DRP/BCP Compliance Michael Whitcomb CEO, Loricca, Inc. Michael has 25 years experience building and supporting secure systems and protecting patient, customer, and company information for.
Download
Report
Transcript DRP/BCP Compliance Michael Whitcomb CEO, Loricca, Inc. Michael has 25 years experience building and supporting secure systems and protecting patient, customer, and company information for.
DRP/BCP
Compliance
Michael Whitcomb
CEO, Loricca, Inc.
Michael has 25 years experience building and supporting secure systems and
protecting patient, customer, and company information for organizations of all
sizes.
Loricca was founded in 2004 with practices in Healthcare, Financial
Services, Insurance, Energy, Communications, Government,
and Commercial enterprises.
Brian Annulis, JD
Ryan Meade, JD
Compliance Round-Up Webinars
2nd Tuesday of each month
[email protected]
www.aegis-compliance.com/compliance-roundup-webinars
BCP/DRP Compliance Webinar
HIPAA Security Rule: DCP is an obligation of both Covered Entities
and Business Associate organizations.
OCR expects a DRP to specifically address recovery of ePHI.
Email Questions to: [email protected]
Agenda
Defining DRP/BCP
Justifying DRP/BCP
How to DRP/BCP
Recovery Strategies
Building Cost Support
What is DRP/BCP?
Disaster Recovery Planning – creating a process to recover and
protect a business IT infrastructure in the event of a disaster.
Business Continuity Planning – creating a plan to continue
operations if a location (e.g., an office, work site or data center)
becomes unusable.
DRP/BCP PCI Compliance
PCI DSS (V3) - 12.10.1 thru 12.10.6
Create the incident response plan to be implemented in the event of a
system breach. Ensure the plan addresses the following at a minimum:
Roles, responsibilities and communication and contact strategies in the vent of a
compromise including notification of the payment brands at a minimum.
Specific incident response procedures
Business recovery and continuity procedures
Data backup processes
Analysis of legal requirements for reporting compromises
Coverage and responses of all critical system components
Reference of inclusion of incident response procedures from the payment brands.
DRP/BCP PCI Compliance
HIPAA/HITECH
45 CFR 164.308(a)(7) Disaster recovery plan (Required). Establish (and
implement as needed) procedures to restore any loss of data.
Data Backup Plan (Required)
Disaster Recovery Plan (Required)
Emergency Mode Operation Plan (Required)
Testing and revision procedures (Addressable)
Applications and data criticality analysis (Addressable)
Justifying DRP/BCP
DRP/BCP Justification
It goes beyond compliance
Compliance standards require DRP/BCP because its “Best Practice”
Large scale events increase risk of data loss and/or breach
Unplanned responses damage the business and customers
Building a useful plan is complicated and requires input from the
business and IT
Not “if” it will happen but when
Financial customer
“if you can’t afford DR then you can’t afford the system”
DRP/BCP Justification
Examples
Joplin MO – St. John’s Mercy Hospital destroyed by tornado
Code Spaces – Growing company to out of business in 12 hours
Hospital – Water main break next to datacenter
Bank Datacenter – Network Outage
Thirty one percent (31%) of HIPAA data breaches cost more
than one million dollars (each). – Ponemon Institute’s HIPAA Data
Breach Economic Impact Study 2012
DRP/BCP Justification
A disaster event could affect multiple functional areas.
Financial impacts – May include costs from:
Investigations
Overtime Pay
Remediation
Penalties/Fines
Notifications
Capital Costs
Lost Revenue
DRP/BCP Justification
Operational Impacts –
Loss of Facilities
Loss of Personnel
Loss of Equipment
Intangible Impacts
Harm to Reputation
Loss of Future Business
Decreased Employee Morale
How to DRP/BCP
How to DRP/BCP
Simple inventory of systems (hardware and software)
Data Criticality Analysis
Where is my data
What kind of data is it (PCI, ePHI, PII, Financial)
eDiscovery
Business Impact Analysis
What is the impact to the business?
Who uses the system?
What is the cost of NOT having the system?
Disaster recovery plans
Business continuity plans
How to DRP/BCP
Data Criticality Analysis
System Name
Location
Contains
ePHI
Recovery
Priority
RTO
RPO
Data Owner
3M Medical
Coding/Transcription
Data Center
Yes
2
48
NA
M. Smith
ADP Time Card/Time
Tracking
Data Center
No
1
8
24
T. Jones
Calendar Creator
Scheduling
Local
No
3
8
NA
K. Smith
Camera Wound Care
Pictures
Local
Yes
2
8
NA
K. Jones
Cactus Physician
Information
Local
No
2
24
24
L. Ortiz
Citrix Remote Access
Data Center
No
3
24
NA
M.E. Yellow
How to DRP/BCP
Data Criticality Analysis
Priority
Process
Business Unit
1
In-house, Patient facing/clinical systems,
Meditech
Emergency, ICU, Lab, Maternity/OB,
Nutrition, Radiology, Surgery, IV Therapy.
Supporting IS systems, Ctr. f/Family Health
2
In-house – Employee/Pt safety,
Communications, IS systems
Facilities/Material Management, Security,
HR, Critical/Clinical Care Dept. heads.
3
External Patient facing/clinical
Home Health, PT, Medical Records,
Registration
4
Critical Business Operations (Payroll,
Insurance verification, Compliance, Risk
Management)
Business Office, Finance, Environmental
Services, Compliance, Risk Management,
Quality,
5
All Other Operations
How to DRP/BCP
Components of a good plan
A process of identifying, qualifying and defining risks
Roles and responsibility for the response team
Links to detailed system technical procedures and configuration
Designation of backup sites and locations
Notification plan which includes contact information for all people
involved in DR procedures and emergency authorities.
Vendor list
Insurance and contractual agreements
Communication plan (includes PR)
Testing and revision
A good plan is a living document
Recovery Strategies
Recovery Strategies
• Decision Points
•
•
•
•
•
•
•
•
•
Confirm downtime impact/criticality
Balance downtime with cost
Determine willingness to rely on Internet/cloud
Financial impact vs cost
Impact to Patient Care (Customer Impact)
Employee Impact
Potential for Data Breach
Change to Methods Used for Management of MIS
Balance Technical Solution with Business Requirements
Recovery Strategies
Decision Point
Strength
Weakness
Lower Cost, Flexible
Control of Data, Requires
Internet, Technically Complex
Outsource to DR Vendor
(eVault, Sungard)
Reduced Complexity,
Stability
Control of Data, Cost,
Requires Contracts, Requires
Internet
Build Internally
Flexible, Less Reliant on
Internet, Scalable
High Cost, Significant
Technical Support, Less
geographic protection
Team with Another
Hospital
Flexible, Moderate Cost,
Reduced Infrastructure
Requires Internet, Significant
Technical Support
Cloud Hosted Servers
(aka Amazon)
Building Cost Support
Building Cost Support
“It’s required for compliance” doesn’t usually work
Is DR an IT cost or a Business cost?
Who uses the application?
What does it cost the business to not have the application?
The BIA will quantify business cost
Additional cost justification is usually necessary
Cost of downtime vs DRP/BCP cost
Engage business users through BIA process to gain their support
Michael Whitcomb
www.loricca.com
[email protected]