Andrew Hicks, Managing Principal, Coalfire
The comments are in and the HHS is scrambling to review them all before they issue the final Stage 3 Meaningful Use rules later this summer. Comments from entities such as CHIME and HIMSS represent good news and bad news for healthcare providers, depending on how you look at it. The HIPAA Security Rule has always required a risk analysis, but now there could be an annual requirement for risk analyses.
It’s simply too risky to have a ‘point-in-time’ risk analysis that often addresses risk for up to three years or more for many organizations. And even riskier is to conduct a baseline risk analysis and not follow through with the risk management component that addresses the identified risks. The other issue brought up in the comments is how healthcare providers are only doing the ‘bare minimum’ when it comes to risk analysis and the final rules should provide guidance on what an acceptable baseline is for a security risk analysis.
Stage 3 of the HITECH Act incentive program is slated to begin in 2017 or 2018 and in January 2018, healthcare providers are required to have a certified EHR system in place or they’ll face financial penalties. So perhaps the CMS will reach middle ground on this risk analysis issue by providing a mandate that requires providers to conduct a risk analysis only at the time of EHR technology installation or when a new version of the technology is implemented.
Stage 3 allows healthcare providers to qualify for an additional incentive by achieving a proposed new list of objectives. One of these proposed requirements is a risk assessment. It states that healthcare providers must conduct a risk assessment that specifically looks at risk to information maintained by their certified EHR technology.
The language in the HHS proposed rule says this, “The requirement of this proposed measure is limited to annually conducting or reviewing a security risk analysis to assess whether the technical, administrative and physical safeguards and risk management strategies are sufficient to reduce the potential risks and vulnerabilities to the confidentiality, availability and integrity of ePHI created by or maintained in the certified EHR technology.” CHIME said that while they agree with the need to safeguard ePHI, they think that providers will be confused by the timing for assessments or reviews. But with all due respect, what’s so confusing about requiring an annual assessment in the same way that PCI and FedRAMP regulations require them?
It may need to get even more stringent by not only requiring an annual risk assessment, but also issuing a mandate to use a third-party assessor organization to conduct the assessment given that providers seem to be doing the bare minimum when actually a far more thorough risk analysis is needed. They could also add a continuous monitoring mandate to the rule, who knows?
In any case, with the fast-growing healthcare ecosystem, there’s data all over the place including the EHR technology, so there’s certainly a need for more thorough risk assessments conducted more often than every three years. Perhaps this is why we’ve seen a huge demand in the past six months for HITRUST assessments and certifications from both BAs and CEs – it’s truly the only risk framework that fills the need described in the final Stage 3 rule for providers.
Andrew Hicks — Managing Principal, Coalfire
Coalfire started in 2001 with a simple idea – cyber threats are increasing, compliance mandates are getting more complicated, and a well-designed cybersecurity program can help fuel your overall success.
Coalfire helps organizations comply with global financial, government, industry and healthcare mandates while helping build the IT infrastructure and security systems that will protect their business from security breaches and data theft. The company is a leading provider of IT advisory services for security in retail, payments, healthcare, financial services, higher education, hospitality, government and utilities.
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The increased need for cyber security has become a common enterprise priority across the globe. However, industry requirements for effective cyber risk management are as distinct as the individual entities under fire. Enterprises and government organizations need more than an off-the-shelf audit to provide an effective threat assessment. They need industry- and organization-specific insights, tools and processes to protect digital assets and ensure compliance.
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"Success" at a government entity looks different at a commercial organization. Create cybersecurity solutions to support your mission goals with a team that understands your unique requirements.
The financial services industry was built upon security and privacy. As cyber-attacks become more sophisticated, a strong vault and a guard at the door won’t offer any protection against phishing, DDoS attacks and IT infrastructure breaches.
The continuum of care is a concept involving an integrated system of care that guides and tracks patients over time through a comprehensive array of health services spanning all levels of care. Interoperability is the central idea to this care continuum making it possible to have the right information at the right time for the right people to make the right decisions.
Maintaining network and data security in any large organization is a major challenge for information systems departments. However, in the higher education environment, the protection of IT assets and sensitive information must be balanced with the need for ‘openness’ and academic freedom; making this a more difficult and complex task.
When it comes to cyber threats, the hospitality industry is not a friendly place. Hotels and resorts have proven to be a favorite target for cyber criminals who are looking for high transaction volume, large databases and low barriers to entry.
The payments industry is undergoing rapid changes and unfortunately, an increasing risk for data breaches. Cyber criminals are growing increasingly businesslike, and payments leaders need to move quickly to cover their cyber risk.
The global retail industry has become the top target for cyber terrorists, and the impact of this onslaught has been staggering to merchants. To secure the complex IT infrastructure of a retail environment, merchants must embrace enterprise-wide cyber risk management practices that reduces risk, minimizes costs and provides security to their customers and their bottom line.
Private enterprises serving government and state agencies need to be upheld to the same information management practices and standards as the organizations they serve. Coalfire has over 16 years of experience helping companies navigate increasing complex governance and risk standards for public institutions and their IT vendors.
Technology innovations are enabling new methods for corporations and governments to operate and driving changes in consumer behavior. The companies delivering these technology products are facilitating business transformation that provides new operating models, increased efficiency and engagement with consumers as businesses seek a competitive advantage.
Cybersecurity has entered the list of the top five concerns for U.S. electric utilities, and with good reason. According to the Department of Homeland Security, attacks on the utilities industry are rising "at an alarming rate".
Cyber risk management, advisory, technology and compliance services. Manage risk and maximize return on investment to prevent data breaches and theft. Coalfire’s solutions are led by a team of industry experts that help enterprise organizations understand a wide range of compliance and risk management initiatives, which enables a consistent cybersecurity framework across the organization.
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