Use Case ePHI and HIPAA

Summary:

The article outlines specific requirements under HIPAA's Security Rule for covered entities to implement various controls aimed at protecting electronic protected health information (ePHI) from unauthorized access and ensuring compliance with implementation specifications. These include audit controls, log-in monitoring, protection against malicious software, review of system activity, and response to security incidents. The document also emphasizes the need for risk analysis under HIPAA's Security Standards, focusing on protecting EPHI through a multi-faceted approach that includes technological mechanisms, procedural reviews, and active responses to detected threats or vulnerabilities.

Details:

The article outlines several requirements under the HIPAA Security Rule for covered entities to implement various controls aimed at protecting electronic protected health information (ePHI) from unauthorized access and ensuring compliance with specific implementation specifications. These include implementing audit controls, log-in monitoring, protection against malicious software, reviewing system activity, and responding to security incidents. 1. Audit Controls: Covered entities must use hardware, software, or procedural mechanisms to record and examine activity in systems containing ePHI (§164.312(b)). This includes creating rules to detect failed attempts by unauthorized users to access another user's account and for detecting failed attempts to connect as an administrative database user. 2. Information System Activity Review: Covered entities must implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports (§164.308(a)(1)(ii)(D)). This involves creating a report that displays all login activities from information resources. 3. Protection From Malicious Software: Procedures must be in place to guard against, detect, and report malicious software (§164.308(a)(5)(ii)(B)). The article mentions the implementation of specific rules from stock ArcSight content for detecting potential SQL Slammer outbreaks and brute force login attempts. 4. Log-In Monitoring: Covered entities must implement procedures to monitor log-in attempts and report discrepancies (§164.308(a)(5)(ii)(C)). This includes the implementation of a rule to detect repeated failed login attempts, referred to as a Brute Force Login rule, also from stock ArcSight content. 5. Response And Reporting: Covered entities must identify and respond to suspected or known security incidents; mitigate harmful effects where possible (§164.308(a)(6)(ii)). All implemented correlation rules help in identifying potential security incidents, and notifications are created to assist in response efforts for potential issues. In summary, these requirements ensure comprehensive protection of electronic health information through a multi-faceted approach that includes technological mechanisms, procedural reviews, and active responses to detected threats or vulnerabilities. The document outlines the requirements for risk analysis under HIPAA's Security Standards, focusing on ensuring the confidentiality, integrity, and availability of electronic protected health information (EPHI). It states that a covered entity must conduct an accurate and thorough assessment of potential risks to EPHI. This involves creating an inventory of critical information assets to enhance rule and report capabilities. The general requirements under HIPAA's Security Standards mandate the protection of all EPHI, including its creation, receipt, maintenance, or transmission. To achieve this, the entity must implement measures such as monitoring network router and switch configurations for changes, detecting potential breaches with rules from ArcSight content that trigger on successful attacks or attempted breaches related to confidentiality and integrity, and adjusting Windows user permissions through specific rule implementation. The document also highlights the creation of reports to analyze trends in security events and detect anomalous activity which may indicate malicious actions. This includes monitoring the number of events grouped by affected asset and device type, as well as implementing a rule to identify changes in Windows user permissions when objects are moved into administrator group containers.

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