biospatial Compliance

> Security Policy Docs
CLOSE MENU

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

Applicable Standards from the HIPAA Security Rule

Maintenance of Policies

  1. 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.
  2. 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.
  3. biospatial employees may request changes to policies using the following process:
    1. 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.
    2. The Security Officer or the Privacy Officer is assigned to review the policy change request.
    3. 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.
    4. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
    5. If the policy change requires technical modifications to production systems, those changes are carried out by authorized personnel.
  4. 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.
  5. 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
    1. Version history of all biospatial policies is performed via Git.
    2. Backup storage of all policies is performed via Git.
  6. 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:
    1. The Security Officer initiates the policy review by creating an Issue in the Redmine Compliance Review Activity (CRA) project.
    2. The Security Officer or the Privacy Officer is assigned to review the current biospatial policies (https://policies.biospatial.io).
    3. If changes are made, the above process is used. All changes are documented in the Issue.
    4. 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.
    5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
    6. Policy review is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.
  7. 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

Applicable Standards from the HIPAA Security Rule

Risk Management Policies

  1. 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.
  2. 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).
    1. Risk assessments are done throughout product life cycles:
    2. 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.
    3. While making changes to biospatial physical equipment and facilities that introduce new, untested configurations.
    4. 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.
  3. biospatial implements security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to:
    1. Ensure the confidentiality, integrity, and availability of all ePHI biospatial receives, maintains, processes, and/or transmits for its Customers;
    2. Protect against any reasonably anticipated threats or hazards to the security or integrity of Customer ePHI;
    3. Protect against any reasonably anticipated uses or disclosures of Customer ePHI that are not permitted or required; and
    4. Ensure compliance by all workforce members.
  4. Any risk remaining (residual) after other risk controls have been applied, requires sign off by the senior management and biospatial's Security Officer.
  5. 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.
  6. 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.
  7. 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.
  8. 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:
    1. The Security Officer or the Privacy Officer initiates the Risk Management Procedures by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
    2. The Security Officer or the Privacy Officer is assigned to carry out the Risk Management Procedures.
    3. All findings are documented in an approved spreadsheet that is linked to the Issue.
    4. 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.
    5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
  9. 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.

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.

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:

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

Applicable Standards from the HIPAA Security Rule

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.

  1. 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.
  2. Assists in the administration and oversight of business associate agreements.
  3. Manage relationships with customers and partners as those relationships affect security and compliance of ePHI.
  4. Assist Security Officer as needed.

The current biospatial Privacy Officer is Jon Woodworth ().

Workforce Training Responsibilities

  1. The Privacy Officer facilitates the training of all workforce members as follows:
    1. New workforce members within their first month of engagement;
    2. Existing workforce members annually;
    3. 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;
    4. Existing workforce members as needed due to changes in security and risk posture of biospatial.
  2. The Security Officer or designee maintains documentation of the training session materials and attendees for a minimum of six years.
  3. The training session focuses on, but is not limited to, the following subjects defined in biospatial's security policies and procedures:
    1. HIPAA Privacy, Security, and Breach notification rules;
    2. Risk Management procedures and documentation;
    3. Auditing. biospatial may monitor access and activities of all users;
    4. Workstations may only be used to perform assigned job responsibilities;
    5. Users may not download software onto biospatial's workstations and/or systems without prior approval from the Security Officer;
    6. Users are required to report malicious software to the Security Officer immediately;
    7. Users are required to report unauthorized attempts, uses of, and theft of biospatial's systems and/or workstations;
    8. Users are required to report unauthorized access to facilities
    9. 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);
    10. Users may not alter ePHI maintained in a database, unless authorized to do so by a biospatial Customer;
    11. Users are required to understand their role in biospatial's contingency plan;
    12. Users may not share their user names nor passwords with anyone;
    13. Requirements for users to create and change passwords;
    14. Users must set all applications that contain or transmit ePHI to automatically log off after 15 minutes of inactivity;
    15. Supervisors are required to report terminations of workforce members and other outside users;
    16. Supervisors are required to report a change in a users title, role, department, and/or location;
    17. Procedures to backup ePHI;
    18. Procedures to move and record movement of hardware and electronic media containing ePHI;
    19. Procedures to dispose of discs, CDs, hard drives, and other media containing ePHI;
    20. Procedures to re-use electronic media containing ePHI;
    21. 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:

  1. Oversees and enforces all activities necessary to maintain compliance and verifies the activities are in alignment with the requirements.
  2. 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.
  3. 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.
  4. Facilitates audits to validate compliance efforts throughout the organization.
  5. 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.
  6. 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.
  7. 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.
  8. Develops and provides periodic security updates and reminder communications for all workforce members.
  9. Implements procedures for the authorization and/or supervision of workforce members who work with ePHI or in locations where it may be accessed.
  10. 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.
  11. 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.
  12. 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.
  13. 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.

  1. Monitor workstations and applications for unauthorized use, tampering, and theft and report non-compliance according to the Security Incident Response policy.
  2. Assist the Security and Privacy Officers to ensure appropriate role-based access is provided to all users.
  3. 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.

  1. 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.
  2. 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.
    • A violation resulting in a breach of confidentiality (i.e. release of PHI to an unauthorized individual), change of the integrity of any ePHI, or inability to access any ePHI by other users, requires immediate termination of the workforce member from biospatial.
  3. The Security Officer facilitates taking appropriate steps to prevent recurrence of the violation (when possible and feasible).
  4. 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.
  5. 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

Applicable Standards from the HIPAA Security Rule

Backup Policy and Procedures

  1. Perform daily snapshot backups of all systems that process, store, or transmit ePHI for biospatial Customers. 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.
  2. biospatial Ops Team, lead by Chief Technology Officer, is designated to be in charge of backups.
  3. Dev Ops Team members are trained and assigned to complete backups using the AWS platform.
  4. Document backups
    • Name of the system
    • Date & time of backup
    • Where backup stored (or to whom it was provided)
  5. Securely encrypt stored backups in a manner that protects them from loss or environmental damage.
  6. 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

Applicable Standards from the HIPAA Security Rule

Access Establishment and Modification

  1. Requests for access to biospatial platform systems and applications is made formally using the following process:
    1. 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.
    2. 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.
    3. 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.
    4. 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.
  2. Access is not granted until receipt, review, and approval by the biospatial Security Officer;
  3. The request for access is retained for future reference.
  4. 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:
    1. The Security Officer initiates the review of user access by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
    2. The Security Officer, or a Privacy Officer, is assigned to review levels of access for each biospatial workforce member.
    3. 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.
    4. 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.
    5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
    6. Review of user access is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.
  5. Any biospatial workforce member can request change of access using the process outlined in Access Establishment and Management.
  6. Access to production systems is controlled by centralized orchestration of user management and authentication.
  7. Accounts are reviewed every 90 days. Accounts that are inactive or no longer serve a business purpose are disabled and/or deleted.
  8. 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.
  9. 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.
  10. 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.
  11. Generic accounts are not allowed on biospatial systems.
  12. 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 inactivity.
  13. 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.
  14. Direct system to system, system to application, and application to application authentication and authorization are limited and controlled to restrict access.

Workforce Clearance

  1. 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.
  2. All access requests are treated on a “least-access principle.”
  3. 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

  1. Role based access categories for each biospatial system and application are pre-approved by the Security Officer or CTO.
  2. biospatial utilizes hardware and software firewalls to segment data, prevent unauthorized access, and monitor traffic for denial of service attacks.

Person or Entity Authentication

  1. Each workforce member has and uses a unique user ID and password that identifies them as the user of the information system.
  2. Each Customer and Partner has and uses a unique user ID and password that identifies them as the user of the information system.
  3. 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

  1. Access to the biospatial platform systems and applications is controlled by requiring unique authentication credentials for each individual user and developer.
  2. All operating system log-ons to biospatial workstations or servers require SSH keys, biometrics, or manually-entered passwords or PINs.
  3. User authentication credentials are never displayed during log-on and are not transmitted or stored in plain text.
  4. Default accounts on all production systems, including root, are disabled.
  5. 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

  1. 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).
  2. Information systems automatically log users off the systems after 15 minutes of inactivity.
  3. 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.

  1. Workstations may not be used to engage in any activity that is illegal or is in violation of organization's policies.
  2. 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.
  3. 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.
  4. Solicitation of non-company business, or any use of organization's information systems/applications for personal gain is prohibited.
  5. Transmitted messages may not contain material that criticizes the organization, its providers, its employees, or others.
  6. Users may not misrepresent, obscure, suppress, or replace another user's identity in transmitted or stored messages.
  7. Workstation hard drives will be encrypted using the operating system’s encryption facility (e.g., FileVault for Mac or Bitlocker for Windows).
  8. All workstations have firewalls enabled to prevent unauthorized access unless explicitly granted.
  9. All computers purchased, owned, and/or managed by biospatial are to display this message 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..

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.

  1. No ePHI may be stored on any mobile device.
  2. Mobile devices are not permitted to connect to the biospatial VPN.
  3. Mobile devices must be set to lock the screen after no more than 3 minutes.
  4. Mobile devices must have screen locking enabled with PINs or passwords of 8 characters or more.
  5. Mobile devices may be unlocked using fingerprints or other biometrics.
  6. Mobile devices must be encrypted.
  7. Mobile devices may only use biospatial resources as defined elsewhere in these policies.
  8. The MAC address of the mobile device is registered with biospatial.
  9. The biospatial work force member agrees to demonstrate that the device is configured in accordance to these policies on demand.
  10. Mobile devices do not need to meet these requirements if they are only used for MFA purposes.

Wireless Access Use

  1. biospatial production systems are not accessible directly over wireless channels.
  2. Wireless access is disabled on all production systems.
  3. When accessing production systems via remote wireless connections, the same system access policies and procedures apply to wireless as all other connections, including wired.
  4. 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;
    • Passwords are rotated on a regular basis, presently quarterly. This process is managed by the biospatial Security Officer.

Employee Termination Procedures

  1. 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”.
  2. The Human Resources Department (if any), users, and supervisors are required to notify the Security Officer or the Information Security Help Desk (if any) 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).
  3. 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.
  4. 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

  1. User IDs and passwords that control access to biospatial systems may not be disclosed to anyone for any reason.
  2. 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.
  3. 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.
  4. 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.
  5. Passwords are inactivated immediately upon an employee's termination (refer to the Employee Termination Procedures).
  6. All default system, application, and Partner passwords are changed before deployment to production.
  7. Upon initial login, users must change any passwords that were automatically generated for them.
  8. Password change methods must use a confirmation method to correct for user input errors.
  9. All passwords used in configuration scripts are secured and encrypted.
  10. If a user believes their user ID has been compromised, they are required to immediately report the incident to the Security Office.
  11. 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

  1. SSH keys that control access to biospatial systems may not be disclosed to anyone for any reason.
  2. 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.
  3. 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.
  4. SSH keys shall be rotated at least annually.
  5. SSH keys are inactivated immediately upon an employee's termination (refer to the Employee Termination Procedures).
  6. If a user believes their SSH key has been compromised, they are required to immediately report the incident to the Security Office.
  7. 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.

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:

This policy applies to all biospatial systems that store, transmit, or process ePHI.

Applicable Standards

Applicable Standards from the HITRUST Common Security Framework

Applicable Standards from the HIPAA Security Rule

Auditing Policies

  1. 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.
  2. biospatial shall commission an external audit of information systems and procedures to ensure compliance with security and privacy policies at least annually.
  3. 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.
  4. 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.
  5. 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.
  6. biospatial utilizes OSSEC to scan all systems for malicious and unauthorized software every day and at reboot of systems.
  7. biospatial leverages process monitoring tools throughout its environment.
  8. biospatial uses OSSEC to monitor the integrity of log files by utilizing OSSEC System Integrity Checking capabilities.
  9. 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).
  10. 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.
  11. Logs are reviewed weekly by the Security Officer or a delegate appointed by the Security Officer and approved by the Privacy Officer.
  12. 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.
  13. 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.
  14. 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).
    • Testing shall be done on a routine basis, currently monthly.
  15. Security and critical bug patches and updates will be applied to all systems in a timely manner.

Audit Requests

  1. 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.
  2. 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.
  3. 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

  1. 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:
    1. The Security Officer initiates the log review by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
    2. The Security Officer, or a biospatial Security Engineer assigned by the Security Officer, is assigned to review the logs.
    3. 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.
    4. 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.
    5. If the Issue is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
  2. 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.
  3. 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.
  4. 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).
  5. 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.
  6. Log review activity is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.

Auditing Customer and Partner Activity

  1. 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.
  2. If it is determined that the Customer or Partner has exceeded the scope of access privileges, biospatial's leadership must remedy the problem immediately.
  3. 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

  1. 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.
  2. All audit logs are protected in transit and encrypted at rest to control access to the content of the logs.
  3. 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

  1. 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.
  2. 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:

Retention of Audit Data

  1. 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.
  2. Reports summarizing audit activities shall be retained for a period of six years.
  3. Audit log data is retained locally on the audit log server for a 90-day period.

Potential Trigger Events

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

Applicable Standards from the HIPAA Security Rule

Configuration Management Policies

  1. Ansible is used to standardize and automate configuration management.
  2. No systems are deployed into biospatial environments without approval of the biospatial CTO.
  3. 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.
  4. All changes to production systems are tested before they are implemented in production.
  5. Implementation of approved changes are only performed by authorized personnel.
  6. An up-to-date inventory of systems is maintained using spreadsheets and documents hosted on Microsoft SharePoint and One-Drive. All systems are categorized as production and utility to differentiate based on criticality.
  7. All frontend functionality (developer dashboards and portals) is separated from backend (database and app servers) systems by being deployed on separate servers.
  8. All software and systems are tested using unit tests and end to end tests.
  9. All committed code is reviewed using pull requests via Git to ensure software code quality and proactively detect potential security issues in development.
  10. biospatial utilizes development and staging environments that mirror production to ensure proper function.
  11. All formal change requests require unique ID and authentication.
  12. 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.
  13. 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.
  14. 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

Applicable Standards from the HIPAA Security Rule

biospatial-Controlled Facility Access Policies

  1. Visitor and third party support access is recorded and supervised. All visitors are escorted.
  2. Repairs are documented and the documentation is retained.
  3. Fire extinguishers and detectors are installed according to applicable laws and regulations.
  4. Maintenance is controlled and conducted by authorized personnel in accordance with supplier-recommended intervals, insurance policies and the organizations maintenance program.
  5. Electronic and physical media containing covered information is securely destroyed (or the information securely removed) prior to disposal.
  6. The organization securely disposes media with sensitive information.
  7. 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.
  8. 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.
  9. 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:

Note: These policies were adapted from 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

Applicable Standards from the HIPAA Security Rule

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:

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

  1. Immediately upon observation biospatial members report suspected and known Events, Precursors, Indications, and Incidents in one of the following ways:
    1. Direct report to management, the Security Officer, Privacy Officer, or other;
    2. Email;
    3. Phone call;
    4. Security Incident response form;
    5. Redmine Security Incident template (select Security tracker if necessary);
    6. Secure Chat.
    7. Anonymously through workforce members desired channels.
  2. 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).
  3. The Security Officer determines if the issue is an Event, Precursor, Indication, or Incident.
    1. If the issue is an event, indication, or precursor the Security Officer forwards it to the appropriate resource for resolution.
      1. Non-Technical Event (minor infringement): the Security Officer completes a Security Incident Initial Report Form found in the biospatial Security Incident Plan and investigates the incident.
      2. Technical Event: Assign the issue to an IT resource for resolution. This resource may also be a contractor or outsourced technical resource, in the event of a small office or lack of expertise in the area. Security Officer completes a SIR Form found in the biospatial Security Incident Plan.
    2. If the issue is a security incident the Security Officer activates the Security Incident Response Team (SIRT) and notifies senior management.
      1. If a non-technical security incident is discovered the SIRT completes the investigation, implements preventative measures, and resolves the security incident.
      2. Once the investigation is completed, progress to Phase V, Follow-up.
      3. If the issue is a technical security incident, commence to Phase II: Containment.
      4. 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.
      5. 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.
      6. 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.
  4. 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.
  5. 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 security incident response process. This provides that the evidence gathered during the security incident can be used successfully during prosecution, if appropriate.

  1. The SIRT reviews any information that has been collected by the Security Officer or any other individual investigating the security incident.
  2. The SIRT secures the network perimeter.
  3. The IT department performs the following:
    1. Securely connect to the affected system over a trusted connection.
    2. Retrieve any volatile data from the affected system.
    3. Determine the relative integrity and the appropriateness of backing the system up.
    4. If appropriate, back up the system.
    5. Change the password(s) to the affected system(s).
    6. Determine whether it is safe to continue operations with the affect system(s).
    7. If it is safe, allow the system to continue to function;
      1. Complete any documentation relative to the security incident on the Security Incident Report Form found in the biospatial Security Incident Plan.
      2. Move to Phase V, Follow-up.
    8. If it is NOT safe to allow the system to continue operations, discontinue the system(s) operation and move to Phase III, Eradication.
    9. The individual completing this phase provides written communication to the SIRT.
  4. Continuously apprise Senior Management of progress.
  5. 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).

  1. Determine symptoms and cause related to the affected system(s).
  2. 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:
    1. An increase in network perimeter defenses.
    2. An increase in system monitoring defenses.
    3. Remediation (“fixing”) any security issues within the affected system, such as removing unused services/general host hardening techniques.
  3. Conduct a detailed vulnerability assessment to verify all the holes/gaps that can be exploited have been addressed.
    1. If additional issues or symptoms are identified, take appropriate preventative measures to eliminate or minimize potential future compromises.
  4. Complete the Security Incident Eradication Checklist found in the biospatial Security Incident Plan.
  5. 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).
  6. Apprise Senior Management of the progress.
  7. Continue to notify affected Customers and Partners with relevant updates as needed.
  8. 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.

  1. The technical team determines if the affected system(s) have been changed in any way.
    1. If they have, the technical team restores the system to its proper, intended functioning (“last known good”).
    2. 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).
    3. 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.
    4. 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.
    5. Update the documentation with the detail that was determined during this phase.
    6. Apprise Senior Management of progress.
    7. Continue to notify affected Customers and Partners with relevant updates as needed.
    8. 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 security incidents be reviewed shortly after resolution to determine where response could be improved. Timeframes may extend to one to two weeks post-incident.

  1. Responders to the security incident (SIRT Team and technical security resource) meet to review the documentation collected during the security incident.
  2. Create a “lessons learned” document and attach it to the completed a Security Incident Report Form found in the biospatial Security Incident Plan.
    1. Evaluate the cost and impact of the security incident to biospatial using the documents provided by the SIRT and the technical security resource.
    2. Determine what could be improved.
    3. Communicate these findings to Senior Management for approval and for implementation of any recommendations made post-review of the security incident.
    4. Carry out recommendations approved by Senior Management; sufficient budget, time and resources should be committed to this activity.
    5. 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:

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

Applicable Standards from the HIPAA Security Rule

biospatial Breach Policy

  1. 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.)
  2. 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.
  3. 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 incident 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.
  4. 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.
  5. 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.
  6. 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.
  7. Methods of Notification: biospatial Customers will be notified via email and phone within the timeframe for reporting breaches, as outlined above.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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

  1. 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.
  2. Notice to Media: biospatial Customers are responsible for providing notice to prominent media outlets at the Customer's discretion.
  3. 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:

Other Optional Considerations:

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:

  1. 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.
  2. Identify the activities, resources, and procedures needed to carry out biospatial processing requirements during prolonged interruptions to normal operations.
  3. Identify and define the impact of interruptions to biospatial systems.
  4. Assign responsibilities to designated personnel and provide guidance for recovering biospatial during prolonged periods of interruption to normal operations.
  5. Ensure coordination with other biospatial staff who will participate in the contingency planning strategies.
  6. 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:

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.

  1. 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.
  2. 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

Applicable Standards from the HIPAA Security Rule

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.

  1. 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.
  2. 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:

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:

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:

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.

  1. Contact Partners and Customers affected - Web Services
  2. Assess damage to the environment - Web Services
  3. Begin replication of new environment using automated and tested scripts, currently Ansible in AWS. - Dev Ops
  4. Test new environment using pre-written tests - Web Services
  5. Test logging, security, and alerting functionality - Dev Ops
  6. Ensure systems are appropriately patched and up to date. - Dev Ops
  7. Deploy environment to production - Web Services
  8. 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.

  1. 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
  2. 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

Applicable Standards from the HIPAA Security Rule

Disposable Media Policy

  1. ePHI is not stored on removable media.
  2. biospatial assumes all disposable media in its platform may contain ePHI, so it treats all disposable media with the same protections and disposal policies.
  3. 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.
  4. 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.
  5. Before reuse of any media, all ePHI is rendered inaccessible, cleaned, or scrubbed to restrict future access.
  6. 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.
  7. Any media containing ePHI is disposed using a method that ensures the ePHI could not be readily recovered or reconstructed.
  8. 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.
  9. 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 AlienVault USM Anywhere 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

Applicable Standards from the HIPAA Security Rule

Intrusion Detection Policy

  1. OSSEC and AlienVault USM Anywhere are used to monitor and correlate log data from different systems on an ongoing basis. IDS alerts are monitored continuously. Comprehensive reviews of OSSEC and AlienVault reports are performed at least monthly by the Security Officer or a delegate appointed by the Security Officer and approved by the Privacy Officer.
  2. OSSEC generates alerts to analyze and investigate suspicious activity or suspected violations.
  3. OSSEC monitors file system integrity and sends real time alerts when suspicious changes are made to the file system.
  4. Automatic monitoring is done to identify patterns that might signify the lack of availability of certain services and systems (DoS attacks).
  5. biospatial firewalls monitor all incoming traffic to detect potential denial of service attacks. Suspected attack sources are blocked automatically. Additionally, our hosting provider actively monitors its network to detect denial of services attacks.
  6. All new firewall rules and configuration changes are tested before being pushed into production. All firewall and router rules are reviewed every quarter.
  7. 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

Applicable Standards from the HIPAA Security Rule

Vulnerability Scanning Policy

  1. Internal vulnerability scanning is performed at a minimum on a quarterly basis.
  2. Third party vulnerability scanning and penetration testing is performed at least annually.
  3. Vulnerability scanning is conducted using authenticated scans when applicable.
  4. Vulnerability assessment is performed by the biospatial Security Officer with assistance from the Chief Technology Officer or their designate.
  5. 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.
  6. 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.
  7. 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.
  8. Penetration testing is performed regularly as part of the biospatial vulnerability management policy.
    • Below is the process used to conduct internal penetration tests.
      1. The Security Officer initiates the penetration test by creating an Issue in the Redmine Compliance Review Activity (CRA) Project.
      2. The Security Officer, or biospatial personnel assigned by the Security Officer, is assigned to conduct the penetration test.
      3. 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.
      4. 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.
      5. 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.

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

Applicable Standards from the HIPAA Security Rule

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

  1. All Production Systems must disable services that are not required to achieve the business purpose or function of the system.

Monitoring Log-in Attempts

  1. All access to Production Systems must be logged. This is done following the biospatial Auditing Policy.

Prevention of Malware on Production Systems

  1. 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.
  2. 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.
  3. All Production Systems are to only be used for biospatial business needs.

Patch Management

  1. 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.
  2. 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

  1. Production systems are monitored using IDS systems. Suspicious activity is logged and alerts are generated.
  2. 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

  1. System, network, and server security is managed and maintained by the CTO and the Security Officer.
  2. Up to date system lists and architecture diagrams are kept for all production environments.
  3. Access to Production Systems is controlled using centralized tools and multi-factor authentication.

Production Data Security

  1. Reduce the risk of compromise of Production Data.
  2. Implement and/or review controls designed to protect Production Data from improper alteration or destruction.
  3. Ensure that confidential data is stored in a manner that supports user access logs and automated monitoring for potential security incidents.
  4. Ensure biospatial Customer Production Data is segmented and only accessible to Customer authorized to access data.
  5. 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.
  6. 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.
  7. Encrypted volumes use AES encryption with a minimum of 256-bit keys, or keys and ciphers of equivalent or higher cryptographic strength.

Transmission Security

  1. 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.
  2. 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.
  3. Transmission encryption is consistent with NIST Special Publication 800-52 Revision 1.
  4. Transmission encryption keys are regenerated annually or as frequently as allowed when regeneration is performed by automated services.
  5. In the case of biospatial provided APIs, provide mechanisms to ensure person sending or receiving data is authorized to send and save data.
  6. 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

Applicable Standards from the HIPAA Security Rule

Employment Policies

  1. All new workforce members, including contractors, are given training on security policies and procedures, including operations security, within 30 days of employment and annually thereafter.
    • 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.
  2. All workforce members are granted access to formal organizational policies, which include the sanction policy for security violations.
  3. 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.
  4. All workforce members are educated about the approved set of tools to be installed on workstations.
  5. All new workforce members are provided mandatory HIPAA training within 30 days of beginning 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.
    • Current biospatial training is hosted here.
  6. 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.
  7. All computers purchased, owned, and/or managed by biospatial are to display this message 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..
  8. 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).
    biospatial workforce members may use desktop and mobile applications and browsers to access biospatial-provided email and Slack from non-biospatial-owned or -managed workstations or mobile devices. Non-biospatial workstations may only use browsers to access SharePoint and OneDrive. Non-biospatial mobile devices may use mobile applications to access SharePoint and OneDrive.
  9. 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.
  10. Request for modifications of access for any biospatial employee can be made using the procedures outlined in Access Establishment and Modification.
  11. 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.
  12. Prior to hiring new employees, biospatial reserves the right to perform background checks on candidate employees, which may include resumes, references, criminal records, and credit history.
  13. 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

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 Office365, including SharePoint & OneDrive.

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.

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

Applicable Standards from the HIPAA Security Rule

Policies to Ensure 3rd Parties Support biospatial Compliance

  1. 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.
  2. All connections and data in transit between the biospatial platform and 3rd parties are encrypted end to end.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. Any changes to Partner and Subcontractor services and systems are reviewed before implementation.
  10. For all partners, biospatial reviews activity annually to ensure partners are in line with SLAs in contracts with biospatial.
  11. SLA review is monitored on a quarterly basis using Redmine reporting to assess compliance with above policy.

Key Definitions

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
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
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
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
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
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
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