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April 11, 2005 1
Information Security Awareness Employee Training
XYZ Medical Center
Gene Hubbard, FISO
April 11, 2005 2
Purpose of this training
The objective of this training is to prepare you to comply with the HIPAA Security Rule and other government regulations.
Our goal is to ensure the confidentiality, integrity, and availability of all electronic protected health information (EPHI) that our facility creates, receives, maintains, or transmits.
April 11, 2005 3
Why Does XYZ Need Information Security?
Information security helps us:
Protect the availability and integrity of clinical and patient
administration systems.
Protect our patients’ confidentiality.
Maintain our facility’s reputation.
Comply with federal and state information security laws,
including the HIPAA Security Rule.
The true cost of ignoring information security is an impact
to patient safety and our quality of patient care!
April 11, 2005 4
Doing Your Part
As an employee, you play a crucial role to protect our patients and our company. You are responsible to:
Protect your passwords.
Create quality passwords.
Safely use email and the Internet to help protect our systems
from malicious software.
Recognize signs of someone attempting to illegally access
our systems.
Get help or more information
about Information Security,
as needed.
April 11, 2005 5
Keeping Passwords Private
To protect your passwords…
Keep your passwords to yourself.
Don’t allow others to give you their passwords, no matter
the circumstance.
Never post passwords around your workstation.
If you suspect anyone has learned your password, change
it. Call the help desk (4357 or H-E-L-P on the keypad) or
your Facility Information Security Official (FISO) for
assistance.
April 11, 2005 6
The Case of the Busy Doctor…
You are a nurse at the Emergency Department nursing station, and a doctor approaches you at the beginning of his rounds. The doctor needs test results for Mrs. Jones. You do not have access to Mrs. Jones’ records, so the doctor wants to give you his user ID and password to print Mrs. Jones’ test results.
Where else could this happen in your facility?
Anywhere a computer is present.
What should you, the nurse, do?
Suggest that the doctor use the computer in the dictation room right next to the nurses’ station (or any common workstation).
What are the possible consequences for a nurse who signs onto a system using a doctor’s user ID and password? For the doctor?
They are both open to sanctions per Company policies.
April 11, 2005 7
Creating Quality Passwords
It can be surprisingly easy for hackers to guess your password!
Create a hard to guess password and never share it.
If the application allows, use a combination of special characters (like @, #, !), numbers, and upper and lower case letters.
Never use words found in a dictionary or proper names.
Do not use social security numbers, names of family members, pet names, or birthdays.
If the application allows, create passwords that contain at least 7 characters.
Passphrases make great, easy to remember, hard to guess passwords!
April 11, 2005 8
Protecting Against Email Viruses
Only open email that you need to perform your job.
Don’t open email attachments in strange or unexpected emails.
Transmit confidential information to appropriate individuals outside the company using only approved, secure methods. (Contact your FISO if you need additional information.)
Only use company approved software – when in doubt, ask!
Only use company supplied diskettes or CDs.
April 11, 2005 9
The Case of the Mysterious Email Attachment…
It’s Christmas time. Mary, an administrative assistant at a facility, receives an email with an attachment from Bill Brown. She does not know Bill, but his email address shows that he works for a company that has a business relationship with her department. The email subject line reads “Dancing Santa Screensaver.”
What should Mary do with the email? Delete it without opening. The subject line indicates it isn’t work related anyway, so there is no reason to take the risk of getting a computer virus.
If Mary received an email like this from a friend, what should she do? Again, delete it without opening. The risk of receiving a computer virus from a friend is just as great.
If you suspect that you have opened an email that contains a virus, what should you do? Notify your Facility Information Security Official (FISO), or other member of your facility’s IT staff immediately.
April 11, 2005 10
Safe Internet Use
Only access websites that you need to perform your job.
Be cautious about entering any company information on an Internet site.
Do not access Internet email accounts (AOL, Hotmail, etc.) through the XYZ network or from XYZ computers.
When on the Internet, use passwords and IDs that are different than your XYZ ID and password.
Never download screensavers, games, or other executable files (such as files ending in .exe, .vbs, or .com) from the Internet or any other outside source.
April 11, 2005 11
The Case of the Downloaded Screensaver…
John finds an Internet site with interesting healthcare-related screensavers. He downloads one that relates to his job.
What can happen as a result of John downloading the screensaver?
What looked like a simple screensaver may actually be a virus. John’s computer, and the entire HCA network, could be exposed. Clinical systems in John’s facility, as well as other facilities, could be shut down in order to contain the virus.
How can John ensure that the screensaver is safe to download?
He can’t. The only way for John to make sure he doesn’t download malicious software is to only use company approved software, including screensavers.
If you suspect that you have downloaded a virus from the Internet, what should you do? Notify your Facility Information Security Official (FISO), Hospital Director of Information Systems (HDIS), or other member of your facility’s IT staff immediately.
April 11, 2005 12
Social Engineering: Recognizing Con Artists
What is a Social Engineer?
“Social Engineers” are con artists who attempt to gain access to confidential information by deceiving you.
They are good at what they do, and they know how to make you believe them.
They sound friendly and trustworthy, and sometimes will appear to be doing you a favor.
Possible Warning Signs
Is someone asking you "out of the blue" questions about patient information, system names, or software?
Has someone asked you for your password(s), or asked you to change your password(s) for them?
Did you initiate the call/email/office visit, or did they?
April 11, 2005 13
Social Engineering: Outwitting Them!
Never give out your password over the phone. Even our own technical support can help you without knowing your password!
If you didn’t initiate the contact, offer to call them back through our facility’s help desk system. If they claim to be part of an authorized technical support team, you should be able to call them through normal channels.
Be aware of your surroundings. If you see someone you are not familiar with, politely ask their identity and ask if you can help them.
Don't be afraid to say "No." If anyone asks for information such as your user ID or password, or asks you to perform a task that goes against any Company policy, just say no.
Report it. If you think you have witnessed an attempted or successful security breach, report the incident to the FISO immediately.
April 11, 2005 14
The Case of the Helpful Computer Technician…
You receive a call from Chris, who says he works for your HDIS. According to Chris, our facility has been exposed to a computer virus and he thinks your computer may be infected. To be sure, he needs your user ID and password. He says the situation is critical. If he can’t find the infected computers quickly, your facility’s network, including clinical systems, will have to be shut down to contain the virus.
Could a call like this ever be legitimate? Should you ever go along with a request for your user ID or password? No! Legitimate computer technicians can always help you without having your user ID or password. Always insist that they do so, even if you know them or recognize their name.
Why would it be easy to fall for something like this?Chris, like most social engineers, sounds legitimate. He appeals to your sense of duty by insinuating that your help could prevent a disruption to patient care. He also adds a sense of urgency, which further pressures you to supply information you may not otherwise share.
If you receive a call such as this, what should you do?Don’t give out any information. Notify your FISO immediately.
April 11, 2005 15
Media Controls
Protecting our systems only works if we also protect media.
Lock up portable storage and hand-held devices when not
in use.
When transferring Electronic Protected Health Information
(EPHI) to media such as USB drives, diskettes, and
removable drives, use passwords, encrypt the data, and
physically protect the media.
Keep sensitive and confidential information in a locked
cabinet or drawer when not in use.
April 11, 2005 16
What Else Can We Do? Be Aware!
Exit applications as soon as you complete your work.
Turn on your password protected screensaver when you
walk away from your workstation.
If you are the only one who should use your computer,
notify your FISO if someone else’s user ID appears on the
login screen.
If you are locked out of a system, be sure to report it to
your FISO.
April 11, 2005 17
What Else Can We Do? Be Aware!(Continued)
In addition…
Read and follow the guidelines contained in the Information Security Guide.
Report any potential or suspected security breaches in your work area.
Use common sense!
Ask questions.
If you make a mistake, be the one to report it.
April 11, 2005 18
Auditing!
Required by HCA, HIPAA and Sarbanes Oxley (SOX)
Access and use of all systems are monitored
Questionable activity and obvious violations are investigated.
All events reviewed by the Privacy/Security Committee composed of Ethics and Compliance Officer, Facility Privacy Officer, Facility Information Security Officer, Human Resources Director, or with the individual’s Director
If you make a mistake, be the one to report it.
April 11, 2005 19
Sanctions for violations
Level 1 – Accidental and/or lack of education. Retraining, coaching.
Level 2 – Repeated Level 1 violations. Oral warning, retraining and re-evaluation, discussion of policy requirements.
Level 3 – Purposeful violation or repeated level 2 violation. Written warning, retraining, and discussion of policy requirements.
Level 4 – Purposeful violation or repeated level 3 violation, associated potential for patient harm. Termination, revocation of Medical Staff privileges, termination of contract.
April 11, 2005 20
Examples of violations
Accessing your own or a family members record. (Level 3).
Accessing patient information (PHI) without a legitimate need to do so. (Level 3).
Using another Meditech user’s username and password to access Meditech. (Level 3) .
Sharing your username and password with any other person. (Level 3).
Improper disposal of PHI. (Level 1)
For more examples please refer to the Market Sanctions for Privacy, Security, and Appropriate Access Violations Policy available on the company’s Intranet
April 11, 2005 21
Question and Answer
April 11, 2005 22
In Closing
Over the past few years, we have moved rapidly into a very different world. More than ever before, we need to protect information systems.
Information security is essential to our business. You have an essential role in our success!
If you have any additional questions or concerns, contact our FISO or another member of our facility’s IT staff.
April 11, 2005 23
Additional Reference Material
You should each have a pocket sized copy of our information Security Guide. This is for your
reference.
April 11, 2005 24
What if…
What if it was your bank and your financial information at stake?
What if your bank’s employees…
Shared passwords that could access your bank account?
Posted passwords in plain site?
Jeopardized your account by opening unnecessary email attachments and accessing non-work related websites?
Let unescorted strangers wander through their work area without anyone asking questions?
Gave information over the phone to people they had never met that allowed strangers to access your account?
The confidentiality, integrity and availability of protected health information is invaluable to our patients!
April 11, 2005 25
It Would Never Happen Here…Impacts of viruses and worms on operations
Patient safety was impacted at one facility when a worm infected and severely impacted the operation of 50 eMAR workstations due to password issues.
Clinical operations were affected throughout the company when SQLSlammer brought down XYZ’s core network for over 12 hours.
MSBlaster worm cost over $1,500,000 and 23,000 man hours of remediation effort (11.5 man years) in the first 4 weeks.
Public knowledge of a significant security incident devalues a company’s stock by an average of 5.5% within the first 3 days. For XYZ, this represents a loss of over $1.09 billion in shareholder value.
April 11, 2005 26
Appropriate Access: What Should We See?
Treat all information as if it were about you or your family.
Only access those systems you are officially authorized to access.
Only access information you need to do your job.
Protect all patient data, such as personal information, social security numbers, and medical data.
Only share sensitive and confidential information with others who have a "need to know."
Do not send protected health information outside our network boundaries unless using an approved means of protection.
April 11, 2005 27
Creating Passphrases
Think of a phrase that is unique and familiar to you, easy to
remember, but not easy to guess.
Use the first letter of each word to create a passphrase.
Example Passphrase
All good cows like to eat green grass.
Take the first letter of each word.
Use the number “2” instead of the letter “t” for “to.”
Your passphrase becomes “Agcl2egG”
This is only an example. Do not use this as a real password!
April 11, 2005 28
Passwords and User IDs: Additional Protection
If an application doesn’t automatically enforce it, remember to:
• Change your password every 180 days.
• Don’t use the same password more than once in 12-month period.
• Never use a generic or “shared” account to access applications that contain sensitive data, such as electronic protected health information (EPHI).
April 11, 2005 29
Best Practices for Working From Home
When using your home computer for work purposes:
• Install anti-virus software on your home PC.
• Set up the anti-virus software so that every update will automatically be applied to your computer.
• Set up an automatic update of the Windows operating system using Windows Update so that every Microsoft update will automatically be applied to the home computer.
• Don’t trade files between your work computer and home system.
• When in doubt, be safe! If you are unsure how to safely use your home computer, contact your FISO for more information.
April 11, 2005 30
Protecting Laptops and PDAs
Use lockdown cables to secure your laptop at your workstation.
Lock up your PDA when it is not in use.
When traveling with a PDA or laptop:
Never leave it unattended, especially in public areas such as airports.
Never check it as baggage.
If your PDA or laptop is stolen, report it immediately to your FISO.
April 11, 2005 31
HIPAA Security Rule
ConfidentialityData or information must not be available or disclosed to unauthorized persons.
IntegrityData or information cannot be altered or destroyed in an unauthorized manner.
AvailabilityData or information is accessible and usable upon demand by an authorized person.
According to the HIPAA Security Rule, our facility must take specific measures to protect the Confidentiality, Integrity and Availability of Electronic Protected Health Information (EPHI).
