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The University of Nebraska Medical Center (UNMC) is an institution that was built back in the 19th century. UNMC’s mission is to improve the health of Nebraska through premier educational programs, innovative research, the highest quality patient care, and outreach to underserved populations (UNMC, 2004). As an institution with key interest to privacy of its students, staff and subordinate staff, UNMC has adopted various policy guidelines to ensure information security system. The Information Security Management Plan (ISMP) describes its safeguards to protect confidential information. These safeguards are meant among another reason to:
Ensure the confidentiality of data
Ensure the integrity of data
Ensure the availability of data
Protect against anticipated threats or hazards to the security or integrity of the information UNMC has adopted information security industry best practices to implement its information security system (UNMC, 2014). They have become so effective that during 2011, a Hitrust Gap assessment was performed, and no significant gaps were found within its security program. The worksheet below outlines how these programs have been rolled out by different offices in the university.
Worksheet: Information Security Program Survey
Security Area Responsible Party / Office of Primary Responsibility Known Vulnerabilities / Risks Countermeasures / Risk Mitigation Strategy Acquisition (systems/services) Information Security Office Breach of the confidentiality clause All service providers must undergo an evaluation process to verify they are qualified. Contracts have a confidentiality clause whose breach terminates the contract. Asset management System Administrator Poor asset management Proper policies and procedure in place to ensure effective asset management. Evaluation to ascertain the qualifications of asset managers. Audit and accountability Information Security Office Dishonest employees disclosing confidential information to third parties Every application contains a log that must be maintained to meet regulatory requirement. There is Information security Incident Response plan to handle any notable strange events. Authentication and authorization System Administrator Covered data may be transferred to third parties without authorization Employees are provided with user name and password to access the data.
Employees are trained on developing a secure password. There are control policies in place governing access to this information. Business continuity Information Security Office Non-coordination and miscommunication between employees All employees are supposed to keep contact information of co-workers and supervisors to seek for help in case of any emergency. Compliance management Compliance Officer the Information Security Officer Employees failure to comply with the set guidelines, policies and procedure There is a compliance form that is filled before a major project is undertaken by the enterprise. The form is to ensure that no new risk is introduced to the enterprise. Configuration control System Administrator Compromised system security Every configuration must have a password. Each password must have at least ten characters.
The password must be encrypted at all times. Data System Administrator Data may be intercepted during transmission Database with security keys is available to authorized employees only. Access to classified data is allowed to limited employees. Information security plan ensures security of covered data. Hardware System Administrator Destruction of hardware in disaster Only employees with technical know-how of operating hardware are allowed to use them. The hardware are encrypted for security purposes. Hardware backup system. Identity management Information Security Office Unauthorized covered data and information transfer through third parties Identity Management Program (IDM) outlines procedure for issuing credentials based on the NIST guidance. Checks are done on employees prior to their employment.
Incident management Command Centre
Incident Response Team Physical loss of data in a disaster An Incident Reporting and Response Plan is in place to report and respond to any identified risk. Availability of a well-trained incident response team. Command Centre is established to manage emergency. Maintenance procedures Change Advisory Board (CAB) Existing patches within the security system A release process is in place to ensure that the changes do not affect non-primary system. Patching policies for workstations to ensure security. Media protection and destruction Information Security Office Unauthorized access covered data as well as information Data storage policies define how data stored in the media is to be protected. Data is only stored in a secured data centre or encrypted medium. Network System Administrator Unauthorized access to the network Network traffic is controlled by Cisco enterprise-class firewall where inbound connects are only allowed to DMZ.
Internal trusted network is provided via an encrypted VPN tunnel. Technical perimeter is established to bar direct access from the internet to the Internal Trusted Area. Planning Information Security Office Poor planning that compromise management of the security system Contingency plan is in place to handle any eventuality. Employees are encouraged to store data on network file servers for backup. All backups are surely stored and marked for easy identification during emergencies. Personnel System Administrator Loss of data integrity Employees are only employed after exhibiting minimum security requirement. Information Security Addendum are to be signed for confidentiality purposes. An insider who ensures that all legal requirements are followed before access is granted must accompany outsiders accessing information. Physical environment System Administrator Physical safety of the environment may be compromised through attacks and burglary No unauthorized personal is allowed within the data centre premises. The data centers are controlled by keycard access.
Policy Information Security Plan Coordinator
Policies may be misinterpreted by the employee The University’s security policy is enshrined in the Privacy, Confidentiality and Security of Patient Proprietary Information Policy and the Computer Use and Electronic Information Security Policy. The two policies require that authorized people can only access this information. The policies are reviewed every two years to make them in tandem with the prevailing circumstances. Operations The Information Security Officer and the Infrastructure Team Failure for operations to comply with the system security policy An operation must fill a compliance Checklist or a Security Risk Assessment form for review to verify that no new risk is introduced to the enterprise.
Outsourcing System Administrator Unauthorized disclosure of security information by third parties Outsourced vendors must comply with UNMC Policy No. 8009, Contract Policy. Vendors accessing classified student information must sign the GLB Act contract addendum. Risk assessments Information Custodian Poor method of risk assessment that may downplay the actual impact of a risk Security assessment I conducted annually. All applications must meet the organizations security policies and procedure. Software System Administrator Software may be infected with a virus Software should not be installed unless the user trusts it. Vendor update and patches must be installed unless directed otherwise.
Software license must be retained to get technical assistance. Training System Administrators and Information Custodians Misuse of security system Loss of data integrity Employees are trained on information security system before they are employed. System administrators and information custodians are annually trained on Specific Information Security Policy and Procedure.
UNMC. (March 2014) Strategic Plan 2010-2013. Retrieved from http://www.unmc.edu/wwwdocs/strategic-plan_06-10_v3-brochure1.pdf United States Government Accountability Office. (February 2010). ELECTRONIC PERSONAL HEALTH INFORMATION EXCHANGE: Health Care Entities’ Reported Disclosure Practices and Effects on Quality of Care. Retrieved from http://www.gao.gov/new.items/d10361.pdf UNMC. (February 9, 2004). Information Security Plan. Retrieved from http://www.unmc.edu/its/docs/UNMCInformationSecurityPlan-Sept2010.pdf