Healthcare Security Compliance: More Than a Check In The Box

Todd Fitzgerald CISSP, Todd Fitzgerald CISSP, CISA,CISM, CGEIT, PMPCISA,CISM, CGEIT, PMP

ISO27000 and ITIL V3 CertifiedISO27000 and ITIL V3 CertifiedNational Government ServicesNational Government Services

PMO & Strategy/Technical PMO & Strategy/Technical Audit & ComplianceAudit & Compliance

Milwaukee, WIMilwaukee, WIHIPAA Collaborative of HIPAA Collaborative of

WisconsinWisconsinOctober 15, 2010October 15, 2010

A Little ‘Presentation Disclaimer’ …

The opinions expressed are solely the opinions of Todd Fitzgerald and do not necessarily represent the opinions of his employer. You may or may not want to adopt the these concepts in your organization. Use a risk-based approach before attempting

this at home.

HOW MANY ARE HIPAA COMPLIANT WITH THE SECURITY RULE?

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Today’s Objective

• PART 1: What We Must Be Aware Of TODAY

• PART 2: Applicable Laws, Regulations, Standards

• PART 3: Anatomy of An Audit• PART 4: What Is A Good Control?• PART 5: Key Problem Areas

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Security Audits Necessary To Ensure Controls Are Functioning

Source: “Learning from Leading Organizations” SGAO/AIMD-98-68 Information Security Management

Assess Risk &Determine Needs

PromoteAwareness

Monitor &Evaluate

ImplementPolicies &Controls

CentralManagement

Audit

Audit

Audit

Audit

Refresher: Security Officer Job Description

Job description: This position will represent the information protection program of the’ region and requires the ability to understand business issues and processes and articulate appropriate security models to protect the assets of and entrusted to. A strong understanding of information security is necessary to manage, coordinate, plan, implement and organize the information protection and security objectives of the’ region. This position is a senior technical role within our information protection and security department. A high-level of technical and security expertise is required and will be responsible for managing information security professionals. This position will play a key role in defining acceptable and appropriate security models for protecting information and enabling secure business operations. This person must be knowledgeable of current data protection best practices, standards and applicable legislation and familiar with principles and techniques of security risk analysis, disaster recovery planning and business continuity processes and must demonstrate an understanding of the management issues involved in implementing security processes and security-aware culture in a large, global corporate environment. He or she will work with a wide variety of people from different internal organizational units, and bring them together to manifest information security controls that reflect workable compromises as well as proactive responses to current and future business risks to enable ongoing operations and protection of corporate assets. RESPONSIBILITIES INCLUDE: • Manage a cost-effective information security program for the Americas region; aligned with the global information security program, business goals and objectives • Assist with RFP and Information Security responses for clients • Implementing and maintaining documentation, policies, procedures, guidelines and processes related to ISO 9000, ISO 27000, ISO 20000, European Union Safe Harbor Framework, Payment Card Industry Data Protection Standards (PCI), SAS-70, General Computer Controls and client requirements • Performing information security risk assessments • Ensuring disaster recovery and business continuity plans for information systems are documented and tested • Participate in the system development process to ensure that applications adhere to an appropriate security model and are properly tested prior to production • Ensure appropriate and adequate information security training for employees, contractors, partners and other third parties • Manage information protection support desk and assist with resolution • Manage security incident response including performing investigative follow-up, assigning responsibility for corrective action, and auditing for effective completion • Manage the change control program • Monitor the compliance and effectiveness of Americas’ region information protection program • Develop and enhance the security skills and experience of infrastructure, development, information security and operational staff to improve the security of applications, systems, procedures and processes •

… The Complete Job Description!

Direct senior security personnel in order to achieve the security initiatives • Participate in the information security steering and advisory committees to address organization-wide issues involving information security matters and

concerns, establish objectives and set priorities for the information security initiatives • Work closely with different departments and regions on information security issues • Consult with and advise senior management on all major information security

related issues, incidents and violations • Update senior management regarding the security posture and initiative progress • Provide advice and assistance concerning the security of sensitive information and the processing of that information •

Participate in security planning for future application system implementations • Stay current with industry trends relating to Information Security • Monitor changes in legislation and standards that affect information security • Monitor and review new technologies • Performs other Information Security projects / duties as needed MINIMUM QUALIFICATIONS: Transferable Skills

(Competencies) • Strong communication and interpersonal skills • Strong understanding of computer networking technologies, architectures and protocols • Strong understanding of client and server technologies, architectures and systems • Strong

understanding of database technologies • Strong knowledge of information security best practices, tools and techniques • Strong conceptual understanding of Information Security theory • Strong working knowledge of security architecture and recovery

methods and concepts including encryption, firewalls, and VPNs • Knowledge of business, security and privacy requirements related to international standards and legislation (including ISO 9001, ISO 27001, ISO 20000, Payment Card Industry data protection standard (PCI), HIPPA, European Union Data Protection Directive, Canada’s Personal Information Protection and Electronic Documents Act, SAS-70 Type II, US state privacy legislation and Mexico’s E-Commerce Act) • Knowledge of risk

analysis and security techniques • Working knowledge of BCP and DR plan requirements and testing procedures • Working knowledge of Windows XP/2000/2003, Active Directory, and IT Infrastructure security and recovery methods and concepts • Working knowledge of Web-based application security and recovery methods and concepts • Working knowledge of AS400

security and recovery methods and concepts • Working knowledge of PeopleSoft security and recovery methods and concepts • Working Knowledge of anti-virus systems, vulnerability management, and violation monitoring • Strong multi-tasking and

analytical/troubleshooting skills • Knowledge of audit and control methods and concepts a plus • Knowledge of SAS-70 audit requirements a plus • Knowledge of ISO 9001 requirements a plus • Knowledge of ISO 27001 requirements a plus • Knowledge of ISO 20001 requirements a plus • Knowledge of COBIT requirements a plus • Knowledge of EU / Safe Harbor requirements a plus •

Knowledge of Linux security a plus • Knowledge of VB.NET, C++, JAVA, or similar programming languages a plus • Proficient in MS-Office suite of products • Professional, team oriented Qualifications • Bachelor’s Degree (B.A., B.S.), or equivalent

combination of education and experience in Information Security, Information Technology, Computer Science, Management Information Systems or similar curriculum • 7+ years of Information Technology or Information Security experience, including at

least 5 years dedicated to Information Security • 2+ years of Travel Industry experience preferred • Must be a Certified Information Systems Security Professional (CISSP) • Certified Information Security Manager (CISM) preferred • Strong

organizational, time management, decision making, and problem solving skills • Strong initiative and self motivated professional • Professional certifications from ISACA, (ISC)2, or SANS preferred • Experience with ISO certified systems a plus

In Other Words…

• Assess the risks• Understand laws,

regulations, standards

• Understand the technology

• Develop alternatives• Implement one or

more solutions• Evaluate residual risk

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Why We Care… 2010 Security Threats

• Phishing reports (40,621), 56,362 unique websites, 341 high jacked brands set record in August

• Russia (13%), Brazil 8.6%) now top two sites creating attack traffic, with US (6.9%) and China (6.5%) dropping 2 positions

• Sophisticated, distributed malware• Mobile banking attacks on smart phones• Social Media sites used to learn about targets, deliver

malicious content• SQL Injection (19% of breaches in 2009 per Verizon)• Home users transferring malware• Adobe Reader and Flash Replacing MS Office as target• Zero-day exploits released on IE in Nov/Dec

Source: Akaimi State of The Internet; Anti-Phishing WorkGroup, McAffee Predictions

Data Breaches Cost $204/Record in 2009, NO CISO $236, CISO $157

– $750K-$31 Million per incident

– 24% due to botnets/ malicious attacks (doubled from 2008)

– First time Malware exceeded user negligence

– 42% involved 3rd parties– 36% involved a mobile

device

$135 Lost Business

$15 Notify Victims

$46 Monitoring

$8 Breach Detection

Source: Ponemon Institute, 2010

“RockYou.com Hacked For 32.6 Million Passwords

• Provider of services for FACEBOOK and MYSPACE

• Hacker ‘igigi’ breaks into database of 32.6 Million Records

• SQL Injection• Hacker posted

partial results

Reactive Security Follows BreachRockYou has become aware of ongoing unauthorized attempts to access the same user data identified in previous reports. RockYou is working to promptly notify our members of these ongoing attempts via email and posts to our Web site. The company is continuing to work with law enforcement to identify the perpetrators. As we stated in our earlier communications, we recommend that all users change their passwords and take other measures to protect their privacy.

RockYou has put in place measures to protect user data, including encrypting all user data and upgrading our security infrastructure. We will also be working with an outside security consulting firm to analyze and improve our security environment. We will continue to assess our security protocols and improve upon them.

We apologize for any inconvenience this has caused our user base and assure our dedicated users that we continue to take their privacy seriously. The RockYou team

Incident Revealed that the Most Common Password Was… ‘123456’

1. 290,731 ‘123456’2. 79.038 ‘12345’3. 76,790 ‘123456789’4. 61,958 ‘password’5. Followed by Princess,

Rockyou, abc123,daniel,nicole,babygirl,monkey,jessica,lovely,michael,ashley,654321,and QWERTY.

Source: Imperva Application Defense Center

Factors Causing Breaches…In 1 Month Alone

Third Party Financial Firm Burglarized

Opened accounts with 10 employee stolen data

Ukraine hackers took control of web domains, redirected traffic

Intercepted payroll mailing to annuity company

Laptops stolen from cars, locked offices

Office backup drive stolen

Emails to personal email SSN spreadsheet

Temp worker steals flu shot records

Financial info from unsecured dumpster

Playlist on MP3 player at thrift shop- US Soldiers

SSNs in US Govt sold filing cabinet Source: www.privacyrights.org

In Our Own Backyard…Milwaukee-based Koss CFO Indicted for Embezzling $31M

• $4.5M on clothing– 461 Boxes of shoes– 34 Fur Coats– 65 Racks of clothes

• Wire Transfers to personal account

• Possible 120 Years In Prison, restitution, $1.5M in fines

Emerging Technologies

• Social Media– LinkedIn– Facebook– Twitter

• Virtualization• Cloud Computing• Mobile Devices

Today's Data Demand: The Right Data, At The Right Time, At The Right Place…

• 1980– Can We Get A Report Run Off the

Mainframe?• 1990’s

– Decision Support Systems, End User Queries

– Synchronized To PDA• 2000’s

– Laptops, FedEx CDs• 2010’s

– Smart Phones, Cloud applications, Virtual Working Environments, Convergence

Where Is The Data Today?

Sylvia

Marc

Julie

Dena

StanProgramming Team

Source: Steve Fried, Mobile Security, Reprinted with Permission

The Evolution of Technology over almost 3 decades

• Huggable Luggables introduced in 1983

• Spreadsheet primary use

• 128K Memory

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Mobile Computing Is Taking Center Stage

• “Office less” work-at-home

• Telecommuters• Road Warriors• Employees at work

working in distributed environments

• After hours work at home

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RECENT STUDY OF WORKERS AT HOME REVEALED THEY WORKED 19 MORE HOURS A WEEK WITHOUT NEGATIVELY IMPACTING FAMILY

OF COURSE… THERE WILL ALWAYS BE EXCEPTIONS…

There Are Inherent Risks

Previous Generation Mobile Device Risks Limited

• WAP-enabled cell phones

• Personal Digital Assistants

• Wireless Data Entry Systems

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Now They Have The Same Risks As Conventional Systems

• Complete operating Systems

• Specially-built Applications

• Users physically removed from immediate security staff control

More Viruses

More Malware

Less Sophistication Required

Different Ways of Approaching The Problem – Data vs. Device Centric

© 2010 Stephen Fried. Reproduction prohibited without written permission.22

Different ways of approaching the problem

Device Centric Data Centric

Data Is Not Static

Data At Rest Data In Motion

Devices Are Converging

• Cell Phones• Cameras• Televisions• Game Consoles• DVRs, DVD

Players• Ipods, IPads, I-?

• Why???

This Company Was One of The Biggest Contributors….

The Connected World We Live In Changes The Role of ‘The Device’

©7

The Workforce THINKS Differently

• Baby Boomers (1946-65) loyal, dependable, workaholics

• Gen Xers (1965-1980) cynical & independent, reject rules

• Gen Y (1980+) short attention span, tech savvy

The Same Security Question Arises.. Our Customers Want It…

How Do We Enable It?

Smartphones: Hacker Opportunity

• UK Dept of Trade Survey:– More than 50% of

companies do not have any controls for securing company data on Smartphones

• Few have invested in technology

Smartphone Application Vulnerabilities• Weak or no authentication (single user

context)– Default passwords– Very few characters

• Missing security functions– Data Encryption– Auditing– Padlocks on Web Browsers– Security Updates– Applications not limited in what they can access– Apps can cause DOS by draining battery

• Unable to determine if Malicious until downloaded!

Major SmartPhone Security Controls

• Appropriate Policy & Standards

• Anti-virus and anti-spyware• Remediation of

vulnerabilities• Strong authentication• Encrypted transmissions

VPN, SSH, SFTP• Secure Wireless Application

Protocol Gateways• Personal Firewalls• Hard Drive Encryption• Regular backups• Security Training &

Awareness

Important Audit Questions

• Policy storing sensitive data? Encrypted? Backups?

• Default passwords• Policy downloading untrusted

applications?• Communication ports turned

off when not in use?• Anti virus updated? Anti-

spyware?• Procedures for finding pirated

mobile apps exist? Enforced?• Prohibitions against Jailbreaking?• Vulnerability Remediation

Process?• Systematic incident response?

• Risk Assessment• Targeted security

awareness training?• Random audits of

devices & applications?• Power-on password?• Personal devices

prohibited?• Know how to report lost

device?• Stored securely?• Security Assessment

tools?• Independent tests nse?

performed?

Sounds Familiar…

May Not Be Pretty Getting There…

PART 2: Laws, Regulations, Standards

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There Are The U.S. Government Regulations That We Are Familiar With…

• NIST 800-53 Controls• FISMA (Federal

Information Security Management Act 2002)

• HIPAA Final Security Rule• Medicare Modernization

Act of 2003 (Section 912)• DISA Security Technical

Implementation Guides (STIGs)

• IRS Regulations

…And These

• Graham-Leach-Bliley (GLBA)• Sarbanes-Oxley• NERC Critical Infrastructure

Protection• Federal Financial Institution

Examination Council (FFEIC)• Federal Information System

Controls Audit Manual (FISCAM)

…And International Control Standards /Frameworks/ and of Course [insert here] Practices

• ISO27001/2 Information Security Management System (ISMS)

• Control Objectives for Information and related Technology (COBIT 4.1)

• Payment Card Industry Data Security Standard (PCI DSS 1.2)

• Information Technology Infrastructure Library (ITIL)

• Vendor Guidance

And More Laws & Regulations Which Impact Privacy• Children’s Online Privacy

protection Act of 1998• Consumer Credit Reporting

Act of 1996• Driver’s Privacy Protection

Act of 1994• Electronic Funds Transfer

Act• European Union Data

Protection Directive of 1995

• Fair Credit Reporting Act of 1999

• Telemarketing and Consumer Fraud Abuse Act

• Family Educational Rights & Privacy Act (FERPA)

• Federal Trade Commission Act (FTCA)

• Freedom of Information Act

• Privacy Act of 1974• USA Patriot Act of 2001

Health Information Technology for Economic and Clinical Health Act (HITECH) Increases Security and Privacy Protections

• Mandatory penalties for willful neglect

• New rules for ‘unsecured breach’– Patients notified– HHS notified >500– Website posting– Local Media– Internal vs. External

• Providers with EHRs must provide ePHI for cost of labor

• Business associates must comply with security rule– Follow safeguards– Report incidents to CE– Civil and Criminal

penalties• HHS Required to

provide audits of CE’s and BA’s

• Penalties increased to $250K, 1.5M for repeated violations

State Attorney Brings First Cause of Action under HITECH Act Jan 13, 2010

Connecticut Attorney General's OfficePress ReleaseAttorney General Sues Health Net For Massive

Security Breach Involving Private Medical Records

And Financial Information On 446,000 Enrollees

                                                  

PCI DSS V1.2 Requirements

Build & Maintain a Secure Network

• Install/maintain firewall configuration• Don’t use vendor-supplied defaults

Protect Cardholder Data • Protect stored cardholder data• Encrypt across open networks

Maintain a Vulnerability Management Program

• Use and regularly update anti-virus• Develop secure systems/applications

Implement Strong Access Control Measures

• Restrict access by need-to-know• Assign unique ID to each person• Restrict physical access

Regularly Monitor & Test Networks

• Track and monitor all access• Regularly test security systems/processes

Maintain an Information Security Policy

• Policy must address infosec

Part 3: Anatomony Of An Audit

1. Planning2. Onsite Arrival3. Execution4. Entrance/Exit/

Status Conferences

5. Report Issuance/Remediation

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Request List

SampleSelection

AgreedUpon

Procedure

Testing

Findings

CorrectiveAction

ANATOMY OF AN AUDIT

1. PLANNING • Receive Prepared By Client (PBC) List; Client Assistance List (CAL)

• Review Requests/Clarify Scope

• Assign to Dir/Mgr/SME• Create Directory

Structure• Schedule Interviews

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Policies & Procedures Requested For 24 e-PHI Security-Related Issues

• Establish/Terminate User Access• Emergency IT System Access• Inactive Sessions• Recording/examining activity• Risk Assessments• Employee violations/sanctions• Electronic transmission• Incident

prevention,detection,containing• Regular access review• Security violation logging• Monitoring systems and network• Physical access to systems

• Types of security access controls

• Remote access• Internet usage• Wireless security• Firewalls, routers, switches• Physical security repair• Encryption/decryption• Transmission • Password and server

configurations• Antivirus software• Network remote access• Patch management

Documentation Requests…

• Information systems, network diagrams

• Terminated employees• New hires• Encryption mechanisms• Authentication methods• Outsourced/contractor access• Transmission methods• Org chart for IT, Security• Systems Security Plans

• All users with access, including rights

• System Administrators, backup operators

• Antivirus servers• Internet access control

software• Desktop antivirus software• Users with remote access• Database security

requirements/settings• Domain controllers, servers• Authentication approaches

The Auditors Have Landed…

2. ONSITE AUDITOR ARRIVAL

• Entrance Meeting• Internet

Connections• Develop

‘communication protocol’

• Establish start/end/status dates

50

What? Didn’t I Give That To You Already? (Maybe..Maybe Not)

3. EXECUTION • Track every communication

• Obtain requests in writing

• Encrypt all files• Schedule all

follow-ups via central person

• Review, Review, Review

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Surprises are for Birthdays & The Holidays, Not Audits4. ENTRANCE

CONFERENCES/STATUS CALLS/EXIT CONFERENCE

• Daily Status Calls

• Weekly Status Reports

• No Surprises?• Risk Ranking of

Issue

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Remediation of Findings Should Be Swift• REPORT

ISSUANCE/REMEDIATION

• Final Draft Report• Management Response• Prior Finding Closure• Corrective Action Plan

(CAP)• 5 Business Days• 30 Calendar Days• 90 Calendar Days• Ink Is Now Dry

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PART 4: A Good Control

54

Discussion

PART 5: Audit Problem Area Discussion

55

Problem Area #1: Policies/Procedures

• Process Changed Mid-Audit Cycle

• Not updated• No Revision History• Improper

Management Approval• Inability to retrieve

w/Revision History• Not Followed

56

Problem Area #2: Security Baseline Configurations

• Not compliant with latest standard (i.e., FDCC, DISA)

• Not documented• No monitoring• No management

approval• New servers, test

servers out of compliance

57

Problem Area #3: Software Patching

• Critical security patches not applied timely (7,15,30 days)

• Adobe, vendor products• Servers, Desktops,

network devices not consistently patched to latest levels

• Time to test patch• Monitoring used to fix

servers?

58

Problem Area #4: Lack of Software Testing

• Applies to all production applications

• Every program should be tested within X years or when changed

• Documented processes followed

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Problem Area #5: Change Control

• Segregation of duties– Requestor– Developer– Implementer– Tester/End User– Change Control/CCB

• Approvals before production implementation

• Emergency Requests• Signoffs

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Problem Area #6: User Access Administration

• Too much access for function

• Unapproved Access (no documentation)

• Terminations too long (> 3 days)

• Lack of recertification of access

• Scope not including all platforms

• Transfers• Contracted background

checks

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Problem Area #7: Vulnerability Assessment/Pen Testing

• Will always find something… always

• Schedule after hours• Schedule during non-

production• Limit testing period• Contracts

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Problem Area #8: Media Sanitization

• Include copiers, scanners, fax machines, routers, servers, USB drives, CDs, desktops, laptops…

• Tapes/Documents shredded onsite

• Inventory assets• Document

sanitization/disposal• Encrypt everywhere

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Problem Area #9: PHI Disclosure/Incident Handling

• Encrypt all external email• Establish Incident

discovery reporting within 1 hour

• Escalation processes• Retain written actions• Automate

monitoring/correlation process

• Management reporting• Documentation of follow-

up

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Remember The Earlier Issue?…

NIST 800-124 Issued Guidance For Smart Phones….• Organization-wide policy for mobile

handheld devices• Risk assessment and management• Security awareness and training• Configuration control and management• Certification and accreditation• Apply critical patches and upgrades• Eliminate unnecessary services and

applications• Install and configure additional

applications that are needed

More NIST 800-124 Guidance

• Configure resource controls• Install content encryption, remote content

erasure, firewall, AV, intrusion detection, antispam,VPN software.

• Perform security testing• User control of device, backup frequently• Enable non-cellular wireless access only when

needed• Report and deactivate compromised devices• Enable log files for compliance• … and the list goes on…

JUST LIKE BLOWING BUBBLES…

Just When Security Problem Gets Bigger

Another Never Materializes

And Another Bursts- Good Luck!

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Thank You For Your Participation!

Todd_Fitzgerald@Yahoo.comTodd.Fitzgerald@WellPoint.com

WWW.linkedin.com/in/toddfitzgerald