Introduction
biospatial, Inc. (“biospatial”) is committed to ensuring the confidentiality, privacy, integrity, and availability of all electronic protected health information (ePHI) it receives, maintains, processes and/or transmits on behalf of its Customers. As stewards of our Customers' data, biospatial strives to maintain compliance, proactively address information security, mitigate risk for its Customers, and ensure known breaches are completely and effectively communicated in a timely manner. The following documents address core policies used by biospatial to maintain compliance and ensure the proper protections of infrastructure used to store, process, and transmit ePHI for biospatial Customers.
biospatial provides data and analytics within a secure and compliant cloud-based environment and architecture. These hosted services fall into the broad category of Data as a Service (DaaS) and will be cited throughout polices as Customers inherit different policies, procedures, and obligations from biospatial.
Note: These policies were adapted from work by Datica Health, Inc. Refer to the linked website for additional copyright information.
Policy Management Policy
biospatial implements policies and procedures to maintain compliance and integrity of data. The Security Officer and Privacy Officer are responsible for maintaining policies and procedures and assuring all biospatial workforce members, business associates, customers, and partners are adherent to all applicable policies. Previous versions of policies are retained to ensure ease of finding policies at specific historic dates in time.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 12.c - Developing and Implementing Continuity Plans Including Information Security
Applicable Standards from the HIPAA Security Rule
- 164.316(a) - Policies and Procedures
- 164.316(b)(1)(i) - Documentation
Maintenance of Policies
- All policies are stored and up to date to maintain biospatial compliance with HIPAA/HITECH, SOC2, and other relevant standards. Updates and version control are performed in a manner similar to source code control.
- Policy update requests can be made by any workforce member at any time. Furthermore, all policies are reviewed annually by both the Security and Privacy Officer to ensure they are accurate and up-to-date.
- biospatial employees may request changes to policies using the following process:
- The biospatial employee initiates a policy change request by creating an Issue in the Redmine Compliance Review Activity (CRA) project. The change request may optionally include a Git pull request from a separate branch or repository containing the desired changes.
- The Security Officer or the Privacy Officer is assigned to review the policy change request.
- Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
- If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
- If the policy change requires technical modifications to production systems, those changes are carried out by authorized personnel.
- All policies are made accessible to all biospatial workforce members. The current master policies are
published at https://policies.biospatial.io.
- The Security Officer communicates policy changes to all employees via Redmine and email. These emails include a high-level description of the policy change using terminology appropriate for the target audience.
- All policies, and associated documentation, are retained for 6 years from the date of its creation or
the date when it last was in effect, whichever is later
- Version history of all biospatial policies is performed via Git.
- Backup storage of all policies is performed via Git.
- The policies and information security policies are reviewed and audited annually, or after significant
changes occur to biospatial's organizational environment. Issues that come up as part of this
process are reviewed by biospatial management to ensure all risks and potential gaps are mitigated
and/or fully addressed. The process for reviewing polices is outlined below:
- The Security Officer initiates the policy review by creating an Issue in the Redmine Compliance Review Activity (CRA) project.
- The Security Officer or the Privacy Officer is assigned to review the current biospatial policies (https://policies.biospatial.io).
- If changes are made, the above process is used. All changes are documented in the Issue.
- Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
- If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
- Policy review is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.
- The policy version number is updated whenever policies are modified such that the meaning or intent of the policy language changes. Minor textual changes for clarity, formatting, or repair of broken links, do not require version number changes. Policy version changes, or lack thereof, are, like all policy changes, subject to review and approval in accordance with the policy change process.
Additional documentation related to maintenance of policies is outlined in Security Officer.
Risk Management Policy
This policy establishes the scope, objectives, and procedures of biospatial's information security risk management process. The risk management process is intended to support and protect the organization and its ability to fulfill its mission.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 03.a - Risk Management Program Development
- 03.b - Performing Risk Assessments
- 03.c - Risk Mitigation
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(1)(ii)(A) - HIPAA Security Rule Risk Analysis
- 164.308(a)(1)(ii)(B) - HIPAA Security Rule Risk Management
- 164.308(a)(8) - HIPAA Security Rule Evaluation
Risk Management Policies
- It is the policy of biospatial to conduct thorough and timely risk assessments of the potential threats and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI) (and other confidential and proprietary electronic information) it stores, transmits, and/or processes for its Customers and to develop strategies to efficiently and effectively mitigate the risks identified in the assessment process as an integral part of the biospatial's information security program.
- Risk analysis and risk management are recognized as important components of biospatial's corporate
compliance program and information security program in accordance with the Risk Analysis and Risk
Management implementation specifications within the Security Management standard and the evaluation
standards set forth in the HIPAA Security Rule, 45 CFR 164.308(a)(1)(ii)(A), 164.308(a)(1)(ii)(B),
164.308(a)(1)(i), and 164.308(a)(8).
- Risk assessments are done throughout product life cycles:
- Before the integration of new system technologies and before changes are made to biospatial
security safeguards; and
- These changes do not include routine updates to existing systems, deployments of new systems created based on previously configured systems, deployments of new Customers, or new code developed for operations and management of the biospatial platform.
- While making changes to biospatial physical equipment and facilities that introduce new, untested configurations.
- biospatial performs periodic technical and non-technical assessments of the security rule requirements as well as in response to environmental or operational changes affecting the security of ePHI.
- biospatial implements security measures sufficient to reduce risks and vulnerabilities to a reasonable
and appropriate level to:
- Ensure the confidentiality, integrity, and availability of all ePHI biospatial receives, maintains, processes, and/or transmits for its Customers;
- Protect against any reasonably anticipated threats or hazards to the security or integrity of Customer ePHI;
- Protect against any reasonably anticipated uses or disclosures of Customer ePHI that are not permitted or required; and
- Ensure compliance by all workforce members.
- Any risk remaining (residual) after other risk controls have been applied, requires sign off by the senior management and biospatial's Security Officer.
- All biospatial workforce members are expected to fully cooperate with all persons charged with doing risk management work, including contractors and audit personnel. Any workforce member that violates this policy will be subject to disciplinary action based on the severity of the violation, as outlined in the biospatial Roles Policy.
- The implementation, execution, and maintenance of the information security risk analysis and risk management process is the responsibility of biospatial's Security Officer (or other designated employee), and the Risk Management Team, which includes the Security Officer, the Chief Technology Officer and others they may designate.
- All risk management efforts, including decisions made on what controls to put in place as well as those to not put into place, are documented and the documentation is maintained for six years.
- The details of the Risk Management Process, including risk assessment, discovery, and mitigation, are
outlined in detail below. The process is tracked, measured, and monitored using the following
procedures:
- The Security Officer or the Privacy Officer initiates the Risk Management Procedures by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
- The Security Officer or the Privacy Officer is assigned to carry out the Risk Management Procedures.
- All findings are documented in an approved spreadsheet that is linked to the Issue.
- Once the Risk Management Procedures are complete, along with corresponding documentation, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
- If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
- The Risk Management Procedure is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.
Risk Management Procedures
Risk Assessment
The intent of completing a risk assessment is to determine potential threats and vulnerabilities and the likelihood and impact should they occur. The output of this process helps to identify appropriate controls for reducing or eliminating risk.
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Step 1. System Characterization
- The first step in assessing risk is to define the scope of the effort. To do this, identify where ePHI is received, maintained, processed, or transmitted. Using information-gathering techniques, the biospatial platform boundaries are identified.
- Output - Characterization of the biospatial platform system assessed, a good picture of the platform environment, and delineation of platform boundaries.
-
Step 2. Threat Identification
- Potential threats (the potential for threat-sources to successfully exercise a particular vulnerability) are identified and documented. All potential threat-sources through the review of historical incidents and data from intelligence agencies, the government, etc., to help generate a list of potential threats.
- Output - A threat list containing a list of threat-sources that could exploit platform vulnerabilities.
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Step 3. Vulnerability Identification
- Develop a list of technical and non-technical platform vulnerabilities that could be exploited or triggered by potential threat-sources. Vulnerabilities can range from incomplete or conflicting policies that govern an organization's computer usage to insufficient safeguards to protect facilities that house computer equipment to any number of software, hardware, or other deficiencies that comprise an organization's computer network.
- Output - A list of the platform vulnerabilities (observations) that could be exercised by potential threat-sources.
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Step 4. Control Analysis
- Document and assess the effectiveness of technical and non-technical controls that have been or will be implemented by biospatial to minimize or eliminate the likelihood / probability of a threat-source exploiting a platform vulnerability.
- Output - List of current or planned controls (policies, procedures, training, technical mechanisms, insurance, etc.) used for the platform to mitigate the likelihood of a vulnerability being exercised and reduce the impact of such an adverse event.
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Step 5. Likelihood Determination
- Determine the overall likelihood rating that indicates the probability that a vulnerability could be exploited by a threat-source given the existing or planned security controls.
- Output - Likelihood rating of low (.1), medium (.5), or high (1). Refer to the NIST SP 800-30 definitions of low, medium, and high.
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Step 6. Impact Analysis
- Determine the level of adverse impact that would result from a threat successfully exploiting a vulnerability. Factors of the data and systems to consider should include the importance to biospatial's mission; sensitivity and criticality (value or importance); costs associated; loss of confidentiality, integrity, and availability of systems and data.
- Output - Magnitude of impact rating of low (10), medium (50), or high (100). Refer to the NIST SP 800-30 definitions of low, medium, and high.
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Step 7. Risk Determination
- Establish a risk level. By multiplying the ratings from the likelihood determination and impact analysis, a risk level is determined. This represents the degree or level of risk to which an IT system, facility, or procedure might be exposed if a given vulnerability were exercised. The risk rating also presents actions that senior management must take for each risk level.
- Output - Risk level of low (1-10), medium (>10-50) or high (>50-100). Refer to the NIST SP 800-30 definitions of low, medium, and high.
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Step 8. Control Recommendations
- Identify controls that could reduce or eliminate the identified risks, as appropriate to the organization's operations to an acceptable level. Factors to consider when developing controls may include effectiveness of recommended options (i.e., system compatibility), legislation and regulation, organizational policy, operational impact, and safety and reliability. Control recommendations provide input to the risk mitigation process, during which the recommended procedural and technical security controls are evaluated, prioritized, and implemented.
- Output - Recommendation of control(s) and alternative solutions to mitigate risk.
-
Step 9. Results Documentation
- Results of the risk assessment are documented in an official report, spreadsheet, or briefing and provided to senior management to make decisions on policy, procedure, budget, and platform operational and management changes.
- Output - A risk assessment report that describes the threats and vulnerabilities, measures the risk, and provides recommendations for control implementation.
Risk Mitigation
Risk mitigation involves prioritizing, evaluating, and implementing the appropriate risk-reducing controls recommended from the Risk Assessment process to ensure the confidentiality, integrity and availability of biospatial platform ePHI. Determination of appropriate controls to reduce risk is dependent upon the risk tolerance of the organization consistent with its goals and mission.
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Step 1. Prioritize Actions
- Using results from Step 7 of the Risk Assessment, sort the threat and vulnerability pairs according to their risk-levels in descending order. This establishes a prioritized list of actions needing to be taken, with the pairs at the top of the list getting/requiring the most immediate attention and top priority in allocating resources
- Output - Actions ranked from high to low
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Step 2. Evaluate Recommended Control Options
- Although possible controls for each threat and vulnerability pair are arrived at in Step 8 of the Risk Assessment, review the recommended control(s) and alternative solutions for reasonableness and appropriateness. The feasibility (e.g., compatibility, user acceptance, etc.) and effectiveness (e.g., degree of protection and level of risk mitigation) of the recommended controls should be analyzed. In the end, select a “most appropriate” control option for each threat and vulnerability pair.
- Output - list of feasible controls
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Step 3. Conduct Cost-Benefit Analysis
- Determine the extent to which a control is cost-effective. Compare the benefit (e.g., risk reduction) of applying a control with its subsequent cost of application. Controls that are not cost-effective are also identified during this step. Analyzing each control or set of controls in this manner, and prioritizing across all controls being considered, can greatly aid in the decision-making process.
- Output - Documented cost-benefit analysis of either implementing or not implementing each specific control
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Step 4. Select Control(s)
- Taking into account the information and results from previous steps, biospatial's mission, and other important criteria, the Risk Management Team determines the best control(s) for reducing risks to the information systems and to the confidentiality, integrity, and availability of ePHI. These controls may consist of a mix of administrative, physical, and/or technical safeguards.
- Output - Selected control(s)
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Step 5. Assign Responsibility
- Identify the workforce members with the skills necessary to implement each of the specific controls outlined in the previous step, and assign their responsibilities. Also identify the equipment, training and other resources needed for the successful implementation of controls. Resources may include time, money, equipment, etc.
- Output - List of resources, responsible persons and their assignments
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Step 6. Develop Safeguard Implementation Plan
- Develop an overall implementation or action plan and individual project plans needed to implement the safeguards and controls identified. The Implementation Plan should contain the following information:
- Each risk or vulnerability/threat pair and risk level;
- Prioritized actions;
- The recommended feasible control(s) for each identified risk;
- Required resources for implementation of selected controls;
- Team member responsible for implementation of each control;
- Start date for implementation
- Target date for completion of implementation;
- Maintenance requirements.
- The overall implementation plan provides a broad overview of the safeguard implementation, identifying important milestones and timeframes, resource requirements (staff and other individuals' time, budget, etc.), interrelationships between projects, and any other relevant information. Regular status reporting of the plan, along with key metrics and success indicators should be reported to biospatial Senior Management.
- Individual project plans for safeguard implementation may be developed and contain detailed steps that resources assigned carry out to meet implementation timeframes and expectations. Additionally, consider including items in individual project plans such as a project scope, a list deliverables, key assumptions, objectives, task completion dates and project requirements.
- Output - Safeguard Implementation Plan
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Step 7. Implement Selected Controls
- As controls are implemented, monitor the affected system(s) to verify that the implemented controls continue to meet expectations. Elimination of all risk is not practical. Depending on individual situations, implemented controls may lower a risk level but not completely eliminate the risk.
- Continually and consistently communicate expectations to all Risk Management Team members, as well as senior management and other key people throughout the risk mitigation process. Identify when new risks are identified and when controls lower or offset risk rather than eliminate it.
- Additional monitoring is especially crucial during times of major environmental changes, organizational or process changes, or major facilities changes.
- If risk reduction expectations are not met, then repeat all or a part of the risk management process so that additional controls needed to lower risk to an acceptable level can be identified.
- Output - Residual Risk documentation
Risk Management Schedule
The two principal components of the risk management process - risk assessment and risk mitigation - will be carried out according to the following schedule to ensure the continued adequacy and continuous improvement of biospatial's information security program:
- Scheduled Basis - an overall risk assessment of biospatial's information system infrastructure will be conducted annually. The assessment process should be completed in a timely fashion so that risk mitigation strategies can be determined and included in the corporate budgeting process.
- Throughout a System's Development Life Cycle - from the time that a need for a new, untested information system configuration and/or application is identified through the time it is disposed of, ongoing assessments of the potential threats to a system and its vulnerabilities should be undertaken as a part of the maintenance of the system.
- As Needed - the Security Officer (or other designated employee) or Risk Management Team may call for a full or partial risk assessment in response to changes in business strategies, information technology, information sensitivity, threats, legal liabilities, or other significant factors that affect biospatial's platform.
Process Documentation
Maintain documentation of all risk assessment, risk management, and risk mitigation efforts for a minimum of six years.
Roles Policy
biospatial has a Security Officer [164.308(a)(2)] and Privacy Officer [164.308(a)(2)] appointed to assist in maintaining and enforcing safeguards towards compliance. The responsibilities associated with these roles are outlined below.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 02.f - Disciplinary Process
- 06.d - Data Protection and Privacy of Covered Information
- 06.f - Prevention of Misuse of Information Assets
- 06.g - Compliance with Security Policies and Standards
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(2) - Assigned Security Responsibility
- 164.308(a)(5)(i) - Security Awareness and Training
Privacy Officer
The Privacy Officer is responsible for assisting with compliance and security training for workforce members, assuring organization remains in compliance with evolving compliance rules, and helping the Security Officer in their responsibilities.
- Provides annual training to all workforce members of established policies and procedures as necessary and appropriate to carry out their job functions, and documents the training provided.
- Assists in the administration and oversight of business associate agreements.
- Manage relationships with customers and partners as those relationships affect security and compliance of ePHI.
- Assist Security Officer as needed.
The current biospatial Privacy Officer is Jon Woodworth ().
Workforce Training Responsibilities
- The Privacy Officer facilitates the training of all workforce members as follows:
- New workforce members within their first month of engagement;
- Existing workforce members annually;
- Existing workforce members whose functions are affected by a material change in the policies and procedures, within a month after the material change becomes effective;
- Existing workforce members as needed due to changes in security and risk posture of biospatial.
- The Security Officer or designee maintains documentation of the training session materials and attendees for a minimum of six years.
- The training session focuses on, but is not limited to, the following subjects defined in biospatial's
security policies and procedures:
- HIPAA Privacy, Security, and Breach notification rules;
- Risk Management procedures and documentation;
- Auditing. biospatial may monitor access and activities of all users;
- Workstations may only be used to perform assigned job responsibilities;
- Users may not download software onto biospatial's workstations and/or systems without prior approval from the Security Officer;
- Users are required to report malicious software to the Security Officer immediately;
- Users are required to report unauthorized attempts, uses of, and theft of biospatial's systems and/or workstations;
- Users are required to report unauthorized access to facilities
- Users are required to report noted log-in discrepancies (i.e. application states users last log-in was on a date user was on vacation);
- Users may not alter ePHI maintained in a database, unless authorized to do so by a biospatial Customer;
- Users are required to understand their role in biospatial's contingency plan;
- Users may not share their user names nor passwords with anyone;
- Requirements for users to create and change passwords;
- Users must set all applications that contain or transmit ePHI to automatically log off after 15 minutes of inactivity;
- Supervisors are required to report terminations of workforce members and other outside users;
- Supervisors are required to report a change in a users title, role, department, and/or location;
- Procedures to backup ePHI;
- Procedures to move and record movement of hardware and electronic media containing ePHI;
- Procedures to dispose of discs, CDs, hard drives, and other media containing ePHI;
- Procedures to re-use electronic media containing ePHI;
- SSH key and sensitive document encryption procedures.
Security Officer
The Security Officer is responsible for facilitating the training and supervision of all workforce members [164.308(a)(3)(ii)(A) and 164.308(a)(5)(ii)(A)], investigation and sanctioning of any workforce member that is in violation of biospatial security policies and non-compliance with the security regulations [164.308(a)(1)(ii)(c)], and writing, implementing, and maintaining all polices, procedures, and documentation related to efforts toward security and compliance [164.316(a-b)].
The current biospatial Security Officer is the Chief Technology Officer, Chris Lunsford ().
Organizational Responsibilities
The Security Officer, in collaboration with the Privacy Officer, is responsible for facilitating the development, testing, implementation, training, and oversight of all activities pertaining to biospatial's efforts to be compliant with the HIPAA Privacy and Security Regulations, SOC2, and any other security and compliance frameworks. The intent of the Security Officer Responsibilities is to maintain the confidentiality, integrity, and availability of ePHI. The Security Officer is appointed by and reports to the Board of Directors and the CEO.
These organizational responsibilities include, but are not limited to the following:
- Oversees and enforces all activities necessary to maintain compliance and verifies the activities are in alignment with the requirements.
- Helps to establish and maintain written policies and procedures to comply with the Security rule and maintains them for six years from the date of creation or date it was last in effect, whichever is later.
- Reviews and updates policies and procedures as necessary and appropriate to maintain compliance and maintains changes made for six years from the date of creation or date it was last in effect, whichever is later.
- Facilitates audits to validate compliance efforts throughout the organization.
- Documents all activities and assessments completed to maintain compliance and maintains documentation for six years from the date of creation or date it was last in effect, whichever is later.
- Provides copies of the policies and procedures to management, customers, and partners, and has them available to review by all other workforce members to which they apply.
- Annually, and as necessary, reviews and updates documentation to respond to environmental or operational changes affecting the security and risk posture of ePHI stored, transmitted, or processed within biospatial infrastructure.
- Develops and provides periodic security updates and reminder communications for all workforce members.
- Implements procedures for the authorization and/or supervision of workforce members who work with ePHI or in locations where it may be accessed.
- Maintains a program promoting workforce members to report non-compliance with policies and procedures.
- Promptly, properly, and consistently investigates and addresses reported violations and takes steps to prevent recurrence.
- Applies consistent and appropriate sanctions against workforce members who fail to comply with the security policies and procedures of biospatial.
- Mitigates, to the extent practicable, any harmful effect known to biospatial of a use or disclosure of ePHI in violation of biospatial's policies and procedures, even if effect is the result of actions of biospatial business associates, customers, and/or partners.
- Reports security efforts and incidents to administration immediately upon discovery. Responsibilities in the case of a known ePHI breach are documented in the biospatial Breach Policy.
- The Security Officer facilitates the communication of security updates and reminders to all workforce
members to which it pertains. Examples of security updates and reminders include, but are not limited
to:
- Latest malicious software or virus alerts;
- biospatial's requirement to report unauthorized attempts to access ePHI;
- Changes in creating or changing passwords;
- Additional security-focused training is provided to all workforce members by the Security Officer. This training includes, but is not limited to:
- Data backup plans;
- System auditing procedures;
- Redundancy procedures;
- Contingency plans;
- Virus protection;
- Patch management;
- Media Disposal and/or Re-use;
- Documentation requirements.
- The Security Officer works with the CEO to ensure that any security objectives have appropriate
consideration during the budgeting process.
- In general, security and compliance are core to biospatial's technology and service offerings; in most cases this means security-related objectives cannot be split out to separate budget line items.
- For cases that can be split out into discrete items, such as licenses for commercial
tooling, the Security Officer follows biospatial's standard corporate budgeting process.
- At the beginning of every fiscal year, the CEO contacts the Security Officer to plan for the upcoming year's expenses.
- The Security Officer works with the CEO to forecast spending needs based on the previous year's level, along with changes for the upcoming year such as additional staff hires.
- During the year, if an unforeseen security-related expense arises that was not in the budget forecast, the Security Officer works with the CEO to reallocate any resources as necessary to cover this expense.
Supervision of Workforce Responsibilities
Although the Security Officer is responsible for implementing and overseeing all activities related to maintaining compliance, it is the responsibility of all workforce members (i.e. team leaders, supervisors, managers, directors, co-workers, etc.) to supervise all workforce members and any other user of biospatial's systems, applications, servers, workstations, etc. that contain ePHI.
- Monitor workstations and applications for unauthorized use, tampering, and theft and report non-compliance according to the Security Incident Response policy.
- Assist the Security and Privacy Officers to ensure appropriate role-based access is provided to all users.
- Take all reasonable steps to hire, retain, and promote workforce members and provide access to users who comply with the Security regulation and biospatial's security policies and procedures.
Sanctions of Workforce Responsibilities
All workforce members report non-compliance of biospatial's policies and procedures to the Security Officer or other individual as assigned by the Security Officer. Individuals that report violations in good faith may not be subjected to intimidation, threats, coercion, discrimination against, or any other retaliatory action as a consequence.
- The Security Officer promptly facilitates a thorough investigation of all reported violations of
biospatial's security policies and procedures. The Security Officer may request the assistance
from others.
- Complete an audit trail/log to identify and verify the violation and sequence of events.
- Interview any individual that may be aware of or involved in the incident.
- All individuals are required to cooperate with the investigation process and provide factual information to those conducting the investigation.
- Provide individuals suspected of non-compliance of the Security rule and/or biospatial's policies and procedures the opportunity to explain their actions.
- The investigator thoroughly documents the investigation as the investigation occurs. This documentation must include a list of all employees involved in the violation.
- Violation of any security policy or procedure by workforce members may result in corrective disciplinary action, up to and including termination of employment. Violation of this policy and procedures by others, including business associates, customers, and partners may result in termination of the relationship and/or associated privileges. Violation may also result in civil and criminal penalties as determined by federal and state laws and regulations.
- The Security Officer facilitates taking appropriate steps to prevent recurrence of the violation (when possible and feasible).
- In the case of an insider threat, the Security Officer and Privacy Officer are to set up a team to investigate and mitigate the risk of insider malicious activity. biospatial workforce members are encouraged to come forward with information about insider threats, and can do so anonymously.
- The Security Officer maintains all documentation of the investigation, sanctions provided, and actions taken to prevent reoccurrence for a minimum of six years after the conclusion of the investigation.
Data Management Policy
biospatial has procedures to create and maintain retrievable exact copies of electronic protected health information (ePHI) stored in conjunction with biospatial's service. The policy and procedures will ensure that complete, accurate, retrievable, and tested backups are available for all systems used by biospatial.
Data backup is an important part of the day-to-day operations of biospatial. To protect the confidentiality, integrity, and availability of ePHI, both for biospatial and biospatial Customers, complete backups are done daily to ensure that data remains available when it needed and in case of a disaster.
Violation of this policy and its procedures by workforce members may result in corrective disciplinary action, up to and including termination of employment.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 01.v - Information Access Restriction
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(7)(ii)(A) - Data Backup Plan
- 164.310(d)(2)(iii) - Accountability
- 164.310(d)(2)(iv) - Data Backup and Storage
Backup Policy and Procedures
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biospatial Backup Policy recognizes three distinct classes of storage locations:
- Data-Bearing Volumes: These volumes must be backed up to meet biospatial disaster recovery and data retention policies. Generally, this means the volume is a primary storage location for file archives, database files, or log files. The data on these volumes cannot be easily recovered or regenerated if lost.
- Ephemeral Volumes: These volumes do not store any critical data that cannot be easily recovered or regenerated. Log data written to Ephemeral Volumes that must be retained must also be stored in another location such as a central location or a Data-Bearing Volume. Systems using Ephemeral Volumes can be recreated from scratch using biospatial infrastructure-as-code tools in approximately the same time as they could be restored from backup.
- Durable Storage Services: Services like AWS S3 that offer data storage with built-in durability and reliability guarantees sufficient to meet biospatial disaster recovery and data retention policies. To qualify as a Durable Storage Service, the service must be able to enforce versioning at the object level.
Durable Storage Services are exempt from the backup requirements that follow. - biospatial Ops Team, lead by Chief Technology Officer, is designated to be in charge of backups.
- Ops team ensures daily snapshot backups of all Data-Bearing Volumes.
At a minimum, the following snapshot backups are retained:
- The last two (2) days of snapshot backups.
- The latest snapshot backup from the prior week.
- The latest snapshot backups from each of the three (3) prior months.
- Ops Team members are trained and assigned to complete backups using the AWS platform.
- Document backups
- Name of the system
- Date & time of backup
- Where backup stored (or to whom it was provided)
- Securely encrypt stored backups in a manner that protects them from loss or environmental damage.
- Test backups and document that files have been completely and accurately restored from the backup media.
System Access Policy
Access to biospatial systems and application is limited for all users, including but not limited to workforce members, volunteers, business associates, contracted providers, consultants, and any other entity, is allowable only on a minimum necessary basis. All users are responsible for reporting an incident of unauthorized user or access of the organization's information systems. These safeguards have been established to address the HIPAA Security regulations including the following:
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 01.d - User Password Management
- 01.f - Password Use
- 01.r - Password Management System
- 01.a - Access Control Policy
- 01.b - User Registration
- 01.h - Clear Desk and Clear Screen Policy
- 01.j - User Authentication for External Connections
- 01.q - User Identification and Authentication
- 01.v - Information Access Restriction
- 02.i - Removal of Access Rights
- 06.e - Prevention of Misuse of Information Assets
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(4)(ii)(C) Access Establishment and Modification
- 164.308(a)(3)(ii)(B) Workforce Clearance Procedures
- 164.308(a)(4)(ii)(B) Access Authorization
- 164.312(d) Person or Entity Authentication
- 164.312(a)(2)(i) Unique User Identification
- 164.308(a)(5)(ii)(D) Password Management
- 164.312(a)(2)(iii) Automatic Logoff
- 164.310(b) Workstation Use
- 164.310(c) Workstation Security
- 164.308(a)(3)(ii)(C) Termination Procedures
Access Establishment and Modification
- Requests for access to biospatial platform systems and applications is made formally using the following
process:
- The biospatial workforce member, or their manager, initiates the access request by completing
this
form and
submitting the form via a secure communications channel or issue tracking tool to the biospatial Security
Officer.
- User identities must be verified prior to granting access to new accounts.
- Identity verification must be done in person where possible; for remote employees, identities must be verified over the phone.
- For new accounts, the method used to verify the user's identity must be recorded on the Issue.
- The Security Officer will grant access to systems as dictated by the employee's job title. If additional access is required outside of the minimum necessary to perform job functions, the requester must include a description of why the additional access is required as part of the access request.
- Once the review is completed, the Security Officer approves or rejects the request and notifies the workforce member via a secure communications channel or issue tracking tool. If the request is rejected, it goes back for further review and documentation.
- If the review is approved, the Security Officer then grants requested access.
- New accounts will be created with a secure password that meets all requirements from Password Management.
- All password exchanges must occur over an authenticated and encrypted channel.
- Access grants are accomplished by leveraging the access control mechanisms built into the system for which access is being granted.
- Account management may be delegated at the discretion of the Security Officer.
- The biospatial workforce member, or their manager, initiates the access request by completing
this
form and
submitting the form via a secure communications channel or issue tracking tool to the biospatial Security
Officer.
- Access is not granted until receipt, review, and approval by the biospatial Security Officer;
- The request for access is retained for future reference.
- All access to biospatial systems and services are reviewed and updated on a quarterly basis to ensure
proper authorizations are in place commensurate with job functions. The process for conducting reviews
is outlined below:
- The Security Officer initiates the review of user access by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
- The Security Officer, or a Privacy Officer, is assigned to review levels of access for each biospatial workforce member.
- If user access is found during review that is not in line with the least privilege principle, the process below is used to modify user access and notify the user of access changes. Once those steps are completed, the Issue is then reviewed again.
- Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
- If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
- Review of user access is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.
- Any biospatial workforce member can request change of access using the process outlined in Access Establishment and Management.
- Access to production systems is controlled by centralized orchestration of user management and authentication.
- Accounts are reviewed every quarter. Accounts that are inactive or no longer serve a business purpose are disabled and/or deleted.
- In the case of non-personal information, such as generic educational content, identification and authentication may not be required. This is the responsibility of biospatial Customers to define, and not biospatial.
- Privileged users must first access systems using standard, unique user accounts before switching to
privileged users and performing privileged tasks.
- For production systems, this is enforced by creating non-privileged user accounts that must
invoke
sudo
to perform privileged tasks. - Rights for privileged accounts are granted by the Security Officer using the process outlined in Access Establishment and Management.
- For production systems, this is enforced by creating non-privileged user accounts that must
invoke
- All application to application communication using service accounts is restricted and not permitted unless absolutely needed. Automated tools are used to limit account access across applications and systems.
- Generic accounts are not allowed on biospatial systems.
- Access is granted through encrypted, VPN tunnels that utilize multi-factor authentication.
- Two-factor authentication is accomplished using a Time-based One-Time Password (TOTP) as the second factor.
- VPN connections use 256-bit AES 256 encryption, or equivalent.
- VPN sessions are automatically disconnected after 30 minutes of network inactivity.
- In cases of increased risk or known attempted unauthorized access, immediate steps are taken by the Security and Privacy Officer to limit access and reduce risk of unauthorized access.
- Direct system to system, system to application, and application to application authentication and authorization are limited and controlled to restrict access.
Workforce Clearance
- The level of security assigned to a user to the organization's information systems is based on the minimum necessary amount of data access required to carry out legitimate job responsibilities assigned to a user's job classification and/or to a user needing access to carry out treatment, payment, or healthcare operations.
- All access requests are treated on a “least-access principle.”
- biospatial maintains a minimum necessary approach to access to Customer data. As such, biospatial workforce members do not have access to any ePHI unless explicitly granted access according to these policies.
Access Authorization
- Role based access categories for each biospatial system and application are pre-approved by the Security Officer or CTO.
- biospatial utilizes hardware and software firewalls to segment data, prevent unauthorized access, and monitor traffic for denial of service attacks.
Person or Entity Authentication
- Each workforce member has and uses a unique user ID and password that identifies them as the user of the information system. In some instances the unique credentials, along with a second factor, are used to generate a temporary certificate which is used by some systems for authentication.
- Each Customer and Partner has and uses a unique user ID and password that identifies them as the user of the information system.
- All Customer support interactions must be verified before biospatial support personnel will satisfy
any request having information security implications.
- Support issues submitted by email or via the in-application Help Desk must be verified by biospatial personnel using a phone number that has been registered with the corresponding account, except as noted below.
- Standard password resets may be initiated on behalf of a user in response to e-mail or Help Desk requests.
Unique User Identification
- Access to the biospatial platform systems and applications is controlled by requiring unique authentication credentials for each individual user and developer.
- All operating system log-ons to biospatial workstations or servers require SSH keys, biometrics, or manually-entered passwords or PINs.
- User authentication credentials (not including usernames and one-time passwords) are never displayed during log-on and are not transmitted or stored in plain text.
- Shared accounts are not allowed within biospatial systems or networks. Users may not allow anyone, for any reason, to have access to any information system using another user's authentication credentials.
Automatic Logoff
- Users are required to make information systems inaccessible by any other individual when unattended by the users (e.g. by using a password protected screen saver or logging off the system).
- Information systems automatically log users off the systems after 15 minutes of network inactivity.
- The Security Officer pre-approves exceptions to automatic log off requirements.
Employee Workstation Use
All workstations at biospatial are company-owned and all are laptop products running either Windows or macOS.
- Workstations may not be used to engage in any activity that is illegal or is in violation of organization's policies.
- Access may not be used for transmitting, retrieving, or storage of any communications of a discriminatory or harassing nature or materials that are obscene or “X-rated”. Harassment of any kind is prohibited. No messages with derogatory or inflammatory remarks about an individual's race, age, disability, religion, national origin, physical attributes, sexual preference, or health condition shall be transmitted or maintained. No abusive, hostile, profane, or offensive language is to be transmitted through organization's system.
- Information systems/applications also may not be used for any other purpose that is illegal, unethical, or against company policies or contrary to organization's best interests. Messages containing information related to a lawsuit or investigation may not be sent without prior approval.
- Solicitation of non-company business, or any use of organization's information systems/applications for personal gain is prohibited.
- Transmitted messages may not contain material that criticizes the organization, its providers, its employees, or others.
- Users may not misrepresent, obscure, suppress, or replace another user's identity in transmitted or stored messages.
- Workstation hard drives will be encrypted using the operating system’s encryption facility (e.g., FileVault for Mac or Bitlocker for Windows).
- All workstations have firewalls enabled to prevent unauthorized access unless an exception is explicitly granted.
- All computers purchased, owned, and/or managed by biospatial are to
display one of these messages at login: This computer is owned or managed by biospatial, Inc. By clicking "OK" you acknowledge you have read, and will follow, the policies posted at https://www.biospatial.io/policies and affirm you
have completed the training at https://policies.biospatial.io/security-training. Contact with issues or concerns.
or
This computer is owned or managed by biospatial, Inc. By clicking "OK" you agree to follow the policies posted at https://www.biospatial.io/policies and affirm you have completed the necessary training. Call [phone_number] if found.
Mobile Device Use
biospatial work force members are permitted to use biospatial-owned or personally-owned mobile devices to access biospatial corporate resources if the following requirements are met.
- No ePHI may be stored on any mobile device.
- Mobile devices are not permitted to connect to the biospatial VPN.
- Mobile devices must be set to lock the screen after no more than 3 minutes.
- Mobile devices must have screen locking enabled with PINs or passwords of 8 characters or more.
- Mobile devices may be unlocked using fingerprints or other biometrics.
- Mobile devices must be encrypted.
- Mobile devices may use biospatial resources only as defined elsewhere in these policies.
- The biospatial work force member agrees to demonstrate that the device is configured in accordance to these policies on demand.
- Mobile devices do not need to meet these requirements if they are only used for MFA purposes.
Wireless Access Use
- biospatial production systems are not accessible directly over wireless channels.
- Wireless access is disabled on all production systems.
- When accessing production systems via remote wireless connections, the same system access policies and procedures apply to wireless as all other connections, including wired.
- Wireless networks managed within biospatial non-production facilities (offices, etc.) are secured with
the following configurations:
- All data in transit over wireless is encrypted using WPA2 encryption or better;
- Passwords are rotated on a regular basis, presently quarterly. This process is managed by the biospatial Security Officer.
Employee Termination Procedures
- The Human Resources Department (or other designated department), users, and their supervisors are required to notify the Security Officer upon completion and/or termination of access needs and facilitating completion of the “Termination Checklist”.
- The Human Resources Department (or other designated department), users, and supervisors are required to notify the Security
Officer or the Information Security Help Desk (or other designated department) to terminate a user's access rights if
there is evidence or reason to believe the following (these incidents are also reported on an incident
report and is filed with the Privacy Officer):
- The user has been using their access rights inappropriately;
- A user's password has been compromised (a new password may be provided to the user if the user is not identified as the individual compromising the original password);
- An unauthorized individual is utilizing a user's User Login ID and password (a new password may be provided to the user if the user is not identified as providing the unauthorized individual with the User Login ID and password).
- The Security Officer will terminate users' access rights immediately upon notification, and will coordinate with the appropriate biospatial employees to terminate access to any non-production systems managed by those employees.
- The Security Officer audits and may terminate access of users that have not logged into organization's information systems/applications for an extended period of time.
Paper Records
biospatial does not use paper records for any sensitive information. Use of paper for recording and storing sensitive data is against biospatial policies.
Password Management
- User IDs and passwords that control access to biospatial systems may not be disclosed to anyone for any reason.
- On all production systems and applications in the biospatial environment, password configurations are
set to require:
- a minimum length of 8 characters;
- at least one upper case character;
- at least one lower case character;
- at least one number;
- at least one non-alphanumeric character;
- a 90-day password expiration;
- prevention of password reuse using a history of the last 24 passwords;
- account lockout for a period of 30 minutes after 5 invalid attempts.
- All system and application passwords must be stored and transmitted securely.
- Where possible, passwords should be stored in a hashed format using a salted cryptographic hash function (SHA-256 or equivalent).
- For example, by concatenating the user's password and a random 256-bit salt value, generated on a per-user basis, and then applying SHA-256 to the value to create a password hash.
- The password hash and the salt are then stored in the backend database and are used for password validation on future user authentication attempts.
- Passwords that must be stored in non-hashed format must be encrypted at rest pursuant to the requirements in Production Data Security.
- Transmitted passwords must be encrypted in flight pursuant to the requirements in Transmission Security.
- Each information system automatically requires users to change passwords at a pre-determined interval as determined by the organization, based on the criticality and sensitivity of the ePHI contained within the network, system, application, and/or database.
- Passwords are inactivated immediately upon an employee's termination (refer to the Employee Termination Procedures).
- All default system, application, and Partner passwords are changed before deployment to production.
- Upon initial login, users must change any passwords that were automatically generated for them.
- Password change methods must use a confirmation method to correct for user input errors.
- All passwords used in configuration scripts are secured and encrypted.
- If a user believes their user ID has been compromised, they are required to immediately report the incident to the Security Office.
- In cases where a user has forgotten their password, the following procedure is used to reset the
password.
- The user submits a password reset request to biospatial IT via e-mail, Redmine, or Slack. The request should include the system(s) to which the user has lost access and needs the password reset.
- An administrator with password reset privileges directly contacts the user requesting the password reset.
- The administrator verifies the identity of the user either in-person or through a separate communication channel such as phone or Slack.
- Once verified, the administrator resets the password.
SSH Key Management
- SSH keys that control access to biospatial systems may not be disclosed to anyone for any reason.
- On all production systems and applications in the biospatial environment, SSH-key-based
authentication utilizes:
- 4096-bit RSA keys or stronger;
- password-based authentication for the private key; password complexity must be consistent with guidance in Password Management.
- SSH Keys must be stored and transmitted securely.
- SSH private keys shall be stored in encrypted form in either the PKCS #8 (RFC 5208) or PPKv2 file format.
- File system permissions for SSH private key files shall restrict access to the key owner only.
- Transmitted keys must be encrypted in flight pursuant to the requirements in Transmission Security.
- SSH keys shall be rotated at least annually.
- SSH keys are inactivated immediately upon an employee's termination (refer to the Employee Termination Procedures).
- If a user believes their SSH key has been compromised, they are required to immediately report the incident to the Security Officer or Director of IT and Security.
- In cases where a user has lost access to their SSH key, the following procedure is used to update
the key.
- The user generates a new SSH key according to the requirements above.
- The user submits a key update request to biospatial IT via e-mail, Redmine, or Slack. The request should include the system(s) to which the user has lost access.
- The user submits the new public key to biospatial IT via Slack, referencing the original key reset request.
- An administrator directly contacts the user requesting the update.
- The administrator verifies the identity of the user either in-person or through a separate communication channel such as phone or Slack.
- Once verified, the administrator updates the SSH key on the system(s) in question.
Certificate Management
- Certificates that control access to biospatial systems may not be disclosed to anyone for any reason.
- On all production systems and applications in the biospatial environment, certificate-based
authentication utilizes:
- 4096-bit RSA keys or stronger;
- unique certificates for each user or service account.
- Certificates must be stored and transmitted securely.
- Certificate private keys shall be stored in PEM or similar format or in a local security container like Keychain on macOS or an authorized password manager.
- File system permissions for certificate private key files shall restrict access to the key owner only.
- Certificates are issued for a short period of time, not to exceed 7 days. Due to their short lifespans, certificates are not revoked upon an employee's termination.
- If a user believes their certificate has been compromised, they are required to immediately report the incident to the Security Officer or Director of IT and Security.
- Users generate their own certificates from the relevant PKI service provider.
- Authentication to generate certificates requires the equivalent of a unique user name, complex password, and a one-time password for a second authentication factor.
Auditing Policy
biospatial shall audit access and activity of electronic protected health information (ePHI) applications and systems in order to ensure compliance. The Security Rule requires healthcare organizations to implement reasonable hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ePHI. Audit activities may be limited by application, system, and/or network auditing capabilities and resources. biospatial shall make reasonable and good-faith efforts to safeguard information privacy and security through a well-thought-out approach to auditing that is consistent with available resources.
It is the policy of biospatial to safeguard the confidentiality, integrity, and availability of applications, systems, and networks. To ensure that appropriate safeguards are in place and effective, biospatial shall audit access and activity to detect, report, and guard against:
- Network vulnerabilities and intrusions;
- Breaches in confidentiality and security of patient protected health information;
- Performance problems and flaws in applications;
- Improper alteration or destruction of ePHI;
- Out of date software and/or software known to have vulnerabilities.
This policy applies to all biospatial systems that store, transmit, or process ePHI.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 0.a Information Security Management Program
- 01.a Access Control Policy
- 01.b User Registration
- 01.c Privilege Management
- 09.aa Audit Logging
- 09.ac Protection of Log Information
- 09.ab - Monitoring System Use
- 06.e - Prevention of Misuse of Information
Applicable Standards from the HIPAA Security Rule
- 45 CFR §164.308(a)(1)(ii)(D) - Information System Activity Review
- 45 CFR §164.308(a)(5)(ii)(B) & (C) - Protection from Malicious Software & Log-in Monitoring
- 45 CFR §164.308(a)(2) - HIPAA Security Rule Periodic Evaluation
- 45 CFR §164.312(b) - Audit Controls
- 45 CFR §164.312(c)(2) - Mechanism to Authenticate ePHI
- 45 CFR §164.312(e)(2)(i) - Integrity Controls
Auditing Policies
- biospatial shall conduct an internal audit of information systems and procedures to ensure compliance with security and privacy policies annually with more frequent audits triggered by audit requests and other trigger events.
- biospatial shall commission an external audit of information systems and procedures to ensure compliance with security and privacy policies at least annually.
- Responsibility for auditing information system access and activity is assigned to biospatial's
Security Officer. The Security Officer shall:
- Assign the task of generating reports for audit activities to the workforce member responsible for the application, system, or network;
- Assign the task of reviewing the audit reports to the workforce member responsible for the application, system, or network, the Privacy Officer, or any other individual determined to be appropriate for the task;
- Organize and provide oversight to a team structure charged with audit compliance activities (e.g., parameters, frequency, sample sizes, report formats, evaluation, follow-up, etc.).
- All connections to biospatial are monitored. Access is limited to certain services, ports, and destinations. Exceptions to these rules, if created, are reviewed on an annual basis.
- biospatial's auditing processes shall address access and activity at the following levels listed
below. Auditing processes may address date and time of each log-on attempt, date and time of each
log-off attempt, devices used, functions performed, etc.
- User: User level audit trails generally monitor and log all commands directly initiated by the user, all identification and authentication attempts, and data and services accessed.
- Application: Application level audit trails generally monitor and log all user activities, including data accessed and modified and specific actions.
- System: System level audit trails generally monitor and log user activities, applications accessed, and other system defined specific actions. biospatial utilizes file system monitoring from OSSEC to ensure the integrity of file system data.
- Network: Network level audit trails generally monitor information on what is operating, penetrations, and vulnerabilities.
- biospatial shall log all incoming and outgoing traffic into and out of its environment. This includes all successful and failed attempts at data access and editing. Data associated with this data will include origin, destination, time, and other relevant details that are available to biospatial.
- biospatial utilizes OSSEC to scan all systems for malicious and unauthorized software every day and at reboot of systems.
- biospatial leverages process monitoring tools throughout its environment.
- biospatial shall identify “trigger events” or criteria that raise awareness of questionable conditions of viewing of confidential information. The “events” may be applied to the entire biospatial platform or may be specific to a Customer, partner, or business associate (See Listing of Potential Trigger Events below).
- In addition to trigger events, biospatial uses automatic log aggregation and monitoring software to proactively identify and alert to anomalous and/or suspicious log data.
- Logs are reviewed weekly by the Security Officer or a delegate appointed by the Security Officer and approved by the Privacy Officer.
- biospatial's Security Officer and Privacy Officer are authorized to select and use auditing tools
that are designed to detect network vulnerabilities and intrusions. Such tools are explicitly prohibited
by others, including Customers and Partners, without the explicit authorization of the Security Officer.
These tools may include, but are not limited to:
- Scanning tools and devices;
- Password cracking utilities;
- Network “sniffers.”
- Passive and active intrusion detection systems.
- The process for review of audit logs, trails, and reports shall include:
- Description of the activity as well as rationale for performing the audit.
- Identification of which biospatial workforce members will be responsible for review (workforce members shall not review audit logs that pertain to their own system activity).
- Frequency of the auditing process.
- Determination of significant events requiring further review and follow-up.
- Identification of appropriate reporting channels for audit results and required follow-up.
- Vulnerability testing software may be used to probe the network to identify what is running (e.g.,
operating system or product versions in place), whether publicly-known vulnerabilities have been
corrected, and evaluate whether the system can withstand attacks aimed at circumventing security
controls.
- Testing may be carried out internally or provided through an external third-party vendor. Whenever possible, a third party auditing vendor should not be providing the organization IT oversight services (e.g. vendors providing IT services should not be auditing their own services - separation of duties).
- Automated vulnerability scanning is performed regularly and results are reviewed weekly.
- Security and critical bug patches and updates will be applied to all systems in a timely manner.
Audit Requests
- A request may be made for an audit for a specific cause. The request may come from a variety of sources including, but not limited to, Privacy Officer, Security Officer, Customer, Partner, or data owner.
- A request for an audit for specific cause must include time frame, frequency, and nature of the request. The request must be reviewed and approved by biospatial's Privacy or Security Officer.
- A request for an audit must be approved by biospatial's Privacy Officer and/or Security Officer
before proceeding. Under no circumstances shall detailed audit information be shared with parties
without proper permissions and access to see such data.
- Should the audit disclose that a workforce member has accessed ePHI inappropriately, the minimum necessary/least privileged information shall be shared with biospatial's Security Officer to determine appropriate sanction/corrective disciplinary action.
- Only de-identified information shall be shared with Customer or Partner regarding the results of the investigative audit process. This information will be communicated to the appropriate personnel by biospatial's Privacy Officer or designee. Prior to communicating with customers and partners regarding an audit, it is recommended that biospatial consider seeking risk management and/or legal counsel.
Review and Reporting of Audit Findings
- Audit information that is routinely gathered must be reviewed in a timely manner, currently monthly, by
the responsible workforce member(s). On a quarterly basis, logs are reviewed to ensure the proper data
is being captured and retained. The following process details how log reviews are done at biospatial:
- The Security Officer initiates the log review by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
- The Security Officer, or a biospatial Security Engineer assigned by the Security Officer, is assigned to review the logs.
- Relevant audit log findings are added to the Issue; these findings are investigated in a later step. Once those steps are completed, the Issue is then reviewed again.
- Once the review is completed, the Security Officer approves or rejects the Issue. Relevant findings are reviewed at this stage. If the Issue is rejected, it goes back for further review and documentation. The communications protocol around specific findings are outlined below.
- If the Issue is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
- The reporting process shall allow for meaningful communication of the audit findings to those workforce
members, Customers, or Partners requesting the audit.
- Significant findings shall be reported immediately in a written format. biospatial's security incident response form may be utilized to report a single event.
- Routine findings shall be reported to the sponsoring leadership structure in a written report format.
- Reports of audit results shall be limited to internal use on a minimum necessary/need-to-know basis. Audit results shall not be disclosed externally without administrative and/or legal counsel approval.
- Security audits constitute an internal, confidential monitoring practice that may be included in biospatial's performance improvement activities and reporting. Care shall be taken to ensure that the results of the audits are disclosed to administrative level oversight structures only and that information which may further expose organizational risk is shared with extreme caution. Generic security audit information may be included in organizational reports (individually-identifiable e PHI shall not be included in the reports).
- Whenever indicated through evaluation and reporting, appropriate corrective actions must be undertaken. These actions shall be documented and shared with the responsible workforce members, Customers, and/or Partners.
- Log review activity is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.
Auditing Customer and Partner Activity
- Periodic monitoring of Customer and Partner activity shall be carried out to ensure that access and activity is appropriate for privileges granted and necessary to the arrangement between biospatial and the 3rd party. biospatial will make every effort to ensure Customers and Partners do not gain access to data outside of their own Environments.
- If it is determined that the Customer or Partner has exceeded the scope of access privileges, biospatial's leadership must remedy the problem immediately.
- If it is determined that a Customer or Partner has violated the terms of the HIPAA business associate agreement or any terms within the HIPAA regulations, biospatial must take immediate action to remediate the situation. Continued violations may result in discontinuation of the business relationship.
Audit Log Security Controls and Backup
- Audit logs shall be protected from unauthorized access or modification, so the information they contain will be made available only if needed to evaluate a security incident or for routine audit activities as outlined in this policy.
- All audit logs are protected in transit and encrypted at rest to control access to the content of the logs.
- Audit logs shall be stored on a separate system to minimize the impact auditing may have on the privacy system and to prevent access to audit trails by those with system administrator privileges. Separate systems are used to apply the security principle of “separation of duties” to protect audit trails from hackers.
Workforce Training, Education, Awareness and Responsibilities
- biospatial workforce members are provided training, education, and awareness on safeguarding the privacy and security of business and ePHI. biospatial's commitment to auditing access and activity of the information applications, systems, and networks is communicated through new employee orientation, ongoing training opportunities and events, and applicable policies. biospatial workforce members are made aware of responsibilities with regard to privacy and security of information as well as applicable sanctions/corrective disciplinary actions should the auditing process detect a workforce member's failure to comply with organizational policies.
- biospatial Customers are provided with necessary information to understand biospatial auditing capabilities.
External Audits of Information Access and Activity
Prior to contracting with an external audit firm, biospatial shall:
- Outline the audit responsibility, authority, and accountability;
- Choose an audit firm that is independent of other organizational operations;
- Ensure technical competence of the audit firm staff;
- Require the audit firm's adherence to applicable codes of professional ethics;
- Obtain a signed HIPAA business associate agreement;
- Assign organizational responsibility for supervision of the external audit firm.
Retention of Audit Data
- Audit logs shall be maintained based on organizational needs. There is no standard or law addressing the
retention of audit log/trail information. Retention of this information shall be based on:
- Organizational history and experience.
- Available storage space.
- Reports summarizing audit activities shall be retained for a period of six years.
- Audit log data is retained for 450 days.
Potential Trigger Events
- High risk or problem prone incidents or events.
- Business associate, customer, or partner complaints.
- Known security vulnerabilities.
- Atypical patterns of activity.
- Failed authentication attempts.
- Remote access use and activity.
- Activity post termination.
- Random audits.
Configuration Management Policy
biospatial standardizes and automates configuration management through the use of Ansible and Terraform as well as documentation of all changes to production systems and networks. Ansible automatically configures all biospatial systems according to established and tested policies, and are used as part of our Disaster Recovery plan and process.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 06 - Configuration Management
Applicable Standards from the HIPAA Security Rule
- 164.310(a)(2)(iii) Access Control & Validation Procedures
Configuration Management Policies
- Ansible is used to standardize and automate configuration management.
- No systems are deployed into biospatial environments without approval of the biospatial CTO.
- All changes to production systems, network devices, and firewalls are approved by the biospatial CTO before they are implemented to ensure they comply with business and security requirements.
- All changes to production systems are tested before they are implemented in production.
- Implementation of approved changes are only performed by authorized personnel.
- An up-to-date inventory of systems is maintained using spreadsheets and documents hosted on Microsoft SharePoint and OneDrive. All systems are categorized as production and utility to differentiate based on criticality.
- All frontend functionality (developer dashboards and portals) is separated from backend (database and app servers) systems by being deployed on separate servers.
- All software and systems are tested using unit tests and end to end tests.
- All committed code is reviewed using pull requests via Git to ensure software code quality and proactively detect potential security issues in development.
- biospatial utilizes development and staging environments that mirror production to ensure proper function.
- All formal change requests require unique ID and authentication.
- Virus scanning software is run on all production hosts. Hosts are scanned daily for malicious binaries in critical system paths. The virus and malware signature database is checked hourly and automatically updated if new signatures are available. Enabling virus protection is a part of our Ansible-based configuration management baseline; this ensure all hosts have antivirus tools running on them.
- All physical media is encrypted at provisioning. To verify encryption is consistent and in place for all production storage, checks are performed on a quarterly basis.
- Clocks are continuously synchronized to an authoritative source across all systems using NTP or a platform-specific equivalent. Modifying time data on systems is restricted.
Facility Access Policy
biospatial works with Subcontractors to ensure restriction of physical access to systems used as part of the biospatial platform. biospatial and its Subcontractors control access to the physical buildings/facilities that house these systems/applications, or in which biospatial workforce members operate, in accordance to the HIPAA Security Rule 164.310 and its implementation specifications. Physical Access to all of biospatial facilities is limited to only those authorized in this policy. In an effort to safeguard ePHi from unauthorized access, tampering, and theft, access is allowed to areas only to those persons authorized to be in them and with escorts for unauthorized persons. All workforce members are responsible for reporting an incident of unauthorized visitor and/or unauthorized access to biospatial's facility.
Of note, biospatial does not have ready access to ePHI, it provides cloud-based, compliant infrastructure to covered entities and business associates. biospatial does not physically house any systems used by its platform in biospatial facilities.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 08.b - Physical Entry Controls
- 08.d - Protecting Against External and Environmental Threats
- 08.j - Equipment Maintenance
- 08.l - Secure Disposal or Re-Use of Equipment
- 09.p - Disposal of Media
Applicable Standards from the HIPAA Security Rule
- 164.310(a)(2)(ii) Facility Security Plan
- 164.310(a)(2)(iii) Access Control & Validation Procedures
- 164.310(b-c) Workstation Use & Security
biospatial-Controlled Facility Access Policies
As of February 1, 2023, biospatial no longer has a physical office. The following policies will apply if biospatial were to occupy another physical office space.
- Visitor and third party support access is recorded and supervised. All visitors are escorted.
- Repairs are documented and the documentation is retained.
- Fire extinguishers and detectors are installed according to applicable laws and regulations.
- Maintenance is controlled and conducted by authorized personnel in accordance with supplier-recommended intervals, insurance policies and the organizations maintenance program.
- Electronic and physical media containing covered information is securely destroyed (or the information securely removed) prior to disposal.
- The organization securely disposes media with sensitive information.
- Physical access is restricted using smart locks that track all access.
- Restricted areas and facilities are locked and when unattended (where feasible).
- Only authorized workforce members receive access to restricted areas (as determined by the Security Officer).
- Access and keys are revoked upon termination of workforce members.
- Workforce members must report a lost and/or stolen key(s) to the Security Officer.
- The Security Officer facilitates the changing of the lock(s) within 7 days of a key being reported lost/stolen.
- Workforce members must report a lost and/or stolen device or document that contains, stores, processes, or is used to access biospatial data or resources. This includes, but is not limited to, any biospatial-issued, workforce member-owned, or other piece of equipment or written communication (family laptops, computers, tablets, phones, notebook or printed/handwritten material) that has been used within the last 6 months to connect to a biospatial resource, or facilitates access to a biospatial resource, as in the case of a device used for MFA, or a password or other credentials written in a notebook or on a sheet of paper. Such reports may be submitted by email, Slack, or submission of a written report, to the Security Officer or Director of IT and Security, and the time of submission must be within 24-hours that the loss has been identified.
- Enforcement of Facility Access Policies
- Report violations of this policy to the restricted area's department team leader, supervisor, manager, or director, or the Privacy Officer.
- Workforce members in violation of this policy are subject to disciplinary action, up to and including termination.
- Visitors in violation of this policy are subject to loss of vendor privileges and/or termination of services from biospatial.
- Workstation Security
- Workstations may only be accessed and utilized by authorized workforce members to complete assigned job/contract responsibilities.
- All workforce members are required to monitor workstations and report unauthorized users and/or unauthorized attempts to access systems/applications as per the System Access Policy.
- All workstations purchased by biospatial are the property of biospatial and are distributed to users by the company.
Incident Response Policy
biospatial implements an information security incident response process to consistently detect, respond, and report incidents, minimize loss and destruction, mitigate the weaknesses that were exploited, and restore information system functionality and business continuity as soon as possible.
The incident response process addresses:
- Continuous monitoring of threats through intrusion detection systems (IDS) and other monitoring applications;
- Establishment of an information security incident response team;
- Establishment of procedures to respond to media inquiries;
- Establishment of clear procedures for identifying, responding, assessing, analyzing, and follow-up of information security incidents;
- Workforce training, education, and awareness on information security incidents and required responses; and
- Facilitation of clear communication of information security incidents with internal, as well as external, stakeholders
Note: These policies were adapted from a 12/18/2014 version of this work by the HIPAA Collaborative of Wisconsin Security Networking Group. Refer to the linked document for additional copyright information.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 11.a - Reporting Information Security Events
- 11.c - Responsibilities and Procedures
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(5)(i) - Security Awareness and Training
- 164.308(a)(6) - Security Incident Procedures
Incident Management Policies
The biospatial incident response process follows the process recommended by SANS, an industry leader in security. The biospatial Security Incident Plan and Security Incident Response Workflow , are drawn from the SANS process which can be found in this document. Contact biospatial for access to these documents, if needed.
biospatial's incident response classifies security-related events into the following categories:
- Events - Any observable computer security-related occurrence in a system or network
with a negative consequence. Examples:
- Hardware component failing causing service outages.
- Software error causing service outages.
- General network or system instability.
- Precursors - A sign that an incident may occur in the future. Examples:
- Monitoring system showing unusual behavior.
- Audit log alerts indicated several failed login attempts.
- Suspicious emails targeting specific biospatial staff members with administrative access to production systems.
- Indications - A sign that an incident may have occurred or may be occurring at the
present time. Examples:
- IDS alerts for modified system files or unusual system accesses.
- Antivirus alerts for infected files.
- Excessive network traffic directed at unexpected geographic locations.
- Incidents - A violation of computer security policies or acceptable use policies, often
resulting in data breaches. Examples:
- Unauthorized disclosure of ePHI.
- Unauthorized change or destruction of ePHI.
- A data breach accomplished by an internal or external entity.
- A Denial-of-Service (DoS) attack causing a critical service to become unreachable.
biospatial employees must report any unauthorized or suspicious activity seen on production systems or associated with related communication systems (such as email or instant messaging). In practice this means keeping an eye out for security events, and letting the Security Officer know about any observed precursors or indications as soon as they are discovered.
Identification Phase
- Immediately upon observation biospatial members report suspected and known Events, Precursors,
Indications, and Incidents in one of the following ways:
- Direct report to management, the Security Officer, Privacy Officer, or other;
- Email;
- Phone call;
- Security Incident response form;
- Redmine Security Incident template (select Security tracker if necessary);
- Secure Chat.
- Anonymously through workforce members desired channels.
- The individual receiving the report facilitates completion of a Security Incident Initial Report Form which can be found in the biospatial Security Incident Plan, or by using the Redmine Security Incident template, and notifies the Security Officer (if not already done).
- The Security Officer determines if the issue is an Event, Precursor, Indication, or Incident.
- If the issue is an Event, Precursor, or Indication, the Security Officer coordinates and oversees resolution. The Security Officer may involve other resources as appropriate, including IT staff, Customers, Subcontractors, etc.
- If the issue is an Incident the Security Officer activates the Security Incident
Response Team (SIRT) and notifies senior management.
- If a non-technical security Incident is discovered, the SIRT completes the investigation, implements preventative measures, and resolves the Incident.
- Once the investigation is completed, progress to Phase V, Follow-up.
- If the issue is a technical security Incident, commence to Phase II: Containment.
- The Containment, Eradication, and Recovery Phases are highly technical. It is important to have them completed by a highly qualified technical security resource with oversight by the SIRT team.
- Each individual on the SIRT and the technical security resource document all measures taken during each phase, including the start and end times of all efforts.
- The lead member of the SIRT team facilitates initiation of a Security Incident Report Form and a Security Incident Survey Form; both are found in the biospatial Security Incident Plan. The intent of the SIR form is to provide a summary of all events, efforts, and conclusions of each Phase of this policy and procedures.
- The Security Officer, Privacy Officer, or biospatial representative appointed notifies any affected Customers and Partners. If no Customers and Partners are affected, notification is at the discretion of the Security and Privacy Officer.
- In the case of a threat identified, the Security Officer is to form a team to investigate and involve necessary resources, both internal to biospatial and potentially external.
Containment Phase (Technical)
In this Phase, biospatial's IT department attempts to contain the security Incident. It is extremely important to take detailed notes during the Incident response process. This provides that the evidence gathered during the Incident can be used successfully during prosecution, if appropriate.
- The SIRT reviews any information that has been collected by the Security Officer or any other individual investigating the security Incident.
- The SIRT secures the network perimeter.
- The IT department performs the following:
- Securely connect to the affected system over a trusted connection.
- Retrieve any volatile data from the affected system.
- Determine the relative integrity and the appropriateness of backing the system up.
- If appropriate, back up the system.
- Change the password(s) to the affected system(s).
- Determine whether it is safe to continue operations with the affect system(s).
- If it is safe, allow the system to continue to function;
- Complete any documentation relative to the Incident on the Security Incident Report Form found in the biospatial Security Incident Plan.
- Move to Phase V, Follow-up.
- If it is NOT safe to allow the system to continue operations, discontinue the system(s) operation and move to Phase III, Eradication.
- The individual completing this phase provides written communication to the SIRT.
- Continuously apprise Senior Management of progress.
- Continue to notify affected Customers and Partners with relevant updates as needed
Eradication Phase (Technical)
The Eradication Phase represents the SIRT's effort to remove the cause, and the resulting security exposures, that are now on the affected system(s).
- Determine symptoms and cause related to the affected system(s).
- Strengthen the defenses surrounding the affected system(s), where possible (a risk assessment may be
needed and can be determined by the Security Officer). This may include the following:
- An increase in network perimeter defenses.
- An increase in system monitoring defenses.
- Remediation (“fixing”) any security issues within the affected system, such as removing unused services/general host hardening techniques.
- Conduct a detailed vulnerability assessment to verify all the holes/gaps that can be exploited have been
addressed.
- If additional issues or symptoms are identified, take appropriate preventative measures to eliminate or minimize potential future compromises.
- Complete the Security Incident Eradication Checklist found in the biospatial Security Incident Plan.
- Update the documentation with the information learned from the vulnerability assessment, including the cause, symptoms, and the method used to fix the problem with the affected system(s).
- Apprise Senior Management of the progress.
- Continue to notify affected Customers and Partners with relevant updates as needed.
- Move to Phase IV, Recovery.
Recovery Phase (Technical)
The Recovery Phase represents the SIRT's effort to restore the affected system(s) back to operation after the resulting security exposures, if any, have been corrected.
- The technical team determines if the affected system(s) have been changed in any way.
- If they have, the technical team restores the system to its proper, intended functioning (“last known good”).
- Once restored, the team validates that the system functions the way it was intended/had functioned in the past. This may require the involvement of the business unit that owns the affected system(s).
- If operation of the system(s) had been interrupted (i.e., the system(s) had been taken offline or dropped from the network while triaged), restart the restored and validated system(s) and monitor for behavior.
- If the system had not been changed in any way, but was taken offline (i.e., operations had been interrupted), restart the system and monitor for proper behavior.
- Update the documentation with the detail that was determined during this phase.
- Apprise Senior Management of progress.
- Continue to notify affected Customers and Partners with relevant updates as needed.
- Move to Phase V, Follow-up.
Follow-up Phase (Technical and Non-Technical)
The Follow-up Phase represents the review of the security Incident to look for “lessons learned” and to determine whether the process that was taken could have been improved in any way. It is recommended all Incidents be reviewed shortly after resolution to determine where response could be improved. Timeframes may extend to one to two weeks post-Incident.
- Responders to the security Incident (SIRT Team and technical security resource) meet to review the documentation collected during the Incident.
- Create a “lessons learned” document and attach it to the completed a Security Incident Report Form
found in the biospatial Security Incident Plan.
- Evaluate the cost and impact of the Incident to biospatial using the documents provided by the SIRT and the technical security resource.
- Determine what could be improved.
- Communicate these findings to Senior Management for approval and for implementation of any recommendations made post-review of the Incident.
- Carry out recommendations approved by Senior Management; sufficient budget, time and resources should be committed to this activity.
- Close the security Incident.
Periodic Evaluation
It is important to note that the processes surrounding security Incident response should be periodically reviewed and evaluated for effectiveness. This also involves appropriate training of resources expected to respond to security Incidents, as well as the training of the general population regarding the biospatial's expectation for them, relative to security responsibilities. The Incident Response Plan is tested annually.
Security Incident Response Team (SIRT)
Current members of the biospatial SIRT:
- Security Officer
- Privacy Officer
- CTO
- Director, IT and Security
Breach Policy
To provide guidance for breach notification when impressive or unauthorized access, acquisition, use and/or disclosure of the ePHI occurs. Breach notification will be carried out in compliance with the American Recovery and Reinvestment Act (ARRA)/Health Information Technology for Economic and Clinical Health Act (HITECH) as well as any other federal or state notification law.
The Federal Trade Commission (FTC) has published breach notification rules for vendors of personal health records as required by ARRA/HITECH. The FTC rule applies to entities not covered by HIPAA, primarily vendors of personal health records. The rule is effective September 24, 2009 with full compliance required by February 22, 2010.
The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, 2009. Title XIII of ARRA is the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH significantly impacts the Health Insurance Portability and Accountability (HIPAA) Privacy and Security Rules. While HIPAA did not require notification when patient protected health information (PHI) was inappropriately disclosed, covered entities and business associates may have chosen to include notification as part of the mitigation process. HITECH does require notification of certain breaches of unsecured PHI to the following: individuals, Department of Health and Human Services (HHS), and the media. The effective implementation for this provision is September 23, 2009 (pending publication HHS regulations).
In the case of a breach, biospatial shall notify all affected Customers. It is the responsibility of the Customers to notify affected individuals.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 11.a Reporting Information Security Events
- 11.c Responsibilities and Procedures
Applicable Standards from the HIPAA Security Rule
- Security Incident Procedures - 164.308(a)(6)(i)
- HITECH Notification in the Case of Breach - 13402(a) and 13402(b)
- HITECH Timeliness of Notification - 13402(d)(1)
- HITECH Content of Notification - 13402(f)(1)
biospatial Breach Policy
- Discovery of Breach: A breach of ePHI shall be treated as “discovered” as of the first day on which such breach is known to the organization, or, by exercising reasonable diligence would have been known to biospatial (includes breaches by the organization's Customers, Partners, or subcontractors). biospatial shall be deemed to have knowledge of a breach if such breach is known or by exercising reasonable diligence would have been known, to any person, other than the person committing the breach, who is a workforce member or Partner of the organization. Following the discovery of a potential breach, the organization shall begin an investigation (see organizational policies for security incident response and/or risk management incident response) immediately, conduct a risk assessment, and based on the results of the risk assessment, begin the process to notify each Customer affected by the breach. biospatial shall also begin the process of determining what external notifications are required or should be made (e.g., Secretary of Department of Health & Human Services (HHS), media outlets, law enforcement officials, etc.)
- Breach Investigation: The biospatial Security Officer shall name an individual to act as the investigator of the breach (e.g., privacy officer, security officer, risk manager, etc.). The investigator shall be responsible for the management of the breach investigation, completion of a risk assessment, and coordinating with others in the organization as appropriate (e.g., administration, security incident response team, human resources, risk management, public relations, legal counsel, etc.) The investigator shall be the key facilitator for all breach notification processes to the appropriate entities (e.g., HHS, media, law enforcement officials, etc.). All documentation related to the breach investigation, including the risk assessment, shall be retained for a minimum of six years. A template breach log is located here.
- Risk Assessment: For an acquisition, access, use or disclosure of ePHI to constitute a breach, it must
constitute a violation of the HIPAA Privacy Rule. A use or disclosure of ePHI that is incidental to an
otherwise permissible use or disclosure and occurs despite reasonable safeguards and proper minimum
necessary procedures would not be a violation of the Privacy Rule and would not qualify as a potential
breach. To determine if an impermissible use or disclosure of ePHI constitutes a breach and requires
further notification, the organization will need to perform a risk assessment to determine if there is
significant risk of harm to the individual as a result of the impermissible use or disclosure. The
organization shall document the risk assessment as part of the investigation in the incident report form
noting the outcome of the risk assessment process. The organization has the burden of proof for
demonstrating that all notifications to appropriate Customers or that the use or disclosure did not
constitute a breach. Based on the outcome of the risk assessment, the organization will determine the
need to move forward with breach notification. The risk assessment and the supporting documentation
shall be fact specific and address:
- Consideration of who impermissibly used or to whom the information was impermissibly disclosed;
- The type and amount of ePHI involved;
- The cause of the breach, and the entity responsible for the breach, either Customer, biospatial, or Partner.
- The potential for significant risk of financial, reputational, or other harm.
- Timeliness of Notification: Upon discovery of a breach, notice shall be made to the affected biospatial Customers no later than 24 hours after the discovery of the breach. It is the responsibility of the organization to demonstrate that all notifications were made as required, including evidence demonstrating the necessity of delay.
- Delay of Notification Authorized for Law Enforcement Purposes: If a law enforcement official states to
the organization that a notification, notice, or posting would impede a criminal investigation or cause
damage to national security, the organization shall:
- If the statement is in writing and specifies the time for which a delay is required, delay such notification, notice, or posting of the timer period specified by the official; or
- If the statement is made orally, document the statement, including the identify of the official making the statement, and delay the notification, notice, or posting temporarily and no longer than 30 days from the date of the oral statement, unless a written statement as described above is submitted during that time.
- Content of the Notice: The notice shall be written in plain language and must contain the following
information:
- A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known;
- A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known;
- Any steps the Customer should take to protect Customer data from potential harm resulting from the breach.
- A brief description of what biospatial is doing to investigate the breach, to mitigate harm to individuals and Customers, and to protect against further breaches.
- Contact procedures for individuals to ask questions or learn additional information, which may include a toll-free telephone number, an e-mail address, a web site, or postal address.
- Methods of Notification: biospatial Customers will be notified via email and phone within the timeframe for reporting breaches, as outlined above.
- Maintenance of Breach Information/Log: As described above and in addition to the reports created for
each incident, biospatial shall maintain a process to record or log all breaches of unsecured ePHI
regardless of the number of records and Customers affected. The following information should be
collected/logged for each breach (see sample Breach Notification Log):
- A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
- A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
- A description of the action taken with regard to notification of patients regarding the breach.
- Resolution steps taken to mitigate the breach and prevent future occurrences.
- Workforce Training: biospatial shall train all members of its workforce on the policies and procedures with respect to ePHI as necessary and appropriate for the members to carry out their job responsibilities. Workforce members shall also be trained as to how to identify and report breaches within the organization.
- Complaints: biospatial must provide a process for individuals to make complaints concerning the organization's patient privacy policies and procedures or its compliance with such policies and procedures.
- Sanctions: The organization shall have in place and apply appropriate sanctions against members of its workforce, Customers, and Partners who fail to comply with privacy policies and procedures.
- Retaliation/Waiver: biospatial may not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against any individual for the exercise by the individual of any privacy right. The organization may not require individuals to waive their privacy rights under as a condition of the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits.
biospatial platform Customer Responsibilities
- The biospatial Customer that accesses, maintains, retains, modifies, records, stores, destroys, or
otherwise holds, uses, or discloses unsecured ePHI shall, without unreasonable delay and in no case
later than 60 calendar days after discovery of a breach, notify biospatial of such breach. The Customer
shall provide biospatial with the following information:
- A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
- A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
- A description of the action taken with regard to notification of patients regarding the breach.
- Resolution steps taken to mitigate the breach and prevent future occurrences.
- Notice to Media: biospatial Customers are responsible for providing notice to prominent media outlets at the Customer's discretion.
- Notice to Secretary of HHS: biospatial Customers are responsible for providing notice to the Secretary of HHS at the Customer's discretion.
Sample Letter to Customers in Case of Breach
[Date]
[Name]
[Name of Customer]
[Address 1]
[Address 2]
[City, State Zip Code]
Dear [Name of Customer]:
I am writing to you from biospatial, Inc., with important information about a recent breach that affects your account with us. We became aware of this breach on [Insert Date] which occurred on or about [Insert Date]. The breach occurred as follows:
Describe event and include the following information:
- A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known.
- A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known.
- Any steps the Customer should take to protect themselves from potential harm resulting from the breach.
- A brief description of what biospatial is doing to investigate the breach, to mitigate harm to individuals, and to protect against further breaches.
- Contact procedures for individuals to ask questions or learn additional information, which includes a toll-free telephone number, an e-mail address, web site, or postal address.
Other Optional Considerations:
- Recommendations to assist customer in remedying the breach.
We will assist you in remedying the situation.
Sincerely,
Jonathan Woodworth
CEO / Co-founder
biospatial, Inc.
Disaster Recovery Policy
The biospatial Contingency Plan establishes procedures to recover biospatial following a disruption resulting from a disaster. This Disaster Recovery Policy is maintained by the biospatial Security Officer and Privacy Officer.
The following objectives have been established for this plan:
- Maximize the effectiveness of contingency operations through an established plan that consists of the
following phases:
- Notification/Activation phase to detect and assess damage and to activate the plan;
- Recovery phase to restore temporary IT operations and recover damage done to the original system;
- Reconstitution phase to restore IT system processing capabilities to normal operations.
- Identify the activities, resources, and procedures needed to carry out biospatial processing requirements during prolonged interruptions to normal operations.
- Identify and define the impact of interruptions to biospatial systems.
- Assign responsibilities to designated personnel and provide guidance for recovering biospatial during prolonged periods of interruption to normal operations.
- Ensure coordination with other biospatial staff who will participate in the contingency planning strategies.
- Ensure coordination with external points of contact and vendors who will participate in the contingency planning strategies.
This biospatial Contingency Plan has been developed as required under the Office of Management and Budget (OMB) Circular A-130, Management of Federal Information Resources, Appendix III, November 2000, and the Health Insurance Portability and Accountability Act (HIPAA) Final Security Rule, Section §164.308(a)(7), which requires the establishment and implementation of procedures for responding to events that damage systems containing electronic protected health information.
This biospatial Contingency Plan is created under the legislative requirements set forth in the Federal Information Security Management Act (FISMA) of 2002 and the guidelines established by the National Institute of Standards and Technology (NIST) Special Publication (SP) 800-34, titled “Contingency Planning Guide for Information Technology Systems” dated June 2002.
The biospatial Contingency Plan also complies with the following federal and departmental policies:
- The Computer Security Act of 1987;
- OMB Circular A-130, Management of Federal Information Resources, Appendix III, November 2000;
- Federal Preparedness Circular (FPC) 65, Federal Executive Branch Continuity of Operations, July 1999;
- Presidential Decision Directive (PDD) 67, Enduring Constitutional Government and Continuity of Government Operations, October 1998;
- PDD 63, Critical Infrastructure Protection, May 1998;
- Federal Emergency Management Agency (FEMA), The Federal Response Plan (FRP), April 1999;
- Defense Authorization Act (Public Law 106-398), Title X, Subtitle G, “Government Information Security Reform,” October 30, 2000
Example of the types of disasters that would initiate this plan are natural disaster, political disturbances, man made disaster, external human threats, internal malicious activities.
biospatial defined two categories of systems from a disaster recovery perspective.
- Critical Systems. These systems host application servers and database servers or are required for functioning of systems that host application servers and database servers. These systems, if unavailable, affect the integrity of data and must be restored, or have a process begun to restore them, immediately upon becoming unavailable.
- Non-critical Systems. These are all systems not considered critical by definition above. These systems, while they may affect the performance and overall security of critical systems, do not prevent Critical systems from functioning and being accessed appropriately. These systems are restored at a lower priority than critical systems.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 12.c - Developing and Implementing Continuity Plans Including Information Security
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(7)(i) - Contingency Plan
Line of Succession
The following order of succession to ensure that decision-making authority for the biospatial Contingency Plan is uninterrupted. The Chief Technology Officer (CTO) is responsible for ensuring the safety of personnel and the execution of procedures documented within this biospatial Contingency Plan. If the CTO is unable to function as the overall authority or chooses to delegate this responsibility to a successor, the CEO shall function as that authority. To provide contact initiation should the contingency plan need to be initiated, please use the contact list below.
Responsibilities
The following teams have been developed and trained to respond to a contingency event affecting the IT system.
- The Ops Team is responsible for recovery of the biospatial hosted environment, network devices, and all servers. Members of the team include personnel who are also responsible for the daily operations and maintenance of biospatial. The team leader is the CTO and directs the Dev Ops Team.
- The Web Services Team is responsible for assuring all application servers, web services, and platform add-ons are working. It is also responsible for testing redeployments and assessing damage to the environment. The team leader is the CTO and directs the Web Services Team.
Members of the Ops and Web Services teams must maintain local copies of the contact information from Line of Succession. Additionally, the CTO must maintain a local copy of this policy in the event Internet access is not available during a disaster scenario.
Testing and Maintenance
The CTO shall establish criteria for validation/testing of a Contingency Plan, an annual test schedule, and ensure implementation of the test. This process will also serve as training for personnel involved in the plan's execution. At a minimum the Contingency Plan shall be tested annually (within 365 days). The types of validation/testing exercises include tabletop and technical testing. Contingency Plans for all application systems must be tested at a minimum using the tabletop testing process. However, if the application system Contingency Plan is included in the technical testing of their respective support systems that technical test will satisfy the annual requirement.
Tabletop Testing
Tabletop Testing is conducted in accordance with the the CMS Risk Management Handbook, Volume 2. The primary objective of the tabletop test is to ensure designated personnel are knowledgeable and capable of performing the notification/activation requirements and procedures as outlined in the CP, in a timely manner. The exercises include, but are not limited to:
- Testing to validate the ability to respond to a crisis in a coordinated, timely, and effective manner, by simulating the occurrence of a specific crisis.
Technical Testing
The primary objective of the technical test is to ensure the communication processes and data storage and recovery processes can function at an alternate site to perform the functions and capabilities of the system within the designated requirements. Technical testing shall include, but is not limited to:
- Process from backup system at the alternate site;
- Restore system using backups; and
- Switch compute and storage resources to alternate processing site.
Disaster Recovery Procedures
Notification and Activation Phase
This phase addresses the initial actions taken to detect and assess damage inflicted by a disruption to biospatial. Based on the assessment of the Event, sometimes according to the biospatial Incident Response Policy, the Contingency Plan may be activated by the CTO.
The notification sequence is listed below:
- The first responder is to notify the CTO. All known information must be relayed to the CTO.
- The CTO is to contact the Web Services Team and inform them of the event. The CTO is to to begin assessment procedures.
- The CTO is to notify team members and direct them to complete the assessment procedures outlined
below to determine the extent of damage and estimated recovery time. If damage assessment cannot
be performed locally because of unsafe conditions, the CTO is to following the steps below.
- Damage Assessment Procedures:
-
- The CTO is to logically assess damage, gain insight into whether the infrastructure is salvageable, and begin to formulate a plan for recovery.
- Alternate Assessment Procedures:
-
- Upon notification, the CTO will follow the procedures for damage assessment with combined Dev Ops and Web Services Teams.
- The biospatial Contingency Plan is to be activated if one or more of the following criteria are
met:
- biospatial will be unavailable for more than 48 hours.
- Hosting facility is damaged and will be unavailable for more than 24 hours.
- Other criteria, as appropriate and as defined by biospatial.
- If the plan is to be activated, the CTO is to notify and inform team members of the details of the event and if relocation is required.
- Upon notification from the CTO, group leaders and managers are to notify their respective teams. Team members are to be informed of all applicable information and prepared to respond and relocate if necessary.
- The CTO is to notify the hosting facility partners that a contingency event has been declared and to ship the necessary materials (as determined by damage assessment) to the alternate site.
- The CTO is to notify remaining personnel and executive leadership on the general status of the incident.
- Notification can be message, email, or phone.
Recovery Phase
This section provides procedures for recovering the application at an alternate site, whereas other efforts are directed to repair damage to the original system and capabilities.
The following procedures are for recovering the biospatial infrastructure at the alternate site. Procedures are outlined per team required. Each procedure should be executed in the sequence it is presented to maintain efficient operations.
Recovery Goal: The goal is to rebuild biospatial infrastructure to a production state.
The tasks outlines below are not sequential and some can be run in parallel.
- Contact Partners and Customers affected - Web Services
- Assess damage to the environment - Web Services
- Begin replication of new environment using automated and tested scripts, currently Ansible in AWS. - Dev Ops
- Test new environment using pre-written tests - Web Services
- Test logging, security, and alerting functionality - Dev Ops
- Ensure systems are appropriately patched and up to date. - Dev Ops
- Deploy environment to production - Web Services
- Update DNS to new environment. - Dev Ops
Reconstitution Phase
This section discusses activities necessary for restoring biospatial operations at the original or new site. The goal is to restore full operations within 24 hours of a disaster or outage. When the hosted data center at the original or new site has been restored, biospatial operations at the alternate site may be transitioned back. The goal is to provide a seamless transition of operations from the alternate site to the computer center.
- Original or New Site Restoration
- Begin replication of new environment using automated and tested scripts, currently Ansible. - Dev Ops
- Test new environment using pre-written tests. - Web Services
- Test logging, security, and alerting functionality. - Dev Ops
- Deploy environment to production - Web Services
- Ensure systems are appropriately patched and up to date. - Dev Ops
- Update DNS to new environment. - Dev Ops
- Plan Deactivation
- If the biospatial environment is moved back to the original site from the alternative site, all hardware used at the alternate site should be handled and disposed of according to the biospatial Media Disposal Policy.
Disposable Media Policy
biospatial recognizes that media containing ePHI may be reused when appropriate steps are taken to ensure that all stored ePHI has been effectively rendered inaccessible. Destruction/disposal of ePHI shall be carried out in accordance with federal and state law. The schedule for destruction/disposal shall be suspended for ePHI involved in any open investigation, audit, or litigation.
biospatial utilizes dedicated hardware from Subcontractors. ePHI is only stored on encrypted volumes in our hosted environment. biospatial does not use, own, or manage any removable media (e.g., SD cards, USB sticks) or tapes that have access to ePHI.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 0.9o - Management of Removable Media
Applicable Standards from the HIPAA Security Rule
- 164.310(d)(1) - Device and Media Controls
Disposable Media Policy
- ePHI is not stored on removable media.
- biospatial assumes all disposable media in its platform may contain ePHI, so it treats all disposable media with the same protections and disposal policies.
- All destruction/disposal of ePHI media will be done in accordance with federal and state laws and regulations and pursuant to Data Use Agreements that Customers enter into with biospatial. Records that have satisfied the period of retention will be destroyed/disposed of in an appropriate manner.
- Records involved in any open investigation, audit or litigation should not be destroyed/disposed of. If notification is received that any of the above situations have occurred or there is the potential for such, the record retention schedule shall be suspended for these records until such time as the situation has been resolved. If the records have been requested in the course of a judicial or administrative hearing, a qualified protective order will be obtained to ensure that the records are returned to the organization or properly destroyed/disposed of by the requesting party.
- Before reuse of any media, all ePHI is rendered inaccessible, cleaned, or scrubbed to restrict future access.
- All biospatial Subcontractors provide that, upon termination of the contract, they will return or destroy/dispose of all patient health information. In cases where the return or destruction/disposal is not feasible, the contract limits the use and disclosure of the information to the purposes that prevent its return or destruction/disposal.
- Any media containing ePHI is disposed using a method that ensures the ePHI could not be readily recovered or reconstructed.
- The methods of destruction, disposal, and reuse are reassessed periodically, based on current technology, accepted practices, and availability of timely and cost-effective destruction, disposal, and reuse technologies and services.
- In the cases of a biospatial Customer terminating a contract with biospatial and no longer utilize biospatial services, the following actions will be taken depending on the biospatial services in use. In all cases it is solely the responsibility of the biospatial Customer to maintain the safeguards required of HIPAA once the data is transmitted out of biospatial Systems.
IDS Policy
In order to preserve the integrity of data that biospatial stores, processes, or transmits for Customers, biospatial implements strong intrusion detection tools and policies to proactively track and retroactively investigate unauthorized access. biospatial currently utilizes OSSEC and Datadog to track file system integrity, monitor log data, detect rootkit access, and monitor network traffic from all IP addresses.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 09.ab - Monitoring System Use
- 06.e - Prevention of Misuse of Information
- 10.h - Control of Operational Software
Applicable Standards from the HIPAA Security Rule
- 164.312(b) - Audit Controls
Intrusion Detection Policy
- Datadog is used to monitor and correlate log data from different systems on an ongoing basis. IDS and service health alerts are monitored continuously. Comprehensive reviews of Datadog events and signals are performed at least monthly by the Security Officer or a delegate appointed by the Security Officer and approved by the Privacy Officer.
- Datadog generates alerts to prompt analysis and investigation of suspicious activity or suspected violations.
- Datadog File Integrity Monitoring and OSSEC monitor file system integrity and send real-time alerts when suspicious changes are made to the file system.
- Automatic monitoring is performed to identify loss of availability of production services and systems.
- Network traffic is monitored to detect potential denial of service attacks. Additionally, our hosting provider actively monitors its network to detect and respond to denial of services attacks.
- All new firewall rules and configuration changes are tested before being pushed into production. All firewall and router rules are reviewed every quarter.
- biospatial utilizes redundant firewall on network perimeters.
Vulnerability Scanning Policy
biospatial is proactive about information security and understands that vulnerabilities need to be monitored and remediated on an ongoing basis. biospatial utilizes automated tools to routinely scan systems and identify vulnerabilities in the underlying operating system, third-party software, and biospatial proprietary software (e.g., the biospatial web application).
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 10.m - Control of Technical Vulnerabilities
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(8) - Evaluation
Vulnerability Scanning Policy
- Automated internal vulnerability scanning is performed regularly and results are reviewed weekly.
- Third party vulnerability scanning and penetration testing is performed at least annually.
- Vulnerability scanning is conducted using authenticated scans when applicable.
- Vulnerability assessment is performed by the biospatial Security Officer with assistance from the Chief Technology Officer or their designate.
- Reviewing vulnerability scan reports and findings, as well as any further investigation into discovered vulnerabilities, are the responsibility of the biospatial Security Officer or their designate.
- In the case of new vulnerabilities, the following steps are taken:
- All new vulnerabilities found by automated vulnerability scans are tracked for review and remediation.
- Vulnerabilities in operating system components are remediated by automated application of all available security patches. Any operating system vulnerabilities remaining after patching are assessed for risk by the security team and are prioritized accordingly.
- Vulnerabilities in third-party and proprietary code are assessed for risk by the security and development teams and are prioritized accordingly. Vulnerabilities in third-party software are remediated by upgrading or replacing the third-party component. Vulnerabilities in proprietary code are remediated by the biospatial development team.
- Vulnerabilities that are reported by third party vulnerability testing are documented and reviewed by the security team. Confirmed vulnerabilities are prioritized for remediation according to risk.
- New vulnerability findings are incorporated into biospatial risk assessments as appropriate. New vulnerabilities may immediately trigger a new risk assessment if they are of sufficient concern, and this process is outlined in detail in the biospatial Risk Assessment Policy.
- All vulnerability scanning reports are retained for 6 years by biospatial. Vulnerability report review is monitored on a quarterly basis to assess compliance with above policy.
- Penetration testing is performed regularly as part of the biospatial vulnerability
management policy.
- Below is the process used
to conduct internal penetration tests.
- The Security Officer initiates the penetration test by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
- The Security Officer, or biospatial personnel assigned by the Security Officer, is assigned to conduct the penetration test.
- Gaps and vulnerabilities identified during penetration testing are reviewed, with plans for correction and/or mitigation, by the biospatial Security Officer before the Issue can move to be approved.
- Once the testing is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further testing and review.
- If the Issue is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
- Penetration tests results are retained for 6 years by biospatial.
- Internal penetration testing is monitored on an annual basis using Redmine reporting to assess compliance with above policy.
- Below is the process used
to conduct internal penetration tests.
Data Integrity Policy
biospatial takes data integrity very seriously. As stewards and partners of biospatial Customers, we strive to ensure data is protected from unauthorized access and that it is available when needed. The following policies drive many of our procedures and technical settings in support of the biospatial mission of data protection.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 10.b - Input Data Validation
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(8) - Evaluation
Data Integrity Policies
Production systems that create, receive, store, or transmit Customer data (hereafter “Production Systems”) must follow the guidelines described in this section.
Disabling Non-Essential Services
- All Production Systems must disable services that are not required to achieve the business purpose or function of the system.
Monitoring Log-in Attempts
- All access to Production Systems must be logged. This is done following the biospatial Auditing Policy.
Prevention of Malware on Production Systems
- All Production Systems must have OSSEC running, and set to scan system every 2 hours and at reboot to ensure not malware is present. Detected malware is evaluated and removed.
- Virus scanning software is run on all Production Systems.
- Hosts are scanned daily for malicious binaries in critical system paths.
- The virus and malware signature database is checked hourly and automatically updated if new signatures are available.
- Logs of virus scans are maintained according to the requirements outlined in Audit Log Security Controls and Backup.
- All Production Systems are to only be used for biospatial business needs.
Patch Management
- Software patches and updates will be applied to all systems in a timely manner. In the case of routine updates, they will be applied after thorough testing. In the case of updates to correct known vulnerabilities, priority will be given to testing to speed the time to production. Critical security patches are applied within 30 days from testing and all security patches are applied within 90 days after testing. Exceptions may be made at the discretion of the CTO.
- Administrators subscribe to mailing lists to ensure up to date on current version of all biospatial managed software on Production Systems.
Intrusion Detection and Vulnerability Scanning
- Production systems are monitored using IDS systems. Suspicious activity is logged and alerts are generated.
- Vulnerability scanning of Production Systems must occur on a predetermined, regular basis, no less than annually. Scans are reviewed by Security Officer, with defined steps for risk mitigation, and retained for future reference.
Production System Security
- System, network, and server security is managed and maintained by the CTO and the Security Officer.
- Up to date system lists and architecture diagrams are kept for all production environments.
- Access to Production Systems is controlled using centralized tools and multi-factor authentication.
Production Data Security
- Reduce the risk of compromise of Production Data.
- Implement and/or review controls designed to protect Production Data from improper alteration or destruction.
- Ensure that confidential data is stored in a manner that supports user access logs and automated monitoring for potential security incidents.
- Ensure biospatial Customer Production Data is segmented and only accessible to Customer authorized to access data.
- All Production Data at rest is stored on encrypted volumes using encryption keys managed by biospatial. Encryption at rest is ensured through the use of automated deployment scripts referenced in the Configuration Management Policy.
- Volume encryption keys and machines that generate volume encryption keys are protected from unauthorized access. Volume encryption key material is protected with access controls such that the key material is only accessible by privileged accounts.
- Encrypted volumes use AES encryption with a minimum of 256-bit keys, or keys and ciphers of equivalent or higher cryptographic strength.
Transmission Security
- All data transmission is encrypted using encryption keys managed by biospatial. Data encryption in transit applies to internal communication within biospatial's cloud environment as well as external connections traversing the Internet.
- Transmission encryption keys and machines that generate keys are protected from unauthorized access. Transmission encryption key material is protected with access controls such that the key material is only accessible by privileged accounts.
- Transmission encryption is consistent with NIST Special Publication 800-52 Revision 1.
- Transmission encryption keys are regenerated annually or as frequently as allowed when regeneration is performed by automated services.
- In the case of biospatial provided APIs, provide mechanisms to ensure person sending or receiving data is authorized to send and save data.
- System logs of all transmissions of Production Data access. These logs must be available for audit.
Employees Policy
biospatial is committed to ensuring all workforce members actively address security and compliance in their roles at biospatial. As such, training is imperative to assuring an understanding of current best practices, the different types and sensitivities of data, and the sanctions associated with non-compliance.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 02.e - Information Security Awareness, Education, and Training
- 06.e - Prevention of Misuse of Information Assets
- 07.c - Acceptable Use of Assets
- 09.j - Controls Against Malicious Code
- 01.y - Teleworking
Applicable Standards from the HIPAA Security Rule
- 164.308(a)(5)(i) - Security Awareness and Training
Employment Policies
- All new workforce members, including contractors, are
given training on HIPAA and biospatial security policies and procedures within 30 days of
employment and annually thereafter. Training includes HIPAA reporting requirements,
including the ability to anonymously report security incidents, and the levels of
compliance and obligations for biospatial and its Customers and Partners.
- Records of training are kept for all workforce members.
- Upon completion of training, workforce members complete this form and and email to .
- Current biospatial training is hosted here.
- Workforce members must complete this training before accessing production systems containing ePHI.
- Newly-hired workforce members who have completed initial training within 60 days of scheduled company-wide annual training will not be required to repeat the training for that year.
- All workforce members are granted access to formal organizational policies, which include the sanction policy for security violations.
- The biospatial Employee
Handbook
clearly states the responsibilities and acceptable
behavior regarding information system usage, including
rules for email, Internet, mobile devices, and social
media usage.
- Workforce members are required to sign an agreement stating that they have read and will abide by all terms outlined in the biospatial Employee Handbook, along with all policies and processes described in this document.
- A Human Resources representative will provide the agreement to new workforce members during their onboarding process.
- All workforce members are educated about the approved set of tools to be installed on workstations.
- All remote (teleworking) workforce members are trained on the risks, the controls implemented, their responsibilities, and sanctions associated with violation of policies. Additionally, remote security is maintained through the use of VPN tunnels for all access to production systems with access to ePHI data.
-
biospatial workforce members, including employees, contractors, and consultants,
may only use biospatial-purchased and -owned workstations for a) accessing corporate VPN,
b) accessing production systems containing ePHI data, c) accessing the non-guest
biospatial Wi-Fi network, and d) syncing SharePoint and OneDrive data.
- Any workstations used to access the above systems must be configured as prescribed in Employee Workstation Use.
- Any workstations used to access the above systems must have antivirus software installed, configured, and enabled.
- biospatial may monitor access and activities of all users on workstations and the above systems in order to meet auditing policy requirements (Auditing Policy).
- Access to internal biospatial systems can be requested using the procedures outlined in Access Establishment and Modification. All requests for access must be granted by the biospatial Security Officer.
- Request for modifications of access for any biospatial employee can be made using the procedures outlined in Access Establishment and Modification.
- Except at the discretion of both the Privacy Officer and
the Security Officer, biospatial employees are strictly forbidden
from downloading any ePHI to their workstations.
- Employees found to be in violation of this policy will be subject to sanctions as described in Security Officer.
- Exceptions to this policy may be granted for brief periods of time and on a limited basis. Exceptions to this policy must be approved by each of the Privacy Officer, Security Officer, and CTO. Employee workstations will be inspected for configuration as prescribed in Employee Workstation Use prior to granting an exception to this policy.
- Prior to hiring new employees, biospatial performs background checks on candidate employees, which may include resumes, references, criminal records, and credit history.
- Employees are required to cooperate with federal and
state investigations.
- Employees must not interfere with investigations through willful misrepresentation, omission of facts, or by the use of threats against any person.
- Employees found to be in violation of this policy will be subject to sanctions as described in Security Officer.
Approved Tools Policy
biospatial utilizes a suite of approved software tools for collaborative internal use by workforce members. These software tools are either self-hosted, with security managed by biospatial, or they are hosted by a Subcontractor with appropriate business associate agreements in place to preserve data integrity. Use of other collaborative or cloud tools requires approval from biospatial leadership. Workforce members are permitted to install applications and tools on their workstations for individual use that are not on this list, subject to the restrictions of the applicable acceptable use policies and the Employee Handbook.
List of Approved Tools
- 1Password. A service to store and share biospatial secrets including user account credentials as well as encryption keys.
- Datadog. Datadog tools and services are used for intrusion detection; centralized log storage, monitoring, search, and visualization; and as a secondary vulnerability scanner (in conjunction with Amazon Web Services Systems Manager).
- Amazon Web Services (AWS). A secure cloud services platform that hosts the biospatial platform and many of the tools used for the development, management, and monitoring of the platform. AWS services in use include, but are not limited to EC2, Route 53, S3, and others. CloudTrail, CloudWatch, and EBS Volumes are listed separately because of the critical configuration and compliance control role they play.
- Ansible. Ansible is used to maintain the software configuration of systems running in AWS.
- ClamAV. ClamAV is the Linux antivirus tool used on our server systems.
- CloudTrail. CloudTrail logs all AWS API calls (e.g., to track changes to provisioned infrastructure).
- CloudWatch. CloudWatch monitors AWS resources and sends e-mail alerts based on configured rules (e.g., when AWS configuration changes, on failed console sign-in attempts, when IAM policies are changed, etc.).
- Consul. Consul is a distributed key/value store, service discovery and DNS component.
- Docker. Docker and the Docker Registry are used to store and deploy lightweight containers that are used to construct the biospatial software infrastructure (e.g., ETL).
- EBS Volumes. Elastic Block Store (EBS) volumes are used as root and data volumes for all EC2 instances in the AWS environment.
- Git. Git is a version control platform used to store and version biospatial software and configuration information.
- Jenkins. A continuous integration tool to automatically build and test code to ensure successful software builds of the biospatial platform.
- Netsparker Web Application Scanning. This tool is used for vulnerability scanning of our web application.
- Microsoft 365. Microsoft 365 is used for email and document collaboration.
- Microsoft Teams. Microsoft Teams is used for online meetings and web conferencing, both internally and with external partners.
- OneDrive. OneDrive, a service of Microsoft 365, is used for storage of files and sharing of files with Partners and Customers.
- OpenVPN. Used for secure point-to-site VPN communications by biospatial employees, contractors, and vendors for access to the resources in the biospatial AWS account.
- OSSEC. OSSEC is a system monitoring (host-based intrusion detection) system.
- Redmine. Redmine is used for issue tracking.
- Review Board. Review Board is used for code review and collaboration.
- SharePoint. SharePoint, a service of Microsoft 365, is used for centralized document storage and management.
- Slack. Slack is used as an instant messaging and collaboration tool.
- Terraform. Terraform (from HashiCorp) is used to provision infrastructure on AWS.
- Vault. Vault (from HashiCorp) is used as a secrets engine.
List of Approved Tools for Storing ePHI
biospatial permits storing ePHI on a limited selection of approved tools. A tool's HIPAA compliance, and even the existence of a BAA with biospatial, does not automatically imply that biospatial permits storage of ePHI in the tool. Storage of ePHI on tools or platforms not on this approved list require a security exception approved by the Security Officer. Explicitly, ePHI may not be stored in Slack or Microsoft 365, including SharePoint & OneDrive.
- Encrypted EBS Volumes.
Additional Tool Approvals for ePHI
The following tools are approved for use with ePHI in a limited way. Each entry below describes the approved use. Any use not expressly listed below is not approved.
- Microsoft Teams Meetings & Microsoft Teams live events. Sharing and discussing ePHI in a Teams teleconference is approved with the following caveats:
- The meeting organizer is responsible for verifying that all participants have a legitimate business need for access to the ePHI that will be shared. This includes monitoring the attendee list during the meeting and, if necessary, challenging attendees who join while the meeting is in progress.
- The meeting organizer is responsible for confirming that all attendees are a part of an organization with a current BAA with biospatial to cover the ePHI exchange.
- The meeting organizer shall remind participants at the beginning of the teleconference that ePHI will be displayed and/or discussed. Participants shall be reminded that they have a shared responsibility to protect ePHI through their BAA with biospatial.
- The meeting organizer is responsible for recording in meeting minutes or notes that ePHI was shared and the list of attendees.
- Meeting organizers shall not use Microsoft Team's recording capabilities to create screen captures of ePHI. Note that it is impossible to prevent participants from using a third-party screen capture tool during the meeting, which is why it is important to remind participants of the shared responsibility to protect ePHI.
3rd Party Policy
biospatial makes every effort to ensure all 3rd party organizations are compliant and do not compromise the integrity, security, and privacy of biospatial or biospatial Customer data. 3rd Parties include Customers, Partners, Subcontractors, and Contracted Developers.
Applicable Standards
Applicable Standards from the HITRUST Common Security Framework
- 05.i - Identification of Risks Related to External Parties
- 05.k - Addressing Security in Third Party Agreements
- 09.e - Service Delivery
- 09.f - Monitoring and Review of Third Party Services
- 09.g - Managing Changes to Third Party Services
- 10.1 - Outsourced Software Development
Applicable Standards from the HIPAA Security Rule
- 164.314(a)(1)(i) - Business Associate Contracts or Other Arrangements
Policies to Ensure 3rd Parties Support biospatial Compliance
- biospatial allows Subcontractors and Contracted Developers to access production systems containing ePHI provided each has a Business Associate Agreement with biospatial, each has provided to biospatial proof of HIPAA privacy and security training, and each has appropriate need to know.
- All connections and data in transit between the biospatial platform and 3rd parties are encrypted end to end.
- A standard business associate agreement with Customers and Partners is defined and includes the required security controls in accordance with the organization's security policies. Additionally, responsibility is assigned in these agreements.
- Where appropriate, biospatial has Service Level
Agreements (SLAs) with Subcontractors with an agreed
service arrangement addressing liability, service
definitions, security controls, and aspects of services
management.
- Subcontractors must coordinate, manage, and communicate any changes to services provided to biospatial.
- Changes to 3rd party services are classified as configuration management changes and thus are subject to the policies and procedures described in Configuration Management Policy; substantial changes to services provided by 3rd parties will invoke a Risk Assessment as described in Risk Management Policies.
- biospatial utilizes monitoring tools to regularly evaluate Subcontractors against relevant SLAs.
- No biospatial Customers or Partners have access outside of their own environment, meaning they cannot access, modify, or delete anything related to other 3rd parties.
- biospatial maintains and annually reviews a list all
current Partners and Subcontractors.
- The list of current Partners and Subcontractors is maintained by the biospatial Privacy Officer, includes details on all provided services (along with contact information), and is recorded in biospatial Organizational Concepts.
- The annual review of Partners and Subcontractors is conducted as a part of the security, compliance, and SLA review referenced below.
- biospatial assesses security, compliance, and SLA
requirements and considerations with all Partners and
Subcontractors. This includes annual assessment of SOC2
Reports for all biospatial infrastructure partners.
- biospatial leverages recurring calendar invites to ensure reviews of all 3rd party services are performed annually. These reviews are performed by the biospatial Security Officer and Privacy Officer.
- Regular review is conducted as required by SLAs to ensure security and compliance. These reviews include reports, audit trails, security events, operational issues, failures and disruptions, and identified issues are investigated and resolved in a reasonable and timely manner.
- Any changes to Partner and Subcontractor services and systems are reviewed before implementation.
- For all partners, biospatial reviews activity annually to ensure partners are in line with SLAs in contracts with biospatial.
- SLA review is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.
Key Definitions
-
Access: Means the ability or the means necessary to read, write, modify, or communicate data/ information or otherwise use any system resource.
-
Application Level: Controls and security associated with an Application.
-
Audit: Internal process of reviewing information system access and activity (e.g., log-ins, file accesses, and security incidents). An audit may be done as a periodic event, as a result of a patient complaint, or suspicion of employee wrongdoing.
-
Audit Controls: Technical mechanisms that track and record computer/system activities.
-
Audit Logs: Encrypted records of activity maintained by the system which provide: 1) date and time of activity; 2) origin of activity (app); 3) identification of user doing activity; and 4) data accessed as part of activity.
-
Backup: The process of making an electronic copy of data stored in a computer system. This can either be complete, meaning all data and programs, or incremental, including just the data that changed from the previous backup.
-
Breach: Means the acquisition, access, use, or disclosure of protected health information (PHI) in a manner not permitted under the Privacy Rule which compromises the security or privacy of the PHI. For purpose of this definition, “compromises the security or privacy of the PHI” means poses a significant risk of financial, reputational, or other harm to the individual. A use or disclosure of PHI that does not include the identifiers listed at §164.514(e)(2), limited data set, date of birth, and zip code does not compromise the security or privacy of the PHI. Breach excludes:
- Any unintentional acquisition, access or use of PHI by a workforce member or person acting under the authority of a Covered Entity (CE) or Business Associate (BA) if such acquisition, access, or use was made in good faith and within the scope of authority and does not result in further use or disclosure in a manner not permitted under the Privacy Rule.
- Any inadvertent disclosure by a person who is authorized to access PHI at a CE or BA to another person authorized to access PHI at the same CE or BA, or organized health care arrangement in which the CE participates, and the information received as a result of such disclosure is not further used or disclosed in a manner not permitted under the Privacy Rule.
- A disclosure of PHI where a CE or BA has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain such information.
-
Business Associate: A person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.
-
Consultant: An individual that provides services to biospatial. A consultant is considered a “biospatial workforce member”. Consultants must complete security training and are required to follow all policies and procedures as if they were directly employed by biospatial. Consultants do not sign BAAs, and to the extent that their work may involve HIPAA-covered data, they are covered by any agreement that biospatial signs, such as BAAs with data providers.
-
Covered Entity: A health plan, health care clearinghouse, or a healthcare provider who transmits any health information in electronic form.
-
Customers: Contractually bound users of biospatial platform.
-
De-identification: The process of removing identifiable information so that data is rendered to not be PHI.
-
Disaster Recovery: The ability to recover a system and data after being made unavailable.
-
Disaster Recovery Service: A disaster recovery service for disaster recovery in the case of system unavailability. This includes both the technical and the non-technical (process) required to effectively stand up an application after an outage.
-
Disclosure: Disclosure means the release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information.
-
Electronic Protected Health Information (ePHI): Any individually identifiable health information protected by HIPAA that is transmitted by, processed in some way, or stored in electronic media.
-
Environment: The overall technical environment, including all servers, network devices, and applications.
-
Event: An event is defined as an occurrence that does not constitute a serious adverse effect on biospatial, its operations, or its Customers, though it may be less than optimal. Examples of events include, but are not limited to:
- A hard drive malfunction that requires replacement;
- Systems become unavailable due to power outage that is non-hostile in nature, with redundancy to ensure ongoing availability of data;
- Accidental lockout of an account due to incorrectly entering a password multiple times.
-
Hardware (or hard drive): Any computing device able to create and store ePHI.
-
Health and Human Services (HHS): The government body that maintains HIPAA.
-
Individually Identifiable Health Information: That information that is a subset of health information, including demographic information collected from an individual, and is created or received by a health care provider, health plan, employer, or health care clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and identifies the individual; or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.
-
Indication: A sign that an Incident may have occurred or may be occurring at the present time. Examples of indications include:
- The network intrusion detection sensor alerts when a known exploit occurs against an FTP server. Intrusion detection is generally reactive, looking only for footprints of known attacks. It is important to note that many IDS “hits” are also false positives and are neither an event nor an incident;
- The antivirus software alerts when it detects that a host is infected with a worm;
- Users complain of slow access to hosts on the Internet;
- The system administrator sees a filename with unusual characteristics;
- Automated alerts of activity from log monitors like OSSEC;
- An alert from OSSEC about file system integrity issues.
-
Intrusion Detection System (IDS): A software tool use to automatically detect and notify in the event of possible unauthorized network and/or system access.
-
IDS Service: An Intrusion Detection Service for providing IDS notification in the case of suspicious activity.
-
Law Enforcement Official: Any officer or employee of an agency or authority of the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, who is empowered by law to investigate or conduct an official inquiry into a potential violation of law; or prosecute or otherwise conduct a criminal, civil, or administrative proceeding arising from an alleged violation of law.
-
Logging Service: A logging service for unifying system and application logs, encrypting them, and providing a dashboard for them.
-
Messaging: API-based services to deliver and receive SMS messages.
-
Minimum Necessary Information: Protected health information that is the minimum necessary to accomplish the intended purpose of the use, disclosure, or request. The “minimum necessary” standard applies to all protected health information in any form.
-
Mobile Device: The term "mobile device" is used in these policies to refer to smartphones and tablets running iOS, iPadOS, or Android (including vendor-specific derivations based on the Android Open Source Project (AOSP)).
-
Off-Site: For the purpose of storage of Backup media, off-site is defined as any location separate from the building in which the backup was created. It must be physically separate from the creating site.
-
Organization: For the purposes of this policy, the term “organization” shall mean biospatial.
-
Partner: Contractual bound 3rd party vendor with integration with the biospatial platform. May offer Add-on services.
-
Platform: The overall technical environment of biospatial.
-
Precursor: A sign that an Incident may occur in the future. Examples of precursors include:
- Suspicious network and host-based IDS events/attacks;
- Alerts as a result of detecting malicious code at the network and host levels;
- Alerts from file integrity checking software;
- Audit log alerts.
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Protected Health Information (PHI): Individually identifiable health information that is created by or received by the organization, including demographic information, that identifies an individual, or provides a reasonable basis to believe the information can be used to identify an individual, and relates to:
- Past, present or future physical or mental health or condition of an individual.
- The provision of health care to an individual.
- The past, present, or future payment for the provision of health care to an individual.
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Restricted Area: Those areas of the building(s) where protected health information and/or sensitive organizational information is stored, utilized, or accessible at any time.
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Risk: The likelihood that a threat will exploit a vulnerability, and the impact of that event on the confidentiality, availability, and integrity of ePHI, other confidential or proprietary electronic information, and other system assets.
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Risk Assessment: (Referred to as Risk Analysis in the HIPAA Security Rule); the process:
- Identifies the risks to information system security and determines the probability of occurrence and the resulting impact for each threat/vulnerability pair identified given the security controls in place;
- Prioritizes risks; and
- Results in recommended possible actions/controls that could reduce or offset the determined risk.
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Risk Management: Within this policy, it refers to two major process components: risk assessment and risk mitigation. This differs from the HIPAA Security Rule, which defines it as a risk mitigation process only. The definition used in this policy is consistent with the one used in documents published by the National Institute of Standards and Technology (NIST).
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Risk Management Team: Individuals who are knowledgeable about the Organization's HIPAA Privacy, Security and HITECH policies, procedures, training program, computer system set up, and technical security controls, and who are responsible for the risk management process and procedures outlined below.
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Risk Mitigation: Referred to as Risk Management in the HIPAA Security Rule, and is a process that prioritizes, evaluates, and implements security controls that will reduce or offset the risks determined in the risk assessment process to satisfactory levels within an organization given its mission and available resources.
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Role: The category or class of person or persons doing a type of job, defined by a set of similar or identical responsibilities.
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Sanitization: Removal or the act of overwriting data to a point of preventing the recovery of the data on the device or media that is being sanitized. Sanitization is typically done before re-issuing a device or media, donating equipment that contained sensitive information or returning leased equipment to the lending company.
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Security Incident (or just Incident): A security incident is an occurrence that exercises a significant adverse effect on people, process, technology, or data. Security incidents include, but are not limited to:
- A system or network breach accomplished by an internal or external entity; this breach can be inadvertent or malicious;
- Unauthorized disclosure;
- Unauthorized change or destruction of ePHI (i.e. delete dictation, data alterations not following biospatial's procedures);
- Denial of service not attributable to identifiable physical, environmental, human or technology causes;
- Disaster or enacted threat to business continuity;
- Information Security Incident: A violation or imminent threat of violation of information security policies, acceptable use policies, or standard security practices. Examples of information security incidents may include, but are not limited to, the following:
- Denial of Service: An attack that prevents or impairs the authorized use of networks, systems, or applications by exhausting resources;
- Malicious Code: A virus, worm, Trojan horse, or other code-based malicious entity that infects a host;
- Unauthorized Access/System Hijacking: A person gains logical or physical access without permission to a network, system, application, data, or other resource. Hijacking occurs when an attacker takes control of network devices or workstations;
- Inappropriate Usage: A person violates acceptable computing use policies;
- Other examples of observable information security incidents may include, but are not limited to:
- Use of another person's individual password and/or account to login to a system;
- Failure to protect passwords and/or access codes (e.g., posting passwords on equipment);
- Installation of unauthorized software;
- Terminated workforce member accessing applications, systems, or network.
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Subservice organization: A vendor is distinguished as a subservice organization for biospatial if the controls at the vendor are relied upon by biospatial to meet biospatial’s SOC 2 trust services criteria covering the service commitments and system requirements with biospatial’s user entities.
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Threat: The potential for a particular threat-source to successfully exercise a particular vulnerability. Threats are commonly categorized as:
- Environmental - external fires, HVAC failure/temperature inadequacy, water pipe burst, power failure/fluctuation, etc.
- Human - hackers, data entry, workforce/ex-workforce members, impersonation, insertion of malicious code, theft, viruses, SPAM, vandalism, etc.
- Natural - fires, floods, electrical storms, tornados, etc.
- Technological - server failure, software failure, ancillary equipment failure, etc. and environmental threats, such as power outages, hazardous material spills.
- Other - explosions, medical emergencies, misuse or resources, etc.
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Threat Source: Any circumstance or event with the potential to cause harm (intentional or unintentional) to an IT system. Common threat sources can be natural, human or environmental which can impact the organization's ability to protect ePHI.
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Threat Action: The method by which an attack might be carried out (e.g., hacking, system intrusion, etc.).
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Trigger Event: Activities that may be indicative of a security breach that require further investigation (See Appendix).
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Unrestricted Area: Those areas of the building(s) where protected health information and/or sensitive organizational information is not stored or is not utilized or is not accessible there on a regular basis.
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Unsecured Protected Health Information: Protected health information (PHI) that is not rendered unusable, unreadable, or indecipherable to unauthorized individuals through the use of technology or methodology specified by the Secretary in the guidance issued under section 13402(h)(2) of Pub. L.111-5 on the HHS website.
- Electronic PHI has been encrypted as specified in the HIPAA Security rule by the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without the use of a confidential process or key and such confidential process or key that might enable decryption has not been breached. To avoid a breach of the confidential process or key, these decryption tools should be stored on a device or at a location separate from the data they are used to encrypt or decrypt. The following encryption processes meet this standard.
- Valid encryption processes for data at rest (i.e. data that resides in databases, file systems and other structured storage systems) are consistent with NIST Special Publication 800-111, Guide to Storage Encryption Technologies for End User Devices.
- Valid encryption processes for data in motion (i.e. data that is moving through a network, including wireless transmission) are those that comply, as appropriate, with NIST Special Publications 800-52, Guidelines for the Selection and Use of Transport Layer Security (TLS) Implementations; 800-77, Guide to IPSec VPNs; or 800-113, Guide to SSL VPNs, and may include others which are Federal Information Processing Standards FIPS 140-2 validated.
- The media on which the PHI is stored or recorded has been destroyed in the following ways:
- Paper, film, or other hard copy media have been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed. Redaction is specifically excluded as a means of data destruction.
- Electronic media have been cleared, purged, or destroyed consistent with NIST Special Publications 800-88, Guidelines for Media Sanitization, such that the PHI cannot be retrieved.
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Vendors: Vendor - A vendor provides goods and/or services to biospatial. Vendors are not individuals but legal entities such as C-corps, LLCs or similar. When appropriate, a vendor may be required to sign a BAA and may have an SLA. Vendors do not complete the biospatial security training.
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Vulnerability: A weakness or flaw in an information system that can be accidentally triggered or intentionally exploited by a threat and lead to a compromise in the integrity of that system, i.e., resulting in a security breach or violation of policy.
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Workforce: Means employees, volunteers, trainees, and other persons whose conduct, in the performance of work for a covered entity, is under the direct control of such entity, whether or not they are paid by the covered entity. For the purposes of these policies, any workforce member with an @biospatial.io email account is considered to be a biospatial workforce member.
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Workstation: An electronic computing device, such as a laptop or desktop computer, or any other device that performs similar functions, used to create, receive, maintain, or transmit ePHI. Workstation devices may include, but are not limited to: laptop or desktop computers, personal digital assistants (PDAs), tablet PCs, or any other handheld device that is not explicitly covered under the Mobile Device definition. For the purposes of this policy, “workstation” also includes the combination of hardware, operating system, application software, and network connection.
Application: An application hosted by biospatial, either maintained and created by biospatial, or maintained and created by a Customer or Partner.
biospatial HIPAA Business Associate Agreement (“BAA”)
The template biospatial HIPAA Business Associate Agreement (BAA) is found here.
HIPAA Mappings to biospatial Controls
Below is a list of HIPAA Safeguards and Requirements and the biospatial controls in place to meet those.
Administrative Controls HIPAA Rule | biospatial Control |
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Security Management Process - 164.308(a)(1)(i) | Risk Management Policy |
Assigned Security Responsibility - 164.308(a)(2) | Roles Policy |
Workforce Security - 164.308(a)(3)(i) | Employee Policies |
Information Access Management - 164.308(a)(4)(i) | System Access Policy |
Security Awareness and Training - 164.308(a)(5)(i) | Employee Policy |
Security Incident Procedures - 164.308(a)(6)(i) | IDS Policy |
Contingency Plan - 164.308(a)(7)(i) | Disaster Recovery Policy |
Evaluation - 164.308(a)(8) | Auditing Policy |
Physical Safeguards HIPAA Rule | biospatial Control |
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Facility Access Controls - 164.310(a)(1) | Facility and Disaster Recovery Policies |
Workstation Use - 164.310(b) | System Access, Approved Tools, and Employee Policies |
Workstation Security - 164.310(c) | System Access, Approved Tools, and Employee Policies |
Device and Media Controls - 164.310(d)(1) | Disposable Media and Data Management Policies |
Technical Safeguards HIPAA Rule | biospatial Control |
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Access Control - 164.312(a)(1) | System Access Policy |
Audit Controls - 164.312(b) | Auditing Policy |
Integrity - 164.312(c)(1) | System Access, Auditing, and IDS Policies |
Person or Entity Authentication - 164.312(d) | System Access Policy |
Transmission Security - 164.312(e)(1) | System Access and Data Management Policy |
Organizational Requirements HIPAA Rule | biospatial Control |
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Business Associate Contracts or Other Arrangements - 164.314(a)(1)(i) | Business Associate Agreements and 3rd Parties Policies |
Policies and Procedures and Documentation Requirements HIPAA Rule | biospatial Control |
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Policies and Procedures - 164.316(a) | Policy Management Policy |
Documentation - 164.316(b)(1)(i) | Policy Management Policy |
HITECH Act - Security Provisions HIPAA Rule | biospatial Control |
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Notification in the Case of Breach - 13402(a) and (b) | Breach Policy |
Timelines of Notification - 13402(d)(1) | Breach Policy |
Content of Notification - 13402(f)(1) | Breach Policy |