Sherlocked Security – HIPAA / HITECH Assessment

Ensuring Compliance with HIPAA/HITECH for Protecting Health Information and Privacy

1. Statement of Work (SOW)

Service Name: HIPAA / HITECH Assessment
Client Type: Healthcare Providers, Health Plans, Healthcare Clearinghouses, Business Associates handling Protected Health Information (PHI)
Service Model: HIPAA Compliance Gap Assessment + Risk Analysis + Remediation Recommendations
Compliance Coverage: HIPAA Privacy Rule, Security Rule, and HITECH Act

Assessment Types:

Risk Analysis (Identifying Vulnerabilities to PHI)
Policies & Procedures Review (Compliance with HIPAA Security and Privacy Rules)
Physical and Network Security Review
Employee Training and Awareness Assessment
Business Associate Agreements (BAA) Review
Encryption, Authentication, and Access Control Measures Review

2. Our Approach

[Scope Identification] → [PHI Flow Mapping] → [Risk Analysis & Control Assessment] → [Vulnerability Scanning] → [Physical Security & Access Control Evaluation] → [Compliance Report Generation] → [Remediation Recommendations]

3. Methodology

[Scope Determination] → [PHI Inventory & Flow Mapping] → [Privacy and Security Rule Assessment] → [Vulnerability Scanning and Penetration Testing] → [Employee & Vendor Security Review] → [Risk Assessment & Residual Risk Analysis] → [Compliance Report]

4. Deliverables to the Client

HIPAA / HITECH Compliance Gap Analysis Report
PHI Flow Mapping and Access Control Review
Vulnerability Scanning and Penetration Test Results
Policies and Procedures Assessment Report
Risk Assessment and Residual Risk Report
Remediation Recommendations for Compliance
Documentation of Employee Training and Vendor Review

5. What We Need from You (Client Requirements)

Access to healthcare systems and infrastructure handling PHI
Network diagrams and data flow maps for PHI storage, transmission, and processing
Policies and procedures related to PHI security, access, and breach notification
Previous audit reports, risk assessments, and vulnerability scanning results
Employee training documentation and business associate agreements (BAAs)
Scope confirmation for the engagement, including third-party vendors or systems handling PHI

6. Tools & Technology Stack

Vulnerability Scanning Tools: Qualys, Nessus, OpenVAS
Penetration Testing Tools: Burp Suite, Metasploit, Hydra
Risk Assessment Tools: RiskWatch, ISMS360
Security Information and Event Management (SIEM): Splunk, LogRhythm
Compliance Mapping Tools: HIPAA Compliance Templates, NIST CSF Mapping
Data Loss Prevention (DLP) Solutions: Symantec DLP, Digital Guardian

7. Engagement Lifecycle

1. Kickoff & Documentation Review → 2. PHI Flow Mapping → 3. Privacy and Security Rule Assessment → 4. Vulnerability Scanning & Penetration Testing → 5. Report Generation → 6. Remediation Recommendations → 7. Final Compliance Report and Certification (if applicable)

8. Why Sherlocked Security?

Feature	Sherlocked Advantage
Comprehensive HIPAA/HITECH Expertise	Our team includes professionals with deep knowledge of HIPAA/HITECH compliance and security controls.
PHI Risk Identification	We offer extensive experience in identifying vulnerabilities and gaps in PHI handling.
In-depth Security Testing	We conduct vulnerability scans and penetration tests tailored for healthcare environments.
Remediation & Guidance	Actionable steps to achieve HIPAA/HITECH compliance with a focus on risk mitigation.
Support for Certification	We provide support throughout the audit process to ensure successful compliance certification.

9. Real-World Case Studies

Breach Due to Unencrypted PHI

Issue: Sensitive PHI was transmitted over unsecured communication channels without encryption.
Impact: Potential exposure of patient data during transmission.
Fix: Implemented strong encryption protocols (TLS, AES) for data in transit and at rest.

Unauthorized Access to PHI

Issue: Employees had excessive access to PHI, violating the principle of least privilege.
Impact: Increased risk of internal misuse of PHI.
Fix: Revoked unnecessary access permissions, implemented role-based access control (RBAC), and enforced MFA.

10. SOP – Standard Operating Procedure

Scope Determination
- Identify all systems, networks, and applications processing, storing, or transmitting PHI.
- Establish boundaries for HIPAA/HITECH compliance assessment.
PHI Inventory and Flow Mapping
- Map out where PHI is stored, processed, and transmitted.
- Identify any third-party vendors or systems involved in PHI handling and assess their security controls.
Privacy and Security Rule Assessment
- Review policies and procedures for compliance with HIPAA Privacy and Security Rules.
- Assess physical, administrative, and technical safeguards to protect PHI.
Vulnerability Scanning
- Perform regular vulnerability scans and penetration testing on PHI-related systems.
- Identify vulnerabilities in security configurations, access controls, and data protection measures.
Employee and Vendor Security Assessment
- Review employee training programs and ensure they include HIPAA-specific content.
- Assess security controls for third-party vendors with access to PHI and verify BAAs.
Risk Assessment and Residual Risk Analysis
- Conduct a risk assessment based on identified vulnerabilities, potential threats, and impacts to PHI.
- Evaluate residual risks after implementing mitigation strategies and provide recommendations.
Remediation Recommendations
- Provide actionable recommendations to address any identified compliance gaps, vulnerabilities, and security issues.
Final Report Generation
- Prepare a comprehensive compliance report and remediation plan for HIPAA/HITECH.
- Provide recommendations for achieving full HIPAA compliance and maintaining ongoing security and privacy controls.

11. HIPAA / HITECH Assessment Checklist

1. Privacy Rule Compliance

Ensure policies for patient privacy, consent, and access to health information are in place.
Implement procedures for handling patient complaints, access requests, and breach notifications.
Provide proper training for staff on privacy-related matters.

2. Security Rule Compliance

Conduct a risk analysis to identify security threats to PHI.
Implement safeguards for protecting PHI, including encryption, access controls, and secure data transmission.
Regularly test and update security measures to address emerging threats.

3. Access Control and Authentication

Ensure role-based access control (RBAC) is implemented to restrict PHI access.
Enforce strong authentication mechanisms, including multi-factor authentication (MFA), for PHI access.
Regularly review and update user access permissions based on the least privilege principle.

4. Data Encryption and Protection

Ensure encryption of PHI both in transit and at rest.
Use secure protocols (e.g., TLS, AES) for transmitting PHI.
Verify that encryption keys are securely managed.

5. Physical Security and Facility Controls

Assess physical security measures, including restricted access to servers and workstations handling PHI.
Implement surveillance, alarms, and access controls for physical locations storing PHI.
Ensure secure disposal of PHI (e.g., shredding, wiping devices).

6. Business Associate Agreements (BAA)

Review and validate BAAs with third-party vendors to ensure they comply with HIPAA requirements.
Ensure BAAs outline responsibilities for protecting PHI and compliance with security standards.

7. Incident Response and Breach Notification

Establish an incident response plan for handling data breaches involving PHI.
Ensure prompt breach notification procedures are in place for affected individuals and regulatory authorities.
Regularly test and update the incident response plan.

8. Documentation and Reporting

Maintain up-to-date documentation of all policies, procedures, and controls related to HIPAA/HITECH compliance.
Provide regular compliance audits and risk assessments to ensure continuous adherence to HIPAA/HITECH standards.
Keep detailed records of employee training and BAA compliance.

HIPAA – HITECH Assessment