Health & Life Sciences Breach Security Assessment Reportsecurity based on this assessment may also help with compliance with privacy and security regulations, data protection laws,

Health & Life SciencesBreach Security Assessment

Report

For Star Healthcare

Fictitious organization and assessment data. For demo purposes only.

Contents

Executive Summary .................................................................................................................................................................... 3

Breach Security Maturity ............................................................................................................................................................ 5

Breach Type Priorities ................................................................................................................................................................ 6

- Cybercrime Hacking ................................................................................................................................................................. 6

- Loss or Theft of Mobile Device or Media ................................................................................................................................ 8

- Insider Accidents or Workarounds ......................................................................................................................................... 10

- Business Associates .............................................................................................................................................................. 12

- Malicious Insiders or Fraud ................................................................................................................................................... 14

- Insider Snooping .................................................................................................................................................................... 16

- Improper Disposal .................................................................................................................................................................. 18

- Ransomware .......................................................................................................................................................................... 20

Breach Security Maturity Model ............................................................................................................................................... 23

Breach Security Gaps and Opportunities for Improvement ..................................................................................................... 24

Breach Security Action Plan .................................................................................................................................................... 26

Breach Security Capabilities .................................................................................................................................................... 27

Confidential. Page 2 of 55

Reported On Wednesday, 4 Jan 2017 15:45 PST

Assessed On Monday, 1 Feb 2016 11:18 PST

Organization Star HealthcareProvider, United States

AccountManager

Kathy TrustworthySenior Account ManagerVMWare123 456 [email protected]

Assessor Joe Whitehat CISSPSenior Security [email protected]

Assessments 52 (Global Scope)

Executive SummaryBreaches are the top privacy and security concern in Health & Life Sciences organizations, according to global Intel researchconducted in 2015. This report highlights the results of an assessment of your organizations breach security capabilities. Italso compares your breach security maturity, priorities across breach types, and your breach security capabilities with the restof the Health & Life Sciences organizations that have also been assessed up to the time of this report. This is a pilot programrunning throughout 2016 and 2017, led by Intel in collaboration with a broad range of partners working in the Health & LifeSciences Industry. We welcome your feedback both on the pilot program in general, and on this report.

This Health & Life Sciences breach security assessment is a high level survey of potential breach security issues and isintended to inform participants where they stand on selected security practices in relation to other similar participants in thisstudy, and is not intended to replace participants other compliance or security due diligence activities. It is also differentfrom and complementary to risk assessments that are required by several regulations and security standards. It provides anopportunity to look at gaps and next steps that can be taken to improve breach security posture. Improvements to breachsecurity based on this assessment may also help with compliance with privacy and security regulations, data protection laws,and standards. Please consult publicly available information on your applicable regulations, laws and standards for furtherinformation.

42 breach security capabilities were assessed in this engagement. Star Healthcare has 75% of the capabilities in the Baselinematurity level (3% ahead of average), 46% in Enhanced (4% behind average), and 29% in Advanced (1% behind average).The breach security maturity level of Star Healthcare peaks in the Baseline level. See Breach Security Maturity for furtherdetails on the assessment of the breach security maturity level of Star Healthcare, and how this compares with the broaderHealth & Life Sciences Industry.

Star Healthcare is leading the industry (upper percentile range) in terms of readiness for the following breach types: Lossor Theft of Mobile Device or Media, Business Associates, and Improper Disposal. Star Healthcare is lagging the industry(lower percentile range) in terms of readiness for the following breach types: Cybercrime Hacking. See Breach Type Prioritiesfor further details on Star Healthcare readiness for various breach types, and how this compares in terms of percentile tothe rest of the Health & Life Sciences Industry. At Star Healthcare, Cybercrime Hacking, Malicious Insiders or Fraud, andRansomware are considered High priority. Loss or Theft of Mobile Device or Media, Insider Accidents or Workarounds,Business Associates, and Insider Snooping are considered Medium priority. Improper Disposal is considered Low priority. 3 ofthese priorities are significantly different from the average priorities assigned by other Health & Life Sciences organizations tothese breach types. See Breach Type Priorities for further details on priorities assigned by Star Healthcare to various breachtypes, and how these priorities compare to the Health & Life Sciences Industry.


mailto:[email protected]?subject=Breach Security Assessment for Star Healthcare

mailto:[email protected]?subject=Breach Security Assessment for Star Healthcare

In the Baseline maturity level, Star Healthcare was behind the average in 4 capabilities: Anti-Malware, Email Gateway, WebGateway and Backup and Restore. In the Enhanced maturity level, Star Healthcare was behind the average in 6 capabilities:Device Control, Penetration Testing, Vulnerability Scanning, Network Data Loss Prevention (Discovery Mode), Multi-FactorAuthentication with Timeout, Secure Remote Administration and Business Associate Agreements. In the Advanced maturitylevel, Star Healthcare was behind the average in 1 capabilities: Security Information and Event Management. See BreachSecurity Maturity Model for how Star Healthcare was assessed across 42 breach security capabilities in the maturity model,and how this compares with the Health & Life Sciences Industry.

30 gaps in breach security capabilities were identifiedduring this assessment. These capabilities representnew opportunities for improvements by Star Healthcareto improve its breach security posture and furthermitigate risk of breaches. These capabilities may alsoimprove usability, reduce cost, and improve efficiencyof IT operations. For details on specific gaps andopportunities for improvement see Breach Security Gapsand Opportunities for Improvement . It is recommendedthat Star Healthcare review these opportunities andspecific products, technologies and services that canhelp together with the account manager and assessorlisted at the beginning of this report.

A 12 step multi-year Breach Security Action Plan is recomended for Star Healthcare to improve breach security posture andfurther reduce residual risk of breaches.

This report includes traceability to the following security and privacy standards, regulations and data protection laws:- HIPAA- ISO/IEC 27000-Series- NIST- PCI DSS- CIS Controls- GDPRIn addressing any breach security capability gaps identified in this report, such traceability helps you understand howaddressing these gaps may also help with compliance with applicable standards, regulations and data protection laws. Pleasesee each of the 42 capabilities in the Breach Security Capabilities section for details.

Thank you for participating in the Intel Health & Life Sciences Breach Security Assessment Program Pilot. We welcome anyupdates you may have on your breach security to ensure the accuracy of your assessment and this report. Please coordinateany such updates with your assessor. We also welcome your feedback on the overall process, as well as this report. Forfurther information about this program please see the Intel Breach Security Assessment Program website.


http://www.intel.com/content/www/us/en/healthcare-it/solutions/breach-security-assessment-program.html

1. Breach Security MaturityThe percentage of breach security capabilitiesyou have implemented at the various maturitylevels. As your breach security posture improves,your assessment at all of these maturity levelswill approach 100%. Important aspects to notein this result are what level your maturity peaksat, as well as how your Baseline, Enhanced, andAdvanced maturity levels compare with the rest ofthe Health & Life Sciences Industry.

Maturity

75% 72%

Baseline

46% 50%

Enhanced

29% 30%

Advanced

Star Healthcare Average


2. Breach Type PrioritiesThis assessment analyzed your level of concern or priority across eight different types of breaches. These results enableyou, for each breach type, to compare your level of concern or priority with the rest of the Health & Life Sciences Industry.For each of the following types of breaches the Priority Assessed reflects the priority or level of concern you assigned to thegiven type of breach. The Priority Assessed value for each type of breach is compared to the Health & Life Sciences Industryaverage for that breach type. If the Priority Assessed is significantly different than the industry average an alert will be shownin Priority Alerts. Readiness Assessed shows for each type of breach the percentage of relevant security capabilities currentlyimplemented at Star Healthcare. Readiness Percentile shows for each type of breach the percentile Star Healthcare fallswithin across all organizations assessed, based on the Readiness Assessed score. The most important result in the followingtable is the Readiness Percentile score for each of the breach types. In particular, it is recommended to pay careful attentionto any Readiness Percentile results that are red, indicating lower percentile range (less than 33%). For more detail on yourreadiness for a given breach type you can drill down by clicking on the associated breach type link.

Star Healthcare Breach Type Priorities

# Breach Priority Readiness Type Assessed Alerts Assessed Percentile

2.1 Cybercrime Hacking High 52% 23%

2.2 Loss or Theft of Mobile Device or Media Medium 58% 67%

2.3 Insider Accidents or Workarounds Medium 56% 54%

2.4 Business Associates Medium 65% 67%

2.5 Malicious Insiders or Fraud High > Avg 53% 54%

2.6 Insider Snooping Medium 55% 65%

2.7 Improper Disposal Low < Avg 67% 85%

2.8 Ransomware High 57% 40%

Star Healthcare priority differs significantly from Health & Life Sciences Industry average

2.1 Cybercrime HackingIn this type of breach an external hacker accesses your organizations network and obtains unauthorized access to sensitivepatient information. A common example of this type of breach starts with the hacker spear- phishing a worker in yourorganization, resulting in that worker clicking on a malicious link, and leading to drive-by download of malware. The malwarethen proliferates inside your intranet and key-logs the database administrator database credentials, at which point it turns intoa bot that logs into your database containing sensitive patient data and exfiltrates this data "low and slow" to evade detection.


Star Healthcare assigned a High priority toCybercrime Hacking .

This is comparable to the average priorityassigned by the rest of the healthcare industry tothis type of breach.

Cybercrime Hacking Priority

8%

Low

27%

Medium

65%

High

Key: Star Healthcare Average

Star Healthcare currently has approximately 52% of the breach security capabilities relevant to Cybercrime Hacking . Basedon this metric, when compared to other healthcare organizations, Star Healthcare is at the 23% readiness percentile , puttingit in the lower percentile range and lagging the healthcare industry. As Star Healthcare improves it's Cybercrime Hackingreadiness the slider on the graph below would move to the right, corresponding to an increase in both its percentage ofrelevant breach security capabilities implemented, and its readiness percentile.

Cybercrime Hacking Readiness

2

25%

2

30%

0

35%

2

40%

3

45%

8

50%

9

55%

2

60%

9

65%

4

70%

4

75%

2

80%

4

85%

1

90%

Key: Star Healthcare Number of Organizations at Readiness %


The capabilities below are relevant to mitigating risk of Cybercrime Hacking type breaches. This table shows the capabilitiesStar Healthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are lagging the industry average,or in other words where on average most other organizations currently have the associated capability implemented.

Star Healthcare Cybercrime Hacking Breach Security Maturity

Baseline Enhanced Advanced

Policy

Risk Assessment

Audit and Compliance

! User Awareness Training

! Anti-Malware

Firewall

! Email Gateway

! Web Gateway

Vulnerability Management,Patching

Security Incident ResponsePlan

! Backup and Restore

! Penetration Testing,Vulnerability Scanning

! Secure RemoteAdministration

Network Segmentation

Network IntrusionPrevention System

Network Data Loss Prevention(Prevention Mode)

Database Activity Monitoring

Digital Forensics

! Security Information and EventManagement

Threat Intelligence

Server Application Whitelisting

De-Identification / Anonymization

Tokenization

Business Continuity and DisasterRecovery

( = present, = partially present, = not present, = lagging industry in implementing, ! = action item in plan )

2.2 Loss or Theft of Mobile Device or MediaIn this type of breach a worker either loses or has stolen a mobile device or media containing sensitive patient data, resultingin potential unauthorized access to that data and a breach.

Star Healthcare assigned a Medium priority toLoss or Theft of Mobile Device or Media .


Loss or Theft of Mobile Device or Media Priority

25%

Low

46%

Medium

29%

High



Star Healthcare currently has approximately 58% of the breach security capabilities relevant to Loss or Theft of MobileDevice or Media . Based on this metric, when compared to other healthcare organizations, Star Healthcare is at the 67% readiness percentile , putting it in the upper percentile range and leading the healthcare industry. As Star Healthcare improvesit's Loss or Theft of Mobile Device or Media readiness the slider on the graph below would move to the right, corresponding toan increase in both its percentage of relevant breach security capabilities implemented, and its readiness percentile.

Loss or Theft of Mobile Device or Media Readiness

3

15%

0

20%

0

25%

1

30%

4

35%

4

40%

7

45%

6

50%

6

55%

14

60%

2

65%

3

70%

1

75%

1

80%



The capabilities below are relevant to mitigating risk of Loss or Theft of Mobile Device or Media type breaches. This tableshows the capabilities Star Healthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are laggingthe industry average, or in other words where on average most other organizations currently have the associated capabilityimplemented.

Star Healthcare Loss or Theft of Mobile Device or Media Breach Security Maturity


Policy

Risk Assessment



! Endpoint Device Encryption

! Mobile Device Management

Endpoint Data Loss Prevention(Discovery Mode)

IAM, Single Factor Access Control


Security Incident Response Plan

Secure Disposal


Client Solid State Drive(Encrypted)

Anti-Theft: Remote Locate,Lock, Wipe

! Multi-Factor Authenticationwith Timeout


Policy Based Encryption forFiles and Folders

Server / Database / BackupEncryption

Virtualization

Server Solid State Drive(Encrypted)

Digital Forensics

! Multi-FactorAuthentication withWalk-Away Lock

Client ApplicationWhitelisting

De-Identification /Anonymization

Tokenization


2.3 Insider Accidents or WorkaroundsIn this type of breach a worker performs a well-intentioned action that results in unauthorized access to sensitive patientinformation. A common example of this type of breach involves a worker emailing unsecured sensitive patient information,resulting in potential unauthorized access to this information, and a breach. This type of breach can involve the use of eithercorporate or BYOD devices by workers.


Star Healthcare assigned a Medium priority toInsider Accidents or Workarounds .


Insider Accidents or Workarounds Priority

17%

Low

48%

Medium

35%

High


Star Healthcare currently has approximately 56% of the breach security capabilities relevant to Insider Accidents orWorkarounds . Based on this metric, when compared to other healthcare organizations, Star Healthcare is at the 54% readiness percentile . As Star Healthcare improves it's Insider Accidents or Workarounds readiness the slider on the graphbelow would move to the right, corresponding to an increase in both its percentage of relevant breach security capabilitiesimplemented, and its readiness percentile.

Insider Accidents or Workarounds Readiness

3

20%

1

25%

0

30%

2

35%

6

40%

3

45%

8

50%

11

55%

6

60%

5

65%

2

70%

3

75%

1

80%

1

85%



The capabilities below are relevant to mitigating risk of Insider Accidents or Workarounds type breaches. This table showsthe capabilities Star Healthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are laggingthe industry average, or in other words where on average most other organizations currently have the associated capabilityimplemented.

Star Healthcare Insider Accidents or Workarounds Breach Security Maturity


Policy

Risk Assessment




Endpoint Data Loss Prevention(Discovery Mode)

! Anti-Malware

! Email Gateway

! Web Gateway



Secure Disposal

Device Control

Endpoint Data LossPrevention (PreventionMode)

Network Data LossPrevention (Discovery Mode)




Network Data LossPrevention (PreventionMode)

Digital Forensics

Threat Intelligence



Tokenization


2.4 Business AssociatesIn this type of breach a third party organization contracted by your organization experiences a breach event involvingunauthorized access to sensitive patient information. In this case the patient information impacted originates from yourorganization and was previously shared for the purpose of the third party organization fulfilling its contractual obligations. Inthe United States these entities are known as Business Associates, while in Europe they are typically referred to as DataProcessors.


Star Healthcare assigned a Medium priority toBusiness Associates .


Business Associates Priority

35%

Low

37%

Medium

29%

High


Star Healthcare currently has approximately 65% of the breach security capabilities relevant to Business Associates . Basedon this metric, when compared to other healthcare organizations, Star Healthcare is at the 67% readiness percentile , puttingit in the upper percentile range and leading the healthcare industry. As Star Healthcare improves it's Business Associatesreadiness the slider on the graph below would move to the right, corresponding to an increase in both its percentage ofrelevant breach security capabilities implemented, and its readiness percentile.

Business Associates Readiness

1

5%

1

10%

0

15%

0

20%

1

25%

2

30%

4

35%

3

40%

4

45%

7

50%

7

55%

2

60%

7

65%

3

70%

3

75%

1

80%

4

85%

2

90%



The capabilities below are relevant to mitigating risk of Business Associates type breaches. This table shows the capabilitiesStar Healthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are lagging the industry average,or in other words where on average most other organizations currently have the associated capability implemented.

Star Healthcare Business Associates Breach Security Maturity


Policy

Risk Assessment




Business AssociateAgreements

Digital Forensics

Threat Intelligence


Tokenization


2.5 Malicious Insiders or FraudIn this type of breach a worker performs a malicious action that results in unauthorized access to sensitive patient information.This could be a disgruntled worker, or done for the purpose of committing fraud. A common example of this type of this breachinvolves medical claims fraud where a worker files dishonest healthcare claims in order to turn a profit, or sells sensitivepatient information on the black market. Prescription fraud and financial fraud are other examples of this type of breach.

Star Healthcare assigned a High priority toMalicious Insiders or Fraud .

This generated an alert because on averagethe healthcare industry prioritizes this type ofbreach lower .

Malicious Insiders or Fraud Priority

40%

Low

35%

Medium

25%

High



Star Healthcare currently has approximately 53% of the breach security capabilities relevant to Malicious Insiders or Fraud .Based on this metric, when compared to other healthcare organizations, Star Healthcare is at the 54% readiness percentile .As Star Healthcare improves it's Malicious Insiders or Fraud readiness the slider on the graph below would move to the right,corresponding to an increase in both its percentage of relevant breach security capabilities implemented, and its readinesspercentile.

Malicious Insiders or Fraud Readiness

1

15%

2

20%

1

25%

0

30%

3

35%

7

40%

4

45%

9

50%

11

55%

5

60%

2

65%

5

70%

1

75%

1

80%



The capabilities below are relevant to mitigating risk of Malicious Insiders or Fraud type breaches. This table shows thecapabilities Star Healthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are lagging theindustry average, or in other words where on average most other organizations currently have the associated capabilityimplemented.

Star Healthcare Malicious Insiders or Fraud Breach Security Maturity


Policy

Risk Assessment





Endpoint Data LossPrevention (Discovery Mode)

IAM, Single Factor AccessControl

Firewall

! Email Gateway

! Web Gateway



Secure Disposal


Device Control














Digital Forensics

! Security Information andEvent Management

Threat Intelligence

! Multi-Factor Authenticationwith Walk-Away Lock


Server ApplicationWhitelisting


Tokenization

Business Continuity andDisaster Recovery


2.6 Insider SnoopingInsider snooping involves a worker accessing the records of patients of your organization without any legitimate need to do so,for example where a patient is not under the direct care of the worker.


Star Healthcare assigned a Medium priority toInsider Snooping .


Insider Snooping Priority

31%

Low

44%

Medium

25%

High


Star Healthcare currently has approximately 55% of the breach security capabilities relevant to Insider Snooping . Based onthis metric, when compared to other healthcare organizations, Star Healthcare is at the 65% readiness percentile . As StarHealthcare improves it's Insider Snooping readiness the slider on the graph below would move to the right, corresponding toan increase in both its percentage of relevant breach security capabilities implemented, and its readiness percentile.

Insider Snooping Readiness

1

10%

2

15%

0

20%

1

25%

0

30%

5

35%

5

40%

9

45%

11

50%

5

55%

6

60%

2

65%

3

70%

1

75%

1

80%



The capabilities below are relevant to mitigating risk of Insider Snooping type breaches. This table shows the capabilities StarHealthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are lagging the industry average, or inother words where on average most other organizations currently have the associated capability implemented.

Star Healthcare Insider Snooping Breach Security Maturity


Policy

Risk Assessment







Firewall

! Web Gateway



Secure Disposal

Device Control












Digital Forensics


Threat Intelligence

! Multi-Factor Authenticationwith Walk-Away Lock




Tokenization


2.7 Improper DisposalImproper disposal of electronic storage devices or media containing sensitive patient information. Examples of this couldinclude dumping of paper based patient records in a dumpster, or selling electronic devices with stored patient records withoutfirst securely wiping them.


Star Healthcare assigned a Low priority toImproper Disposal .

This generated an alert because on averagethe healthcare industry prioritizes this type ofbreach higher .

Improper Disposal Priority

40%

Low

38%

Medium

21%

High


Star Healthcare currently has approximately 67% of the breach security capabilities relevant to Improper Disposal . Basedon this metric, when compared to other healthcare organizations, Star Healthcare is at the 85% readiness percentile , puttingit in the upper percentile range and leading the healthcare industry. As Star Healthcare improves it's Improper Disposalreadiness the slider on the graph below would move to the right, corresponding to an increase in both its percentage ofrelevant breach security capabilities implemented, and its readiness percentile.

Improper Disposal Readiness

1

0%

1

5%

1

10%

1

15%

1

20%

1

25%

4

30%

1

35%

6

40%

8

45%

0

50%

9

55%

10

60%

2

65%

4

70%

1

75%

0

80%

1

85%



The capabilities below are relevant to mitigating risk of Improper Disposal type breaches. This table shows the capabilities StarHealthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are lagging the industry average, or inother words where on average most other organizations currently have the associated capability implemented.

Star Healthcare Improper Disposal Breach Security Maturity


Policy

Risk Assessment








Secure Disposal






Digital Forensics


Tokenization


2.8 RansomwareRansomware breaches involve malware infections, often through spear phishing and drive by download, where the malwareencrypts patient data in electronic form and the hackers behind it withold the decryption keys, typically demanding a ransom.This type of breach compromises the availability of the patient records, and can also involve unauthorized access to patientinformation, depending on the malware and hacker access to the internal network and data of the health and life sciencesorganization.


Star Healthcare assigned a High priority toRansomware .


Ransomware Priority

6%

Low

12%

Medium

83%

High


Star Healthcare currently has approximately 57% of the breach security capabilities relevant to Ransomware . Based onthis metric, when compared to other healthcare organizations, Star Healthcare is at the 40% readiness percentile . As StarHealthcare improves it's Ransomware readiness the slider on the graph below would move to the right, corresponding to anincrease in both its percentage of relevant breach security capabilities implemented, and its readiness percentile.

Ransomware Readiness

1

15%

0

20%

0

25%

3

30%

0

35%

4

40%

2

45%

4

50%

10

55%

10

60%

4

65%

3

70%

4

75%

4

80%

3

85%



The capabilities below are relevant to mitigating risk of Ransomware type breaches. This table shows the capabilities StarHealthcare has, and where there are gaps. Alerts are shown where gaps in capabilities are lagging the industry average, or inother words where on average most other organizations currently have the associated capability implemented.

Star Healthcare Ransomware Breach Security Maturity


Policy

Risk Assessment



! Anti-Malware


! Email Gateway

! Web Gateway




Device Control




Network Intrusion PreventionSystem


Digital Forensics


Threat Intelligence

Client Application Whitelisting





3. Breach Security Maturity ModelThe capabilities in the maturity model below are directly relevant tomitigating risk of various types of breaches. This view presents acomprehensive overview of all 42 assessed breach capabilities. To seethe subset of capabilities relevant to a particular breach type see theprevious section for that breach type. Each capability is classified intothe Baseline, Enhanced or Advanced breach security maturity levels. Onthe left of each breach security capability is a circle indicating whetherthis capability is currently present ( ), partially present ( ), or absent( ) at Star Healthcare respectively. ( ) indicates a capability where StarHealthcare is significantly behind the Health & Life Sciences Industryaverage in implementing the capability.

Star Healthcare Breach Security Maturity


Policy

Risk Assessment





Endpoint Data LossPrevention (DiscoveryMode)

! Anti-Malware


Firewall

! Email Gateway

! Web Gateway



Secure Disposal


Device Control

! Penetration Testing, VulnerabilityScanning


Endpoint Data Loss Prevention(Prevention Mode)

Network Data Loss Prevention(Discovery Mode)

Anti-Theft: Remote Locate, Lock,Wipe

! Multi-Factor Authentication withTimeout

! Secure Remote Administration

Policy Based Encryption for Filesand Folders



Network Intrusion PreventionSystem

Business Associate Agreements

Virtualization



Database ActivityMonitoring

Digital Forensics


Threat Intelligence

! Multi-FactorAuthentication with Walk-Away Lock




Tokenization




4. Breach Security Gaps and Opportunities for ImprovementSecurity capabilities for which your implementation was assessed as either "No" ( ) or "Partial" ( ) are listed below togetherwith the maturity level of the safeguard, its relevance across breach types, and whether your gap is significantly behind therest of the Health & Life Sciences organizations assessed. Capabilities that are assessed as not present ( ) will tend toappear higher on this list that ones assessed as partially present ( ) . Capabilities that are relevant across more breach types( ) will tend to appear higher on this list than ones relevant to fewer breach types. Capabilities relevant to breach types thatyou rated as higher priority will tend to appear higher on the list than those relevant to breach types that you rated as lowerpriority. Capabilities for which you assessed as significantly behind the Health & Life Sciences average ( ) will tend to appearhigher on the list than ones where your gap is typical across the Health & Life Sciences organizations assessed. This list isnot intended to be prescriptive. Please consult your account manager and assessor for further guidance in interpreting theseresults.

Star Healthcare Breach Security Gaps# Security Capability Assess Breach Types Mitigated

and Star Healthcare PrioritiesBehindIndustry

CybercrimeHacking

Loss orTheft

InsiderAccidents

BusinessAssociates

MaliciousInsidersor Fraud

InsiderSnooping

ImproperDisposal

Ransomware

High Medium Medium Medium High Medium Low High

1 Secure RemoteAdministration

2 Penetration Testing,Vulnerability Scanning

3 Security Information andEvent Management

4 Device Control

5 Tokenization

6 Network Data LossPrevention (DiscoveryMode)

7 Multi-Factor Authenticationwith Timeout

8 Web Gateway

9 Network Data LossPrevention (PreventionMode)

10 Email Gateway

11 Backup and Restore

12 Digital Forensics

13 User Awareness Training

14 Vulnerability Management,Patching


Star Healthcare Breach Security Gaps# Security Capability Assess Breach Types Mitigated

and Star Healthcare PrioritiesBehindIndustry

CybercrimeHacking

Loss orTheft

InsiderAccidents

BusinessAssociates

MaliciousInsidersor Fraud

InsiderSnooping

ImproperDisposal

Ransomware

High Medium Medium Medium High Medium Low High

15 Anti-Malware

16 De-Identification /Anonymization

17 Threat Intelligence

18 Multi-Factor Authenticationwith Walk-Away Lock

19 Server Solid State Drive(Encrypted)

20 Client ApplicationWhitelisting

21 Server ApplicationWhitelisting

22 Mobile Device Management

23 Policy Based Encryption forFiles and Folders

24 Endpoint Device Encryption

25 Business Continuity andDisaster Recovery

26 Database Activity Monitoring

27 Anti-Theft: Remote Locate,Lock, Wipe

28 Network IntrusionPrevention System

29 Business AssociateAgreements

30 Virtualization

( = present, = partially present, = not present, =lagging industry in implementing, ! = action item in plan )


5. Breach Security Action PlanThe following 12 step multi-year action plan is recommended for Star Healthcare to improve their breach security posture andreduce residual risk of breaches.

2016

1. User Awareness Training : Enhance training to include spear-phishing, and add new security training at the time ofemployee role changes.

2. Secure Remote Administration : Add ability to efficiently administer remote endpoints for maintenance, patching,updates and support.

3. Backup and Restore : Add backup and restore (versioned) for all data for availability and protection againstransomware.

4. Endpoint Device Encryption : Add encryption to smartphones and tablets.

2017

5. Security Information and Event Management : Implement SIEM for improved detection of breaches to minimizebusiness impact.

6. Penetration Testing, Vulnerability Scanning : Conduct penetration testing on external interfaces. Complete vulnerabilityscan to find unsecured machines, including unsecured development and test databases with PHI.

7. Multi-Factor Authentication with Timeout : Add tap and go MFA with proximity cards to improve usability and security.

8. Mobile Device Management : Add MDM for corporate provisioned mobile endpoints.

2018

9. Multi-Factor Authentication with Walk-Away Lock : Upgrade tap and go MFA to also include walk-away lock to minimizerisk of session hijacking when clinicians leave.

10. Email Gateway : Add monitoring of alerts, and management for Email Gateway.

11. Web Gateway : Add monitoring of alerts, and management for Web Gateway.

12. Anti-Malware : Add anti-malware to smartphones and tablets.


6. Breach Security CapabilitiesThis assessment evaluated the presence of 42 breach security capabilities in Star Healthcare . This section defines eachcapability and shows how Star Healthcare compares with the Health & Life Sciences Industry in implementing each capability.

6.1 PolicyAccurate, complete and up to date privacy & security policy.This is the internal document used to govern healthcareemployee responsibilities with regard to privacy and securityof patient information.

More Info

Notes: Need to update for BYOD.

HIPAA: 45 CFR 164.308(a)

ISO: 27001:2013 Section 5.2 Policy

NIST: SP 800-53 Rev. 4 PS-1, PS-7

PCI DSS: v3.1 Section 12.1

CIS: v6.1 CSC Governance Item #4: Policies

GDPR: Regulation 78 internal policies

Policy Capability

8%

Absent

27%

Partial

65%

Present


Policy is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal - Ransomware

6.2 Risk AssessmentDocumented risk assessments done annually.

More Info

Notes: Last one completed about 2 years ago. Not currentlydone regularly.

HIPAA: 45 CFR 164.308(a)(1)

ISO: 27001:2013 Section 8.2 Information Security RiskAssessment

NIST: SP 800-53 Rev. 4 RA-1 to RA-3


CIS: v6.1 CSC 13.1

GDPR: Regulation 76 risk assessment

Risk Assessment Capability

23%

Absent

35%

Partial

42%

Present


Risk Assessment is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal - Ransomware


https://en.wikipedia.org/wiki/Security_policy

https://www.law.cornell.edu/cfr/text/45/164.308

http://www.iso.org/iso/catalogue_detail?csnumber=54534

http://nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-53r4.pdf

https://www.pcisecuritystandards.org/documents/PCI_DSS_v3-1.pdf

https://www.cisecurity.org/critical-controls/Library.cfm

http://ec.europa.eu/justice/data-protection/reform/files/regulation_oj_en.pdf

https://en.wikipedia.org/wiki/Risk_assessment








6.3 Audit and ComplianceAudit and compliance technology and processes in place todetect and remedy non-compliance with policy.

More Info

Notes: Logging and regular audits done to verify compliancewith policy.

HIPAA: 45 CFR 164.312(b)

ISO: 27001:2013 Section 9.2 Internal Audit

NIST: SP 800-53 Rev. 4 AU-1 to 16

PCI DSS: v3.1 Requirement 10

CIS: v6.1 CSC 6

GDPR: Regulation 74 demonstrate compliance

Audit and Compliance Capability

13%

Absent

54%

Partial

33%

Present


Audit and Compliance is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal - Ransomware

6.4 User Awareness TrainingTraining of healthcare workers on security and privacy. Maybe implemented at time of hire, change of role, annually, ormore frequently. May also be triggered by specific events.More advanced training may use gamified techniques, forexample for spear phishing, to help train healthcare workerson the job.

More Info

Notes: New employees trained. Need training on role changeand spear phishing.

! Recommended Action: 2016 : Enhance training to includespear-phishing, and add new security training at the time ofemployee role changes. See Action Plan.

HIPAA: 45 CFR 164.308(a)(5)

ISO: 27002:2013 Section 7.2.2 Information SecurityAwareness, Education and Training

NIST: SP 800-53 Rev. 4 AT-1 to 4

PCI DSS: v3.1 Section 9.9.3

CIS: v6.1 CSC 17

GDPR: Article 39 awareness raising and training of staff

User Awareness Training Capability

19%

Absent

33%

Partial

48%

Present


User Awareness Training is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal - Ransomware


https://en.wikipedia.org/wiki/Information_technology_security_audit







https://en.wikipedia.org/wiki/Security_awareness








6.5 Endpoint Device EncryptionClient devices storing sensitive patient information haveencryption of data at rest.

More Info

Notes: Laptops encrypted. Need encryption for smartphonesand tablets.

! Recommended Action: 2016 : Add encryption tosmartphones and tablets. See Action Plan.

HIPAA: 45 CFR 164.312

ISO: 27002:2013 Section 10 Cryptography

NIST: SP 800-53 Rev. 4 SC-28


CIS: v6.1 CSC 13.2

GDPR: Article 32 1a encryption of personal data

Endpoint Device Encryption Capability

15%

Absent

42%

Partial

42%

Present


Endpoint Device Encryption is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal


https://en.wikipedia.org/wiki/Encryption







6.6 Mobile Device ManagementManagement of mobile client devices including smartphonesand tablets. Often used with BYOD devices. Functionalitymay include secure container for whitelisted business appsand data with access control and encryption, as well asremote management including remote lock and wipe.

More Info

Notes: Currently in place for BYOD smartphones. Need forcorporate smartphones and tablets.

! Recommended Action: 2017 : Add MDM for corporateprovisioned mobile endpoints. See Action Plan.

HIPAA: Security Rule - Protect Confidentiality - TechnicalSafeguard

ISO: 27002:2013 Section 6.2 Mobile Devices andTeleworking

NIST: SP 800-53 Rev. 4 AC-19


CIS: v6.1 CSC 13

GDPR: Regulation 83 accidential or unlawful loss of personaldata

Mobile Device Management Capability

23%

Absent

27%

Partial

50%

Present


Mobile Device Management is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal


https://en.wikipedia.org/wiki/Mobile_device_management

http://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/









6.7 Endpoint Data Loss Prevention (Discovery Mode)Data Loss Prevention ability to discover and possibly alsoclassify sensitive patient data at rest on clients or servers.

More Info

Notes: Currently used to discover patient data stored onlaptops etc.


ISO: 27002:2013 Section 18.1.3 Protection of Records

NIST: SP 800-53 Rev. 4 AU-13 to AU-14


CIS: v6.1 CSC 13.9

GDPR: Regulation 83 accidential loss of personal data

Endpoint DLP Discovery Capability

71%

Absent

15%

Partial

13%

Present


Endpoint Data Loss Prevention (Discovery Mode) is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal

6.8 Anti-MalwareAbility to detect and remediate blacklisted executables.May be signature based or heuristics / behavior based.Remediation may include quarantine or removal of anymalware detected.

More Info

Notes: Currently running on laptops. Need for smartphonesand tablets as well.

! Recommended Action: 2018 : Add anti-malware tosmartphones and tablets. See Action Plan.


ISO: 27002:2013 Section 12.2 Protection from Malware

NIST: SP 800-53 Rev. 4 SI-3


CIS: v6.1 CSC 8

GDPR: Regulation 49 prevent malicious code distribution

Anti-Malware Capability

2%

Absent

15%

Partial

83%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Anti-Malware capability.

Anti-Malware is relevant to the following breach types: - Cybercrime Hacking - Insider Accidents or Workarounds - Ransomware


https://en.wikipedia.org/wiki/Data_loss_prevention_software








https://en.wikipedia.org/wiki/Antivirus_software








6.9 IAM, Single Factor Access ControlAccess control using a single factor, either "what youknow", "what you have" or "what you are" / biometrics.Username / password is a very common form of "whatyou know" single factor authentication. There may bemultiple sets of credentials across different domains,applications and solutions. This capability includes bothtechnology and processes covering full IAM (Identity andAccess Management) lifecycle such as authentication andauthorization / privilege management.

More Info

Notes: Microsoft Windows login, as well as logins acrossvarious applications.

HIPAA: 45 CFR 164.312

ISO: 27002:2013 Section 9 Access Control

NIST: SP 800-53 Rev. 4 AC-1 to 3


CIS: v6.1 CSC 14, CSC 5

GDPR: Regulation 39 security and preventing unauthorisedaccess

IAM, Single Factor Access Control Capability

8%

Absent

23%

Partial

69%

Present


IAM, Single Factor Access Control is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Login








6.10 FirewallThe external firewall provides network perimeter defenseagainst unauthorized access to healthcare organizationssystems and sensitive patient information. Also includesinternal host based firewalls. Services may includeprovisioning / deployment, upgrade, patching, policy /configuration updates, network traffic monitoring, etc.

More Info

Notes: Currently have firewalls in place on perimeter ofnetwork, as well as endpoints.


ISO: 27002:2013 Section 13.1.2 Security of Network Services

NIST: SP 800-53 Rev. 4 SC-7


CIS: v6.1 CSC 9.2, CSC 9.6, CSC 12, CSC 18.2


Firewall Capability

0%

Absent

17%

Partial

83%

Present


Firewall is relevant to the following breach types: - Cybercrime Hacking - Malicious Insiders or Fraud - Insider Snooping


https://en.wikipedia.org/wiki/Firewall_(computing)









6.11 Email GatewaySafeguard for email and may include inbound threatprotection, outbound encryption, compliance, data lossprevention, and administration.

More Info

Notes: We have the appliance in place but need to establishprocess to configure and monitor it.

! Recommended Action: 2018 : Add monitoring of alerts, andmanagement for Email Gateway. See Action Plan.


ISO: 27002:2013 Section 13.1 Network Security Management



CIS: v6.1 CSC 7

GDPR: Regulation 49 resist accidental events thatcompromise confidentiality

Email Gateway Capability

0%

Absent

15%

Partial

85%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Email Gateway capability.

Email Gateway is relevant to the following breach types: - Cybercrime Hacking - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Ransomware


https://en.wikipedia.org/wiki/Email_privacy









6.12 Web GatewaySafeguard for web requests and content returned inresponses and may include analysis of the nature and intentof all content and code entering the network from requestedweb pages, to provide protection against malware and otherhidden threats.

More Info

Notes: Appliance in place but need resources and process tomonitor it to get full benefit.

! Recommended Action: 2018 : Add monitoring of alerts, andmanagement for Web Gateway. See Action Plan.





CIS: v6.1 CSC 7, CSC 12


Web Gateway Capability

8%

Absent

15%

Partial

77%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Web Gateway capability.

Web Gateway is relevant to the following breach types: - Cybercrime Hacking - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Web_application_security









6.13 Vulnerability Management, PatchingAbility (technology and processes) to manage vulnerabilitieson endpoint devices through configuration updates, signatureupdates, patching, and so forth. This can include patching ofoperating systems, security solutions, as well as office andhealthcare applications to ensure they are up to date andsecure.

More Info

Notes: Currently PC's configured for automatic updates.Need to do more vulnerability management eg with clientconfiguration.


ISO: 27002:2013 Section 12.6 Technical VulnerabilityManagement

NIST: SP 800-53 Rev. 4 CM-1 to 11, MA-1 to 6


CIS: v6.1 CSC 3, CSC 11, CSC 15, CSC 18, CSC 4.5

GDPR: Regulation 83 implement state of the art measures

Vulnerability Management, Patching Capability

6%

Absent

40%

Partial

54%

Present


Vulnerability Management, Patching is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal - Ransomware

6.14 Security Incident Response PlanPlans in place covering what do to in the event of a suspecteddata security incident or breach.

More Info

Notes: Currently in place and tested. Good to go.

HIPAA: 45 CFR 164.308(a)(6)

ISO: 27002:2013 Section 16 Information Security IncidentManagement

NIST: SP 800-53 Rev. 4 IR-1 to 10


CIS: v6.1 CSC 19

GDPR: Article 32 1 protect confidentiality, integrity, availabilityof personal data

Security Incident Response Plan Capability

21%

Absent

38%

Partial

40%

Present


Security Incident Response Plan is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal - Ransomware


https://en.wikipedia.org/wiki/Vulnerability_management









https://en.wikipedia.org/wiki/Computer_security_incident_management









6.15 Secure DisposalTechnology and processes to securely dispose of devicesand media containing sensitive healthcare information. Thiscan include secure wipe of disk drives, shredding of paperrecords, and so forth.

More Info

Notes: Secure wipe for hard drives. Shredding for paperrecords.

HIPAA: 45 CFR 164.310(d)(2)(i)

ISO: 27002:2013 Section 8.3.2 Disposal of Media, 11.2.7Secure Disposal or Re-Use of Equipment

NIST: SP 800-53 Rev. 4 MP-6


CIS: v6.1 CSC Privacy Impact Assessment: Disposal

GDPR: Regulation 83 protect confidentiality of personal data

Secure Disposal Capability

10%

Absent

17%

Partial

73%

Present


Secure Disposal is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal


https://en.wikipedia.org/wiki/Data_erasure








6.16 Backup and RestoreAbility to securely backup systems and data, store versionedbackups in a secure managed backup system. At least oneversion should be air-gapped / offline. This also includes theability restore systems that become corrupt or infected. Forthis capability to be considered fully implemented it should beregularly tested through a full backup and restore cycle.

More Info

Notes: Some endpoints including smartphones and tabletsnot yet backed up.

! Recommended Action: 2016 : Add backup and restore(versioned) for all data for availability and protection againstransomware. See Action Plan.

HIPAA: Security Rule - Protect Availability - TechnicalSafeguard

ISO: 27002:2013 Section 12.3 Backup

NIST: SP 800-53 Rev. 4 CP-9, 10


CIS: v6.1 CSC 10

GDPR: Article 32 1c restore availability and access topersonal data

Backup and Restore Capability

0%

Absent

19%

Partial

81%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Backup and Restore capability.

Backup and Restore is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Ransomware


https://en.wikipedia.org/wiki/Backup









6.17 Device ControlAbility to enforce a healthcare organizations policy regardingremovable storage devices that may be connected byhealthcare workers to endpoint client devices. Typicallyincludes representation of policy rules, as well as technologyand processes to enforce such rules. Examples include USBsticks or other removable storage.

More Info

Notes: Need to get this to prevent use of USB keys withlaptops.


ISO: 27002:2013 Section 8.3.1 Management of RemovableMedia

NIST: SP 800-53 Rev. 4 MP-7, SC-18, SC-41


CIS: v6.1 CSC 13.5


Device Control Capability

31%

Absent

31%

Partial

38%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Device Control capability.

Device Control is relevant to the following breach types: - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Removable_media










6.18 Penetration Testing, Vulnerability ScanningPenetration testing or vulnerability scanning has beenconducted within the last year to discover vulnerabilities in ahealthcare organizations IT infrastructure or applications.

More Info

Notes: Need to conduct this, especially on external networkinterfaces.

! Recommended Action: 2017 : Conduct penetration testingon external interfaces. Complete vulnerability scan to findunsecured machines, including unsecured development andtest databases with PHI. See Action Plan.


ISO: 27002:2013 Section 18.2.3 Technical ComplianceReview

NIST: SP 800-53 Rev. 4 CA-8, RA-5, RA-6


CIS: v6.1 CSC 9, CSC 4, CSC 15.2, CSC 18.4

GDPR: Article 32 1d regular testing, assessing, evaluatingeffectiveness of security

Pen Testing, Vulnerability Scanning Capability

17%

Absent

35%

Partial

48%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Penetration Testing, Vulnerability Scanningcapability.

Penetration Testing, Vulnerability Scanning is relevant to the following breach types: - Cybercrime Hacking - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Penetration_test










6.19 Client Solid State Drive (Encrypted)Self-encrypting solid state drives are used on client / endpointdevices to protect sensitive patient information at rest, withhigh performance.

More Info

Notes: Currently used in laptops.

HIPAA: 45 CFR 164.312


NIST: SP 800-53 Rev. 4 SC-28


CIS: v6.1 CSC 13.2, CSC 14.5


Client SSD (Encrypted) Capability

63%

Absent

17%

Partial

19%

Present


Client Solid State Drive (Encrypted) is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal

6.20 Endpoint Data Loss Prevention (Prevention Mode)Data Loss Prevention for endpoint / client devices. Enforcesrules derived from the policy of the healthcare organizationthat are intended to protect sensitive patient data. Includescapability to monitor user actions, detect potential non-compliance, and take action according to policy rules. Actionsmay include notifying the user, logging information in an auditlog, preventing an action, or protecting data used in an actionfor example using encryption.

More Info

Notes: Working well as intended.


ISO: 27002:2013 Section 18.1.3 Protection of Records



CIS: v6.1 CSC 13.9, CSC 13.4


Endpoint DLP Prevention Capability

69%

Absent

23%

Partial

8%

Present


Endpoint Data Loss Prevention (Prevention Mode) is relevant to the following breach types: - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Solid-state_drive
















6.21 Network Data Loss Prevention (Discovery Mode)Network based Data Loss Prevention ability to monitor (scanand analyze) network traffic in real time, detect and classifysensitive patient data, and discover unknown risks.

More Info

Notes: We don't currently have a network DLP appliance.



NIST: SP 800-53 Rev. 4 AU-13, 14, 16AU-14


CIS: v6.1 CSC 13.6

GDPR: Regulation 83 accidential loss of personal data

Network DLP Discovery Capability

65%

Absent

15%

Partial

19%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Network Data Loss Prevention (DiscoveryMode) capability.

Network Data Loss Prevention (Discovery Mode) is relevant to the following breach types: - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping

6.22 Anti-Theft: Remote Locate, Lock, WipeAbility for IT Administrators in healthcare organizations toremotely locate lost or stolen mobile client devices, lock them,or wipe them to remove sensitive patient data and therebyreduce risk of breach.

More Info

Notes: We have remote locate / lock / wipe only onsmartphones and tablets, not on laptops currently.


ISO: 27002:2013 Section 6.2 Mobile Devices andTeleworking

NIST: SP 800-53 Rev. 4 AC-7, AC-19


CIS: v6.1 CSC 3.4


Anti-Theft Capability

35%

Absent

33%

Partial

33%

Present


Anti-Theft: Remote Locate, Lock, Wipe is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Improper Disposal










https://en.wikipedia.org/wiki/Anti-theft_system










6.23 Multi-Factor Authentication with TimeoutAccess control with multiple factors: what you know (egusername / password), what you have (eg security hardwaretoken), or what you are (biometrics). Timeout functionalityautomatically locks access after a policy defined period ofinactivity, intended to reduce risk of an unauthorized accessand breach that may result from an unauthorized personaccessing an abandoned secure session.

More Info

Notes: We don't currently have MFA, but looking at Tap andGo prox cards.

! Recommended Action: 2017 : Add tap and go MFA withproximity cards to improve usability and security. See ActionPlan.

HIPAA: 45 CFR 164.312


NIST: SP 800-53 Rev. 4 IA-2, AC-2, AC-11, AC-12


CIS: v6.1 CSC 5.6, CSC 11.4, CSC 12.6, CSC 16.11


MFA with Timeout Capability

29%

Absent

54%

Partial

17%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Multi-Factor Authentication with Timeoutcapability.

Multi-Factor Authentication with Timeout is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Insider Snooping


https://en.wikipedia.org/wiki/Multi-factor_authentication








6.24 Secure Remote AdministrationAbility for IT Administrator in healthcare organization tosecurely and remotely administer client devices containingsensitive patient information. This can include diagnostics,remediation of issues, patching, updates eg anti-malwaresignatures, configurations, upgrades, and so forth.

More Info

Notes: We don't currently have vPro laptops with ActiveManagement Technology.

! Recommended Action: 2016 : Add ability to efficientlyadminister remote endpoints for maintenance, patching,updates and support. See Action Plan.



NIST: SP 800-53 Rev. 4 MA-4


CIS: v6.1 CSC 3.4


Secure Remote Administration Capability

10%

Absent

27%

Partial

63%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Secure Remote Administration capability.

Secure Remote Administration is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping


https://en.wikipedia.org/wiki/Remote_administration










6.25 Policy Based Encryption for Files and FoldersEncryption of specific files or folders based on policy ofthe healthcare organization, and classification of files, inorder to ensure only authorized access to files and folderscontaining sensitive patient data, and thereby reduce risk ofunauthorized access and mitigation of risk of breach.

More Info

Notes: X-Ray images are automatically encrypted per policy.Need to get this in place for other types of files.

HIPAA: 45 CFR 164.312


NIST: SP 800-53 Rev. 4 SC-28


CIS: v6.1 CSC 13.2, CSC 14.5


Policy Based Encryption Capability

85%

Absent

12%

Partial

4%

Present


Policy Based Encryption for Files and Folders is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal

6.26 Server / Database / Backup EncryptionEncryption of servers, databases running on servers orSAN's, and encryption of backup archives.

More Info

Notes: Server filesystem encrypted. Database full diskencryption in place. Backups encrypted before going ontotape.

HIPAA: 45 CFR 164.312


NIST: SP 800-53 Rev. 4 SC-28


CIS: v6.1 CSC 10.3, CSC 13.2, CSC 14.5


Server / Database / Backup Encryption Capability

40%

Absent

44%

Partial

15%

Present


Server / Database / Backup Encryption is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal
















6.27 Network SegmentationNetwork is segmented to protect critical assets. This caninclude use of guest network, medical devices network, orother segmentations to isolate vulnerabilities.

More Info

Notes: Currently have network segmented for Intranet, DMZ,Guest and Medical Devices.


ISO: 27002:2013 Section 13.1.3 Segregation in Networks

NIST: SP 800-53 Rev. 4 SC-7, SC-32


CIS: v6.1 CSC 14.1, CSC 12, CSC 15.9

GDPR: Regulation 49 resist unlawful or malicious actions

Network Segmentation Capability

4%

Absent

52%

Partial

44%

Present


Network Segmentation is relevant to the following breach types: - Cybercrime Hacking - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Ransomware

6.28 Network Intrusion Prevention SystemTechnology and processes to detect and prevent intrusionsthe healthcare organizations network.

More Info

Notes: Needs better monitoring.



NIST: SP 800-53 Rev. 4 SI-4, SC-7


CIS: v6.1 CSC 12, CSC 15.3


Network IPS Capability

29%

Absent

17%

Partial

54%

Present


Network Intrusion Prevention System is relevant to the following breach types: - Cybercrime Hacking - Ransomware


https://en.wikipedia.org/wiki/Network_segmentation








https://en.wikipedia.org/wiki/Intrusion_prevention_system








6.29 Business Associate AgreementsContractual agreements covering the security and privacy ofsensitive patient data with all third party sub-contractors ordata processors that work with sensitive patient information.

More Info

Notes: Most of our contractors have signed a BAA. Workingon getting others.

HIPAA: 45 CFR 164.308(b)(1)

ISO: 27002:2013 Section 13.2.4 Confidentiality or Non-Disclosure Agreements

NIST: SP 800-53 Rev. 4 SA-9


GDPR: Article 32 4 controller and processor ensurecompliance

Business Associate Agreements Capability

2%

Absent

21%

Partial

77%

Present


Star Healthcare is lagging the healthcare industry inimplementing the Business Associate Agreements capability.

Business Associate Agreements is relevant to the following breach types: - Business Associates

6.30 VirtualizationVirtualizing clients so that sensitive healthcare data existsonly on strongly managed and secured servers, and not onclients and mobile devices that are at higher risk of loss ortheft.

More Info

Notes: We have some VDI from zero client terminals, but westill have a significant portion of our endpoint PC's withoutVDI.


ISO: 27002:2013 Section 11.2.1 Equipment Siting andProtection

NIST: SP 800-53 Rev. 4 SC-2, SC-7, SI-14


CIS: v6.1 CSC 2.4


Virtualization Capability

12%

Absent

31%

Partial

58%

Present


Virtualization is relevant to the following breach types: - Loss or Theft of Mobile Device or Media


http://www.ehow.com/about_6304836_business-associate-agreement_.html








https://en.wikipedia.org/wiki/Virtualization









6.31 Server Solid State Drive (Encrypted)Solid state drive with encryption for protection of sensitivepatient data at rest on the drive.

More Info

Notes: We don't use any SSD's on the server at present.

HIPAA: 45 CFR 164.312


NIST: SP 800-53 Rev. 4 SC-28


CIS: v6.1 CSC 13.2, CSC 14.5


Server SSD (Encrypted) Capability

87%

Absent

8%

Partial

6%

Present


Server Solid State Drive (Encrypted) is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Improper Disposal

6.32 Network Data Loss Prevention (Prevention Mode)Network Data Loss Prevention ability to prevent non-compliance with the policy of the healthcare organizationregarding network traffic. For example if a healthcareorganization has a policy against sending patient informationattached to emails NDLP can detect and block such emailsand notify the sender to reduce risk of recurrence.

More Info

Notes: We don't currently have network DLP.





CIS: v6.1 CSC 13.6


Network DLP Prevention Capability

75%

Absent

15%

Partial

10%

Present


Network Data Loss Prevention (Prevention Mode) is relevant to the following breach types: - Cybercrime Hacking - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Solid-state_drive
















6.33 Database Activity MonitoringMonitoring of database activity in order to detect possibleintrusion, for example in a case where database administratorcredentials may have been compromised and used for covertunauthorized access to sensitive patient information in thedatabase.

More Info

Notes: We currently only have this on some of our databasescontaining patient information.


ISO: 27002:2013 Section 12.4 Logging and Monitoring

NIST: SP 800-53 Rev. 4 AC-23


CIS: v6.1 CSC 5.1


DB Activity Monitoring Capability

56%

Absent

31%

Partial

13%

Present


Database Activity Monitoring is relevant to the following breach types: - Cybercrime Hacking - Malicious Insiders or Fraud - Insider Snooping

6.34 Digital ForensicsAbility to conduct forensic analysis of IT infrastructure,often in the event of a suspected security incident, to detectunauthorized access to sensitive patient information andestablish whether breach occurred and if so characteristicssuch as timing and extent.

More Info

Notes: We contract an external organization for parts of this.

HIPAA: Incident Management - Forensics

ISO: 27002:2013 Section 16.1.7 Collection of Evidence

NIST: SP 800-53 Rev. 4 IR-7, 10

PCI DSS: v3.1 Sections 10.3 and A1.4

CIS: v6.1 CSC 17


Digital Forensics Capability

44%

Absent

19%

Partial

37%

Present


Digital Forensics is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal - Ransomware


https://en.wikipedia.org/wiki/Database_activity_monitoring









https://en.wikipedia.org/wiki/Digital_forensics

http://www.hhs.gov/ocio/securityprivacy/incidentmanagement/incidentresp.html






6.35 Security Information and Event ManagementSecurity Information and Event Management includes real-time analysis of logs and security alerts generated by networkhardware and applications.

More Info

Notes: We really need this to improve our detectioncapabilities.

! Recommended Action: 2017 : Implement SIEM for improveddetection of breaches to minimize business impact. SeeAction Plan.


ISO: 27002:2013 Section 12.4 Logging and Monitoring

NIST: SP 800-53 Rev. 4 SI-4


CIS: v6.1 CSC 6.6


SIEM Capability

56%

Absent

23%

Partial

21%

Present


Star Healthcare is lagging the healthcare industryin implementing the Security Information and EventManagement capability.

Security Information and Event Management is relevant to the following breach types: - Cybercrime Hacking - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Security_information_and_event_management









6.36 Threat IntelligenceAcquisition of threat intelligence information such as wheresuspicious activities or intrusions have occurred, the nature ofthe incidents, appropriate safeguards and actions to mitigate,and sharing this information across security infrastructurenear real time to improve defense and minimize recurrence /extent of future intrusions / breaches. Threat intelligencecan include reputational information, information acquiredthrough sandboxing and static or dynamic analysis of suspectexecutables, or behavioral analytics.

More Info

Notes: We get updates on new threats from our securityprovider. We really need the ability to automate update ofsecurity controls based on this feed though.



NIST: SP 800-53 Rev. 4 SI-4, SI-5, SC-7, SC-44


CIS: v6.1 CSC 8.5, CSC 12, CSC 16.10


Threat Intelligence Capability

50%

Absent

23%

Partial

27%

Present


Threat Intelligence is relevant to the following breach types: - Cybercrime Hacking - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Ransomware


https://en.wikipedia.org/wiki/Cyber_threat_intelligence










6.37 Multi-Factor Authentication with Walk-Away LockMulti-Factor Authentication including multiple factors from:what you know (eg username / password), what you have (egsecurity hardware token), and what you are (eg biometrics).Walk away lock is ability to automatically lock a securesession the moment a healthcare worker walks away from theendpoint device running that terminal. Intended to mitigaterisk of an unauthorized individual hijacking a secure sessionthat an authorized user established and has abandoned (yettimeout lock has not yet occurred).

More Info

Notes: We don't currently have MFA. Once we have MFA wewant to get this through Imprivata walk-away lock based onfacial recognition.

! Recommended Action: 2018 : Upgrade tap and go MFAto also include walk-away lock to minimize risk of sessionhijacking when clinicians leave. See Action Plan.

HIPAA: 45 CFR 164.312


NIST: SP 800-53 Rev. 4 IA-2, AC-2, AC-11, AC-12


CIS: v6.1 CSC 5.6, CSC 11.4, CSC 12.6, CSC 16.11


MFA with Walk-Away Lock Capability

73%

Absent

23%

Partial

4%

Present


Multi-Factor Authentication with Walk-Away Lock is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Malicious Insiders or Fraud - Insider Snooping


https://en.wikipedia.org/wiki/Multi-factor_authentication








6.38 Client Application WhitelistingAbility to control what applications run on a client deviceand block unauthorized applications from running. Typicallysignature based detection and enforcement. Includessecure processes for provisioning, managing, and updatingwhitelists.

More Info

Notes: We have this on some medical device machines. Weneed it on more.


ISO: 27002:2013 Section 12.2.1 Controls Against Malware

NIST: SP 800-53 Rev. 4 CM-7


CIS: v6.1 CSC 2.2


Client Application Whitelisting Capability

63%

Absent

27%

Partial

10%

Present


Client Application Whitelisting is relevant to the following breach types: - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Malicious Insiders or Fraud - Insider Snooping - Ransomware


http://itlaw.wikia.com/wiki/Application_whitelisting








6.39 Server Application WhitelistingAbility to control what applications run on servers and blockunauthorized applications from running. Typically signaturebased detection and enforcement. Includes secure processesfor provisioning, managing, and updating whitelists.

More Info

Notes: Some servers associated with medical devices havethis, but need it on all medical device servers.


ISO: 27002:2013 Section 12.2.1 Controls Against Malware

NIST: SP 800-53 Rev. 4 CM-7


CIS: v6.1 CSC 2.2


Server Application Whitelisting Capability

58%

Absent

31%

Partial

12%

Present


Server Application Whitelisting is relevant to the following breach types: - Cybercrime Hacking - Malicious Insiders or Fraud - Insider Snooping - Ransomware

6.40 De-Identification / AnonymizationThe ability to remove or mask personally identifiable fields insensitive patient information to enable use while minimizingrisk of breach.

More Info

Notes: We currently do this on data for research.

HIPAA: HHS Guidance

ISO: 27002:2013 Section 9.4.1 Information AccessRestriction

NIST: SP 800-53 Rev. 4 MP-6, DM-2, DM-3


GDPR: Regulation 26 anonymous information

De-Id, Anonymize Capability

37%

Absent

35%

Partial

29%

Present


De-Identification / Anonymization is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal


http://itlaw.wikia.com/wiki/Application_whitelisting








https://en.wikipedia.org/wiki/De-identification

http://www.hhs.gov/hipaa/for-professionals/privacy/special-topics/de-identification/index.html






6.41 TokenizationReplacing personally identifiable fields in sensitive patientrecords with opaque unique tokens and storing the mappingsfrom these tokens back to the real data values in a secureaccess controlled database.

More Info

Notes: We don't do this but could use it for areas of ournetwork that do payment processing and are subject to PCIDSS compliance.

HIPAA: HHS Guidance

ISO: 27002:2013 Section 9.4.1 Information AccessRestriction

NIST: SP 800-53 Rev. 4 MP-6, DM-2, DM-3


GDPR: Article 32 1a pseudonymisation of personal data

Tokenization Capability

79%

Absent

13%

Partial

8%

Present


Tokenization is relevant to the following breach types: - Cybercrime Hacking - Loss or Theft of Mobile Device or Media - Insider Accidents or Workarounds - Business Associates - Malicious Insiders or Fraud - Insider Snooping - Improper Disposal

6.42 Business Continuity and Disaster RecoveryPeople, process and technology to enable the recovery orcontinuation of vital technology infrastructure and systemsfollowing a natural or human-induced disaster or disruption.

More Info

Notes: Some core / critical systems still need to be added.

HIPAA: Security Rule - Protect Availability

ISO: 27002:2013 Section 11.1.4 Protecting Against Externaland Environmental Threats

NIST: SP 800-53 Rev. 4 CP-1 to 13


CIS: v6.1 CSC Governance Item #4: Business Continuity andDisaster Recovery


BC / DR Capability

15%

Absent

48%

Partial

37%

Present


Business Continuity and Disaster Recovery is relevant to the following breach types: - Cybercrime Hacking - Malicious Insiders or Fraud - Ransomware

Intel, and the Intel logo are trademarks of Intel Corporation in the United States and other countries. Other names and brands may be claimed as the property of others. Intel technologies'features and benefits depend on system configuration and may require enabled hardware, software or service activation. Performance varies depending on system configuration. Nocomputer system can be absolutely secure. Check with your system manufacturer or retailer or learn more at intel.com .


https://en.wikipedia.org/wiki/Tokenization_(data_security)

http://www.hhs.gov/hipaa/for-professionals/privacy/special-topics/de-identification/index.html






https://en.wikipedia.org/wiki/Business_continuity










http://intel.com

Documents

Health & Life Sciences Breach Security Assessment Reportsecurity based on this assessment may also help with compliance with privacy and security regulations, data protection laws,