditing - Does the application create and maintain an audit trail Configuration, Change Management and System Integrity - Are the hardware, operating system, related software, and interfaces documented Business Continuity and Disaster Recovery Planning - Are application or system outages and other application problems documented and tracked Direct, Remote, and Wireless Connectivity and Transmission of Data - Is all sensitive data (PHI, PII, SSN, credit or debit card data) that are transmitted over untrusted networks such as the Internet, properly encrypted

33 Non-Technical Discussion List all significant Applications, Hardware, Processes critical to the proper operation of your business IT Risk Assessment (checklist results) should become The IT Security Plan Implement the IT security plan Update plan to reflect changes in the configuration Assess the impact of change requests on IT security Monitor implementation of the IT security plan Align IT security procedures to policies and procedures

34 View from the Top (de-identified)

35 Activities in Forensic Auditing Advanced d Persistent Threats Data at Rest Data in Use Data in Transit Pi Privacy Monitoring i Fraud Monitoring

36 PREPARING FOR AN IT AUDIT USING CERTIFIED KNOWLEDGE Thank you very much, Tom Zimmerman

37 Save the Date September 21-24, rd Annual Conference Austin, Texas 37

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