MAX Insight Whitepaper An Effective MSP Approach Towards HIPAA Compliance An independent review of HIPAA requirements, detailed recommendations and vital resources to aid in achieving compliance.
Table of Contents About this Document 3 About the Author 3 Introduction to HIPAA 4 Compliance Scope 4 Role of MSP s within a HIPAA Compliant Environment 4 MAXfocus s Commitment to Security 5 Approach 5 An Integral Partner in Information Assurance 5 Summary of HIPAA Security Requirements 6 Detailed Matrix - HIPAA Safeguards 7 Detailed Matrix - HIPAA Technical Safeguards 10 Additional Reading & Resources 11 Links to US Federal Security Standards & Recommendations 11 Industry Resources 11 Appendix A: HIPAA Security Review Checklist 12 FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 2
About this Document HIPAA, 5 short letters which often instill a significant amount of confusion and a healthy dose of fear for many healthcare organizations and associated MSP partners. The purpose of this document is to provide the following: Detailed clarification regarding HIPAA security requirements, helping to reduce HIPAA confusion Advice for MSP s and security best practices to assist your customers in attaining compliance Help and resources from the industry to further assist in compliance This document was authored by an independent industry expert with extensive experience in the HIPAA compliance sector and an exhaustive review of the MAXfocus platform was also performed and compared against HIPAA requirements. In addition to the hardening guide, a separate document, MAXfocus HIPAA Whitepaper outlines general HIPAA best practices towards establishing and maintaining a compliant environment. About the Author Fabian J. Oliva, CISSP is an accomplished expert within the security compliance and governance industry and brings more than 15 years of information security experience. Fabian formerly was an executive at IBM with global responsibility for the governance, risk and compliance services line of business, which included HIPAA and PCI amongst other key regulatory issues. While at IBM, Fabian led key projects to secure some of the worlds most well known organizations, such as United Healthcare, PayPal and Nokia, among many others. Fabian has consulted with major healthcare institutions to architect HIPAA compliance strategies since 2000. He also was one of the first 100 people in the world to become a qualified assessor for PCI compliance (PCI QSA) and was one of the first 15 people in the world to become a payment applications qualified assessor (PA QSA). Prior to IBM, Fabian held senior positions at Northrop Grumman, Sprint and Nortel Networks designing and implementing complex security solutions across the US and Western Europe. FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 3
Introduction to HIPAA HIPAA, the Health Insurance Portability and Accountability Act, sets the standard for protecting sensitive patient data. All entities which maintain and or transmit electronic healthcare data are required to comply. Compliance Scope The HIPAA Security Rule applies to all health plans, health care clearinghouses, and to any health care provider who transmits health care data in electronic form, otherwise referred to as a Covered Entity (CE). Further, HIPAA requires that any person or organization that conducts business with the Covered Entity that involves the specific usage or disclosure of individually identifiable health information, otherwise referred to as a Business Associate (BA), must also comply and adhere to HIPAA security requirements. In order to be considered a Business Associate, the work of an organization must deal directly with the use and or disclosure of protected health information. Examples of such include: outsourced billing providers, collections providers, transcriptionists and EMR providers among many others. Role of MSP s within a HIPAA Compliant Environment MSP s play a critical role towards helping to ensure that their customers maintain a secure and HIPAA compliant environment. Most importantly, they must ensure that their internal processes and procedures are in accordance with the HIPAA security requirements. The following document outlines how specifically the MAX product line can be successfully utilized within an MSP s managed HIPAA environment and can assist with ensuring compliance to specific requirements. FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 4
MAXfocus s Commitment to Security Approach MAXfocus is committed to maintaining the security and privacy of customer information and has instituted several key administrative and technical measures in accordance with such. Defense in Depth. This means formulating and adopting information assurance strategies within every aspect of our business, from including security requirements within product design to security source code reviews during development and even post-sales within technical support processes. Secure by Default. Where such configurations will not interfere with the normal and secure operation of MAXfocus products, we adopt and recommend the most secure, default configurations of our products. An Integral Partner in Information Assurance Recently, VISA issued a warning to all associated merchants that the most frequent attack vectors used by hackers are remote access vulnerabilities. Misconfigured open source solutions such as SSH, VNC and Terminal Services were highlighted as risk prone. Source: http://usa.visa.com/download/merchants/alertremote-access-vulnerabilities-041911.pdf Secure remote access is a key component of any information assurance program and MAXfocus provides a comprehensive, centrally managed platform for management and monitoring for MSP s. Properly implemented, MAXfocus can proactively maintain a secure remote access posture; highlighting and alerting insecure and misconfigured systems, thereby improving the security level of MSP clients.. FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 5
Summary of HIPAA Security Requirements HIPAA Security Rules specifically outline US national security standards to protect health data created, received, maintained or transmitted electronically, also known as electronic protected health information (ephi). The HIPAA Security Rules are divided into 3 distinct categories and below is a summary of each. Safeguards. This section of the HIPAA security requirements is focused upon establishing a risk analysis process, with periodic reviews, assigning security management responsibilities, formulating security policies and procedures and establishling appropriate workforce security training. Safeguards. This section of the HIPAA security requirements is focused upon securely controlling physical access: to data processing facilities, workstations and devices as well as physical media which contains PHI (personal health information). Technical Safeguards. This section of the HIPAA security requirements is focused upon establishing specific technical security controls which aim to protect PHI via the following key aspects: data access control, data & access auditing, integrity and transmission security. FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 6
Detailed Matrix - HIPAA Safeguards Security policies and standards are often one of the most overlooked, yet one of the most critical components of an information assurance program. All physical and technical safeguards are directed and effectively managed by having relevant security policies, guidelines and procedures. REQUIREMENT Has a Risk Analysis been completed in accordance with NIST Guidelines? (R) Has the Risk Management process been completed in accordance with NIST Guidelines? (R) Do you have formal sanctions against employees who fail to comply with security policies and procedures? (R) Have you implemented procedures to regularly review records of IS activity such as audit logs, access reports, and security incident tracking? (R) Have you implemented procedures for the authorization and/or supervision of employees who work with ephi or in locations where it might be accessed? (A) Have you implemented procedures to determine that the Access of an employee to ephi is appropriate? (A) Have you implemented procedures for terminating access to ephi when an employee leaves you organization or as required by paragraph (a)(3)(ii)(b) of this section? (A) If you are a clearinghouse that is part of a larger organization, have you implemented policies and procedures to protect ephi from the larger organization? (A) Have you implemented policies and procedures for granting access to ephi, for example, through access to a workstation, transaction, program, or process? (A) MAXFOCUS APPLICABLE? RECOMMENDATION Develop procedures to require a risk analysis process in accordance with NIST guidelines. Develop procedures to require a risk management process in accordance with NIST guidelines. Formulate procedures that require formal sanctions against employees, leading up to termination, for failure to abide by HIPAA requirements. Create procedures that require the regular review and audit of access reports, security incident tracking and audit logs. Develop formal procedures to authorize and supervise employees in locations with potential access to ephi. Create formal access control review procedures to determine and review the on-going need for a given employees access to ephi data. Utilize the MAXfocus dashboard to remotely remove terminated employees from all in- scope ephi related systems. Create policies and procedures to ensure adequate segregation from other entities. Develop access control procedures for officially granting access to ephi related applications and data. FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 7
REQUIREMENT Have you implemented policies and procedures that are based upon your access authorization policies, established, document, review, and modify a user s right of access to a workstation, transaction, program, or process? (A) Do you provide periodic information security reminders? (A) Do you have policies and procedures for guarding against, detecting, and reporting malicious software? (A) Do you have procedures for monitoring login attempts and reporting discrepancies? (A) Do you have procedures for creating, changing, and safeguarding passwords? (A) Do you have procedures to identify and respond to suspected or know security incidents; mitigate to the extent practicable, harmful effects of known security incidents; and document incidents and their outcomes? (R) Have you established and implemented procedures to create and maintain retrievable exact copies of ephi? (R) Have you established (and implemented as needed) procedures to restore any loss of ephi data that is stored electronically? (R) Have you established (and implemented as needed) procedures to enable continuation of critical business processes and for protection of ephi while operating in the emergency mode? (R) Have you implemented procedures for periodic testing and revision of contingency plans? (A) MAXFOCUS APPLICABLE? RECOMMENDATION Create formal access control review procedures to determine and review the on-going need for a given employees access to ephi data. Utilize MAX RMM to push periodic reminders to the inscope workstations. MAXfocus provides managed antivirus services that guard, detect and report against malicious software. Via utilizing the MAX dashboard, develop procedures to periodically review audit logs and login attempts Via the centralized management capabilities of the MAX dashboard, develop procedures to create, change and safeguard passwords. Create a security incident response plan that takes into account the sensitivity of ephi data. Establish procedures to maintain backup copies of ephi data. Establish procedures to recover ephi data in event of a loss. Create a disaster recovery procedure that ensures the continuation of critical business areas and protection of ephi data. Develop procedures to periodically test contingency plans. FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 8
REQUIREMENT Have you assessed the relative criticality of specific applications and data in support of other contingency plan components? (A) Have you established a plan for periodic technical and non-technical evaluation, based initially upon the standards implemented under this rule and subsequently, in response to environmental or operational changes affecting the security of ephi that establishes the extent to which an entity s security policies and procedures meet the requirements of this subpart? (R) Have you established written contracts or other arrangements with your trading partners that documents satisfactory assurances required by paragraph (b)(1) of this section that meets the applicable requirements of Sec. 164.314(a)? (R) MAXFOCUS APPLICABLE? RECOMMENDATION Perform a periodic assessment to determine the criticality of applications and data in conjunction with the disaster recovery plan. Create a policy that requires periodic reviews of compliance to the HIPAA Security Rules and requires reviews upon major changes to the HIPAA environment. Formulate a policy that classifies business partners with direct access to ephi data as business associates and requires their adherence to HIPAA Security Rules. FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 9
Detailed Matrix - HIPAA Technical Safeguards Technical Safeguards are tactical measures which enforce established security policies and standards to protect ephi from 3 key perspectives: Integrity, Confidentiality and Authorisation. Examples of technical safeguards include role based access control systems, encryption software and VPN connections among others. MAXFOCUS REQUIREMENT RECOMMENDATION APPLICABLE? Have you assigned a unique name and/or number for identifying and tracking user identity? (R) Have you established (and implemented as needed) procedures for obtaining for obtaining necessary ephi during and emergency? (R) Have you implemented procedures that terminate an electronic session after a predetermined time of inactivity? (A) Have you implemented a mechanism to encrypt and decrypt ephi? (A) Have you implemented Audit Controls, hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ephi? (R) Have you implemented electronic mechanisms to corroborate that ephi has not been altered or destroyed in an unauthorized manner? (A) Have you implemented Person or Entity Authentication procedures to verify that a person or entity seeking access ephi is the one claimed? (R) Have you implemented security measures to ensure that electronically transmitted ephi is not improperly modified without detection until disposed of? (A) Have you implemented a mechanism to encrypt ephi whenever deemed appropriate? (A) MAXfocus requires each user ID to be unique and tracks activity according to such Establish a data access procedure to encompass emergency situations MAXfocus automatically times out inactive user sessions MAX MAIL automatically and transparently encrypts all mail archives with secure AES 256bit encryption, thereby protecting any ephi information potentially contained within the archive. User audit reports are dynamically generated by default and can be accessed at any time via the MAX dashboard Implement integrity measures such as file integrity monitoring with associated data hashing Consult with your client and determine the appropriate level of security. Upon such, implement strong password authentication & further security, configure the MAX dashboard to validate IP addresses Implement integrity measures such as file integrity monitoring with associated data hashing Configure MAX Mail to only transmit email traffic via IMAPS (IMAP over SSL) as this will securely encrypt and protect ephi transmitted via email over the Internet FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 10
Additional Reading & Resources Links to US Federal Security Standards & Recommendations Department of Health and Human Services, Educational Series: Security 101 for Covered Entities http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/security101.pdf Department of Health and Human Services, Educational Series: Safeguards http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/adminsafeguards.pdf Department of Health and Human Services, Educational Series: Safeguards http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/physsafeguards.pdf Department of Health and Human Services, Educational Series: Technical Safeguards http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/techsafeguards.pdf NIST HIPAA Security Rule Toolkit http://scap.nist.gov/hipaa/ HIPAA Security Checklist http://www.ihs.gov/hipaa/documents/ihs_hipaa_security_checklist.pdf Industry Resources HIPAA Collaborative of Wisconsin http://hipaacow.org/resources/ SANS HIPAA Security Policies http://www.sans.org/security-resources/policies/hipaa.php FOLLOW US & SHARE AN EFFECTIVE APPROACH TOWARDS HIPAA COMPLIANCE 11
Appendix A: HIPAA Security Review Checklist Complete and consolidated checklist of all HIPAA Security Rules which can be utlized when performing a periodic self assessment. Note: Requirements which have an (R) are fully required in order to achieve compliance and requirements with an (A) allow for alternative options if not economically and or technically feasible within the Covered Entity s specific environment. Audit Review Completion Date: Completed By: SECURITY CONTROL ID TYPE DESCRIPTION STATUS 164.308(a)(1)(ii)(A) Has a Risk Analysis been completed IAW NIST Guidelines? (R) 164.308(a)(1)(ii)(B) Has the Risk Management process been completed IAW NIST Guidelines? (R) 164.308(a)(1)(ii)(C) 164.308(a)(1)(ii)(D) 164.308(a)(3)(ii)(A) 164.308(a)(3)(ii)(B) 164.308(a)(3)(ii)(C) 164.308(a)(4)(ii)(A) 164.308(a)(4)(ii)(B) 164.308(a)(4)(ii)(C) Do you have formal sanctions against employees who fail to comply with security policies and procedures? (R) Have you implemented procedures to regularly review records of IS activity such as audit logs, access reports, and security incident tracking? (R) Have you implemented procedures for the authorization and/or supervision of employees who work with ephi or in locations where it might be accessed? (A) Have you implemented procedures to determine that the Access of an employee to ephi is appropriate? (A) Have you implemented procedures for terminating access to ephi when an employee leaves you organization or as required by paragraph (a)(3)(ii)(b) of this section? (A) If you are a clearinghouse that is part of a larger organization, have you implemented policies and procedures to protect ephi from the larger organization? (A) Have you implemented policies and procedures for granting access to ephi, for example, through access to a workstation, transaction, program, or process? (A) Have you implemented policies and procedures that are based upon your access authorization policies, established, document, review, and modify a user s right of access to a workstation, transaction, program, or process? (A)
SECURITY CONTROL ID TYPE DESCRIPTION STATUS 164.308(a)(5)(ii)(A) Do you provide periodic information security reminders? (A) 164.308(a)(5)(ii)(B) Do you have policies and procedures for guarding against, detecting, and reporting malicious software? (A) 164.308(a)(5)(ii)(C) Do you have procedures for monitoring login attempts and reporting discrepancies? (A) 164.308(a)(5)(ii)(D) Do you have procedures for creating, changing, and safeguarding passwords? (A) 164.308(a)(6)(ii) 164.308(a)(7)(ii)(A) 164.308(a)(7)(ii)(B) 164.308(a)(7)(ii)(C) Do you have procedures to identify and respond to suspected or know security incidents; mitigate to the extent practicable, harmful effects of known security incidents; and document incidents and their outcomes? (R) Have you established and implemented procedures to create and maintain retrievable exact copies of ephi? (R) Have you established (and implemented as needed) procedures to restore any loss of ephi data that is stored electronically? (R) Have you established (and implemented as needed) procedures to enable continuation of critical business processes and for protection of ephi while operating in the emergency mode? (R) 164.308(a)(7)(ii)(D) Have you implemented procedures for periodic testing and revision of contingency plans? (A) 164.308(a)(7)(ii)(E) 164.308(a)(8) 164.308(b)(4) Have you assessed the relative criticality of specific applications and data in support of other contingency plan components? (A) Have you established a plan for periodic technical and non-technical evaluation, based initially upon the standards implemented under this rule and subsequently, in response to environmental or operational changes affecting the security of ephi that establishes the extent to which an entity s security policies and procedures meet the requirements of this subpart? (R) Have you established written contracts or other arrangements with your trading partners that documents satisfactory assurances required by paragraph (b)(1) of this section that meets the applicable requirements of Sec. 164.314(a)? (R)
SECURITY CONTROL ID TYPE DESCRIPTION STATUS 164.310(a)(2)(i) 164.310(a)(2)(ii) 164.310(a)(2)(iii) 164.310(a)(2)(iv) 164.310(b) 164.310(c) 164.310(d)(2)(i) 164.310(d)(2)(ii) 164.310(d)(2)(iii) Have you established (and implemented as needed) procedures that allow facility access in support of restoration of lost data under the disaster recovery plan and emergency mode operations plan in the event of an emergency? (A) Have you implemented policies and procedures to safeguard the facility and the equipment therein from unauthorized physical access, tampering, and theft? (A) Have you implemented procedures to control and validate a person s access to facilities based on their role or function, including visitor control, and control of access to software programs for testing and revision? (A) Have you implemented policies and procedures to document repairs and modifications to the physical components of a facility, which are related to security (for example, hardware, walls, doors, and locks)? (A) Have you implemented policies and procedures that specify the proper functions to be performed, the manner in which those functions are to be performed, and the physical attributes of the surroundings of a specific workstation or class of workstation that can access ephi? (R) Have you implemented physical safeguards for all workstations that access ephi to restrict access to authorized users? (R) Have you implemented policies and procedures to address final disposition of ephi, and/or hardware or electronic media on which it is stored? (R) Have you implemented procedures for removal of ephi from electronic media before the media are available for reuse? (R) Do you maintain a record of the movements of hardware and electronic media and the person responsible for its movement? (A) 164.310(d)(2)(iv) Do you create a retrievable, exact copy of ephi, when needed, before movement of equipment? (A) 164.312(a)(2)(i) Technical Have you assigned a unique name and/or number for identifying and tracking user identity? (R) 164.312(a)(2)(ii) Technical Have you established (and implemented as needed) procedures for obtaining for obtaining necessary ephi during and emergency? (R)
SECURITY CONTROL ID TYPE DESCRIPTION STATUS 164.312(a)(2)(iii) Technical Have you implemented procedures that terminate an electronic session after a predetermined time of inactivity? (A) 164.312(a)(2)(iv) Technical Have you implemented a mechanism to encrypt and decrypt ephi? (A) 164.312(b) 164.312(c)(2) 164.312(d) 164.312(e)(2)(i) Technical Technical Technical Technical Have you implemented Audit Controls, hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ephi? (R) Have you implemented electronic mechanisms to corroborate that ephi has not been altered or destroyed in an unauthorized manner? (A) Have you implemented Person or Entity Authentication procedures to verify that a person or entity seeking access ephi is the one claimed? (R) Have you implemented security measures to ensure that electronically transmitted ephi is not improperly modified without detection until disposed of? (A) 164.312(e)(2)(ii) Technical Have you implemented a mechanism to encrypt ephi whenever deemed appropriate? (A)
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