Author: Bill

A document obtained by Computerworld from a reliable source indicates that Piedmont was presented with a list of 42 items that HHS officials wanted information on within 10 days. Specifically, Piedmont was asked to provide policies and procedures for:

1. Establishing and terminating users’ access to systems housing electronic patient health information (ePHI).
2. Emergency access to electronic information systems.
3. Inactive computer sessions (periods of inactivity).
4. Recording and examining activity in information systems that contain or use ePHI.
5. Risk assessments and analyses of relevant information systems that house or process ePHI data.
6. Employee violations (sanctions).
7. Electronically transmitting ePHI.
8. Preventing, detecting, containing and correcting security violations (incident reports).
9. Regularly reviewing records of information system activity, such as audit logs, access reports and security incident tracking reports.
10. Creating, documenting and reviewing exception reports or logs. Please provide a list of examples of security violation logging and monitoring.
11. Monitoring systems and the network, including a listing of all network perimeter devices, i.e. firewalls and routers.
12. Physical access to electronic information systems and the facility in which they are housed.
13. Establishing security access controls; (what types of security access controls are currently implemented or installed in hospitals’ databases that house ePHI data?).
14. Remote access activity i.e. network infrastructure, platform, access servers, authentication, and encryption software.
15. Internet usage.
16. Wireless security (transmission and usage).
17. Firewalls, routers and switches.
18. Maintenance and repairs of hardware, walls, doors, and locks in sensitive areas.
19. Terminating an electronic session and encrypting and decrypting ePHI.
20. Transmitting ePHI.
21. Password and server configurations.
22. Anti-virus software.
23. Network remote access.
24. Computer patch management.

HHS also had a slew of other requests:

1. Please provide a list of all information systems that house ePHI data, as well as network diagrams, including all hardware and software that are used to collect, store, process or transmit ePHI.
2. Please provide a list of terminated employees.
3. Please provide a list of all new hires.
4. Please provide a list of encryption mechanisms use for ePHI.
5. Please provide a list of authentication methods used to identify users authorized to access ePHI.
6. Please provide a list of outsourced individuals and contractors with access to ePHI data, if applicable. Please include a copy of the contract for these individuals.
7. Please provide a list of transmission methods used to transmit ePHI over an electronic communications network.
8. Please provide organizational charts that include names and titles for the management information system and information system security departments.
9. Please provide entity wide security program plans (e.g System Security Plan).
10. Please provide a list of all users with access to ePHI data. Please identify each user’s access rights and privileges.
11. Please provide a list of systems administrators, backup operators and users.
12. Please include a list of antivirus servers, installed, including their versions.
13. Please provide a list of software used to manage and control access to the Internet.
14. Please provide the antivirus software used for desktop and other devices, including their versions.
15. Please provide a list of users with remote access capabilities.
16. Please provide a list of database security requirements and settings.
17. Please provide a list of all Primary Domain Controllers (PDC) and servers (including Unix, Apple, Linux and Windows). Please identify whether these servers are used for processing, maintaining, updating, and sorting ePHI.
18. Please provide a list of authentication approaches used to verify a person has been authorized for specific access privileges to information and information systems.

Source: HIPAA audit: The 42 questions HHS might ask

Jeff of the HIPAA Blog talks more about the questions here and that the questions are pertinent to all firms with information security requirements.

From Susan Bradley’s blog(aka SBS Diva) comes…

I have rec’d an email from one of my clients saying that he needs to recover email from 2005 in regards to a lawsuit. There is barely a backup plan in place. It holds backups of everything for a few days only, written only to an external hard drive. I don’t think our users have any idea what pst files are. Is there anything inherent to SBS2003 that would help? Is there any products you recommend for the future?

There was never any requirement for archiving purposes in the past so no company policy was forwarded to me. So I don’t think there is anyway that I am liable.

First off you are not. Secondly, you are only required to do your best efforts to recover that email. In a typical SBS network here’s the forensic places that email will land.

First off when email comes into the server (assuming you’ve set it up so that the SBS holds the email and it grabs the email) and dumps it into the Exchange store. When your end users read their email and hit the delete key in their personal email boxes, it doesn’t really “delete” the email but rather it merely moves it to the deleted email folder. Unless you set a rule to delete that email, chances are, that email of 2005 might be there. If someone has deleted the email, then it sits on the server in the mail store for 30 days before it truly and utterly gets deleted.

If your clients use the default SBS mailbox setup, they don’t have pst’s but rather ost’s that the SBS box sets up automagically as part of it’s Cached mode setup. Outlook has a rule set up (I’ve forgotten when it kicks in) of prompting you every now and then “do you want to archive your email”. Once again, it won’t truly delete the email, but will move it to an archive folder.

You might find it easier to get onto their ‘exact’ profile to see the Outlook folder structures they have on the local system as well as the files on the server.

But last but not least, you are only required to make a reasonable effort to recover this. If your policy is to NOT store emails, then you can’t be liable if you can’t find them. Where you get into issues (as in Enron/Arthur Anderson) is when you have a policy regarding email (or any correspondence for that matter) and don’t follow it. If you say you are going to delete after 30 days and don’t, or retain all email regarding X client and don’t, that’s when it’s an issue.

Remember that the new Federal Rules of Evidence kick in when you get a lawsuit in Federal Court. At THAT time you need to ensure that all electronic documentation is maintained.

But need to have a long term need to archive? Check out Message Journaling (native), check out GFI (third party) http://www.gfi.com/mailarchiver/

Computers do add some nuances to rules of evidence and you can see in these articles – http://searchsecurity.techtarget.com/tip/0,289483,sid14_gci1253827,00.html and http://www.usdoj.gov/criminal/cybercrime/usamarch2001_4.htm

Link to Susan Bradley’s “Need to archive” article
[tags]security[/tags]

Link to Don’t Panic, But New Discovery Of Electronically Stored Information In Litigation Rules Now Apply :: WRAL.com

Today I read a post over on Susan Bradley’s blog about the need to archive and I remembered this article. This article is a couple of months old and was written by lawyers practicing in the ESI area. It provides a nice overview of the discovery rules and the problems the lawyers are facing. Once you have a grasp of the discovery rules, it is much easier to recommend the policies and tools that will help you and your clients create a ESI plan/policy that will reduce the impact of discovery requests in the future. The final step is for your clients to run the ESI plan by their lawyer.