Risk and Security LLC

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Red Flag FACT

How your health records are safer — or at least you’ll know about all the disclosures now….

Well – it wasn’t a billion dollar bailout and it wasn’t a new ‘public option’, but it was, on September 23rd, the official STARTING DAY of the new HIPAA breach disclosure rule, another tangible effect of the American Recovery and Reinvestment Act of 2009.

The breach disclosure rule is a little unusual in the way it dictates how healthcare entities have to behave if there is a disclosure of YOUR PHI (i.e. Protected Health Information). Your PHI could be interesting little tidbits of information like:

– detailed health info on 1000 Hollywood celebrities, probably all about face lifts, nose jobs and liposuction.

– Details on whose tubes got tied

– Embarrassing information on warts and other disgusting physical problems
– Just info you don’t want everyone to know about.

The new Breach Disclosure rules protect you. Here are some of the details about what the organization that leaked your sensitive info has to do…

If the breach involved less than 500 individuals’ information, then you must be notified within sixty days and “without reasonable delay”. If more than 500 individuals’ information is breached, then the organization has to not only notify the Department of Health and Human Services, but also has to send out a press release and notify the media — film at eleven.

Covered organizations (covered entities) will not be penalized until February 22, 2010. So for now, organizations should make sure they have these disclosure guidelines in place and practice them, including training and awareness exercises, so they will be ready by February.

Organizations must also do an individual RISK ASSESSMENT on each breach to calculate the harm that the breach may do to an individual. For example, whether the breach would affect their health insurance, or their relationship!
There are additional considerations about whether the breach was done in error and actual disclosure was limited; or whether it was malicious disclosure – done on purpose, or for financial gain.

The breach notification rule, in my opinion, is just another manifestation of how serious the government has become about protecting personal information, whether it is protected health information, or personal financial information.

The FTC reported that identity theft is the one number consumer complaint and so protection of your information has moved up to the top of the list. Lucky us

Assessing PCI Compliance — World’s Biggest Standard

Everyone has a credit card these days.  Ever take it out and take a good look at that little magnetic strip on the back of a credit card?  It’s only about 2 1/2 inches long and quite thin.  That little strip contains all the personal information about you — your name, address, password, mother’s maiden name, perhaps your social security number and your financial account number and even more information about your account.

Who wrote the program that ended up on that magnetic strip? Are there copies of that magnetic strip information stored somewhere?  And this is only ONE card; you probably have a wallet full of them.

These payment cards (PC= Payment Card Industry) are the biggest deal in information security these days because of a new standard call the PCI-DSS standard (Payment Card Industry- Data Security Standard).  The PCI Security Standards Council, which created the standard, was founded by American Express, Discover Financial Services, JCB International, MasterCard Worldwide, and Visa Inc.

Credit card companies want you to charge it and they know that concerns about identity theft might possibly slow down your card use — so it is in their best interests to make sure that a solid security standard is in place to protect you.  The standard has turned into a requirement for everyone who takes a credit card and that turns out to be literally millions of grocers, retailers, online retail outlets, government agencies, convenience stores, utilities — almost everyone.  So the PCI-DSS standard may be the most widely applied information (data) security standard in the world.

With such a widespread and critical standard, there is confusion about how to meet the standard because just doing a self-assessment isn’t enough — you are also required to do penetration tests on your systems that handle and transmit this electronic customer information and ATTEST that you use the standard in your information systems.  

This includes having strong firewalls that protect cardholder data and making sure to remove
the generic vendor-supplied passwords; using good storage devices for sensitive customer information and encrypting data that flows over your network.  In addition, the card manager has to use anti-virus software, and also build secure systems.  Once proper controls are in place, these controls need to be monitored and tested. 

Doing a full compliance and vulnerability assessment annually is the best way to make sure that you can prove you have done all the specific activities required in the PCI-DSS standard.  The assessment actually breaks the entire standard down into smaller, manageable chunks and then each one is monitored, or validated, with an audit trail, so that is easy to prove that you have evaluated your organization’s compliance with the PCI-DSS standard.

The PCI-DSS standard is actually mild, as information security standards go, and not as far-reaching or intrusive as, for example, the HIPAA standard (Healthcare Insurance Portability and Accountability Act) which has completely revised the way healthcare organizations do business.  Nor is it as complicated as the BSA (Bank Secrecy Act) or the International Standards Organization’s 27001 standard (ISO 27001 and 27002).  

After the infamous TJMAXX identify theft incident — consumers should welcome the PCI standard and retailers and others affected by it should be grateful that is just another way of encouraging good information security practices.

Regularly Monitor and Test Networks

Requirement 10: Track and monitor all access to network resources and cardholder data
Requirement 11: Regularly test security systems and processes

Maintain an Information Security Policy

Requirement 12: Maintain a policy that addresses information security