2018 HIPAA One All Rights Reserved. Beyond HIPAA Compliance to Certification
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1 2018 HIPAA One All Rights Reserved. Beyond HIPAA Compliance to Certification
2 Presenters Jared Hamilton CISSP CCSK, CCSFP, MCSE:S Healthcare Cybersecurity Leader, Crowe Horwath Erika Del Giudice CISA, CRISC, CCSFP HITRUST Solution Leader, Crowe Horwath Steven Marco, CISA President, HIPAA One
3 Today s Agenda Live Interactive Session Assessment vs Analysis Defined Setting the Right Goal: Regulation vs Certification Deep-Dive into HIPAA, SOC, HITRUST
4 Company Introduction HIPAA Compliance & Data Security - Healthcare compliance and risk management - Experts in talent, solutions and methodologies - Dedicated to constant improvement HIPAA One Risk Analysis Software: - Over 7,000 sites (CEs and BAs) protecting ephi - Automation of all mundane labor-intensive activities - Includes Security and Privacy and Breach Notification Developed and Maintained in USA - Current with updated HIPAA Phase 2 Audit Protocol Disclaimer: We are not attorneys, but as auditors must understand HIPAA!
5 Crowe Horwath Intro 8 th largest public accounting, consulting and technology firm Dedicated healthcare cybersecurity team with deep specialization Operate as virtual CISO We answer healthcare s toughest questions: - Are we meeting HIPAA compliance? - What is our cybersecurity risk? - Could we be hacked? - Are we susceptible to phishing attacks? - How can we control biomedical and IOT risks? - How can customers trust us with their data? - How can I best managed vendor risks? Leverage HIPAA One to focus on results, strategy and post-assessment remediation
6 Poll Question Which option below best describes your current role? A. Administrative B. EHR/IT Team C. Clinical Staff D. Legal Counsel
7 Poll Question Did your office complete a HIPAA Security Risk Analysis last year? A. Yes B. No C. What s a risk analysis?
8 Poll Question If audited tomorrow, are you 100% confident you would pass? Yes No
9 Gap Assessment vs. Risk Analysis Gap Assessment High level review of controls Narrow focus Comparison of safeguards vs. reality - Administrative - Physical - Technical Identification of Gaps - Documentation % - Implementation % Commonly referred to as a HIPAA Compliance Program Review or Audit. Risk Analysis Comprehensive: Goal is to accurately and thoroughly assess all risks to ephi (created, received, maintained or stored). Not prescribed, but good ones include: - Scope - Data collection - Threats and vulnerabilities - Current controls - Likelihood and impact - Computed risk - Documentation - Maintenance of process (review & update) Just the first step!
10 HIPAA Security Risk Assessment
11 How a HIPAA Risk Assessment Is Done Using Crowe Horwath Step 1 Gather Information, Interviews, Inventory, etc. Participant login, answer simple questions and interview Import last year s work Step 2 Remediation Planning Results of Step 1, Develop and Assign tasks Step 3 Sign & Add Reviewers Download PnP examples Ongoing Remediation and documentation
12 HIPAA SRA Estimates HR Director: 30 min EMR/ePHI System Admin: 45 min Average Time Per Interview* IT Network Manager: 30 min IT Server Manager: 60 min HIPAA Security Officer: 90 min Facilities Manager: 30 min * Add 10 minutes for every 1K employees
13 HIPAA Poll Question How are you addressing biomedical/iot device risks? A. We have inventoried, assessed and are managing are biomedical device risks B. We have a great inventory of medical devices, but do not know their risks C. We don t know where to even begin when it comes to non traditional networked devices
14 Data Security Poll Question Do you perform penetration testing? A. Absolutely, it s key to understanding gaps in our overall cybersecurity program B. We have before, as it helps supplement our HIPAA compliance C. No, as it s not required by HIPAA D. What is penetration testing?
15 HITRUST Poll Question Where is your organization s status with HITRUST? A. We are HITRUST Certified B. We are in the process of becoming HITRUST Certified C. We are thinking about becoming HITRUST Certified D. What is HITRUST?
16 HITRUST Overview A common security framework that helps healthcare organizations do more with less The HITRUST CSF is a combination of the most common regulations, which allows organizations to reduce their number of audits possible control statements to assess, 5 maturity levels within each control statement HITRUST CSF assessments scale according to the size and complexity of the organization
17 HITRUST Poll Question How can you convince your healthcare partners that your mature security program is appropriately protecting patient data? A. Proof of HIPAA Security Risk Analysis B. HITRUST Certification C. SOC 2 Certification D. None of the above E. All of the above F. I don t see the need to convince my partners that their patient data is protected
18 HITRUST Poll Question What value do you see (or have you heard) about the HITRUST framework? A. Leveraging the framework to validate your cybersecurity program/controls B. Providing HITRUST certification to a business partner to place reliance on HITRUST C. Limiting the audits your organization is performing and testing controls once, using many time D. Understanding the controls in place at your BAs and how they are protecting data E. All of the above
19 Assess Remediate Maintain HITRUST CSF Subscription Self- Assessment Remediation* Validated Assessment Certification What type of assessment is needed? Scope is determined Controls are established Interviews with control owners Evidence is gathered Gaps are identified Implement controls Assign responsibility Determine audit program Inspect evidence Perform sample testing Assign scores Submit assessment to HITRUST Respond to QA requests Receive certification letter and report Crowe can assist in many of the phases of the HITRUST CSF process, including: Self-assessment Assist the client with understanding the HITRUST CSF process and reviewing HITRUST CSF controls in preparation for certification, especially helpful for first year clients. Remediation Once gaps have been identified, Crowe can assist in helping build control structures for the gaps. Remediation activities can also occur after the assessment, during the corrective action management phase. Validated Assessment Crowe has many certified assessors able to validate any size or scope assessment. *Crowe cannot assist in remediation if engaged for the validated assessment.
20 How to Utilize HITRUST Beyond HIPAA Think: Benchmarking Analysis Ask yourself these questions: Do you have a common framework for implementing security controls? Are you confident you have implemented all the right controls to align with the framework? Have you determined if the framework is benefitting the organization? Have you been asked by senior leadership how you know you re following the framework and what gaps exist? A Benchmarking Analysis may be for YOU!! HITRUST can be used by any U.S. healthcare organization to assess the organization s cybersecurity posture and provide comfort to the Board and other stakeholders. Benchmark your security posture against the robust HITRUST framework Leveraging the ISO, PCI, NIST, HIPAA, and SOC frameworks Using the self-assessment portion of the MyCSF tool to pull in appropriate controls based on a scoping exercise
21 Another Way to Use HITRUST Think: Vendor Management Ask yourself these questions: Do you know which Business Associates (BAs) and vendors have performed a HIPAA Security Risk Analysis, SOC 2 or HITRUST certification or SHOULD have one, but don t? When you receive a HITRUST certification from a vendor or BA, do you know what that means? Have you been asked by senior leadership how your vendors are protecting your data? Crowe can provide assistance related to vendor management, HIPAA, SOC 2 and HITRUST! Vendors and BAs are a critical component to the operations and success of any U.S. healthcare organization and often times have access to patient data that needs to be protected. Understand how you would benefit from your vendors and BAs having a HIPAA, SOC 2 or HITRUST Certification Interpret the HITRUST results you receive from vendors and BAs
22 SOC Poll Question What is your organization s status with SOC 2? A. We have performed a SOC 2 Examination B. We are in the process of performing a SOC 2 Examination C. We are thinking about performing a SOC 2 Examination D. We are exploring SOC 2+ HITRUST E. What is SOC 2?
23 SOC Decision Tree
24 HITRUST CSF Controls Reporting Service Descriptions Attestation Services SOC 2+ HITRUST CSF Examination - Attestation services that result in a formal report on controls to be provided to your customers. A SOC 2 report is intended to be used by user organizations that rely on a service organization to perform controls related to the SOC 2 Trust Services Criteria (TSC). This service ties the SOC 2 TSC to the HITRUST CSF requirements in one report for distribution to your users. SOC 2+ HITRUST CSF Certification - Attestation services that result in a formal report on controls to be provided to your customers. Organizations receive both a SOC 2 report from their CPA firm and a HITRUST CSF certification from HITRUST.
25 HITRUST Report Decision Tree SOC 2 SOC 2+ HITRUST CSF SOC 2+ HITRUST CSF + HITRUST CSF Certification HITRUST CSF Self Assessment HITRUST CSF Validated Assessment (Certification) Yes Yes No No Yes No
26 Assurance Effort Pick Your Path Certification of Controls (Certified Assessor) HITRUST Reporting on Controls (CPA firm per AICPA) SOC 2 Required Controls (Certified Auditor) HIPAA Represents unit of effort to do a HIPAA SRA per 45 CFR (a)(1)(ii)(A).
27 Thank You For Joining Us Next Steps! Contact Us to Learn More Follow us on Social: HIPAA
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