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The Security Risk Assessment Handbook: A Comple...


All e-PHI created, received, maintained or transmitted by an organization is subject to the Security Rule. The Security Rule requires entities to evaluate risks and vulnerabilities in their environments and to implement reasonable and appropriate security measures to protect against reasonably anticipated threats or hazards to the security or integrity of e-PHI. Risk analysis is the first step in that process.We understand that the Security Rule does not prescribe a specific risk analysis methodology, recognizing that methods will vary dependent on the size, complexity, and capabilities of the organization. Instead, the Rule identifies risk analysis as the foundational element in the process of achieving compliance, and it establishes several objectives that any methodology adopted must achieve.




The Security Risk Assessment Handbook: A Comple...



RISK ANALYSIS (Required).Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the [organization].


The security measures implemented to reduce risk will vary among organizations. For example, small organizations tend to have more control within their environment. Small organizations tend to have fewer variables (i.e. fewer workforce members and information systems) to consider when making decisions regarding how to safeguard e-PHI. As a result, the appropriate security measures that reduce the likelihood of risk to the confidentiality, availability and integrity of e-PHI in a small organization may differ from those that are appropriate in large organizations.7


A truly integrated risk analysis and management process is performed as new technologies and business operations are planned, thus reducing the effort required to address risks identified after implementation. For example, if the covered entity has experienced a security incident, has had change in ownership, turnover in key staff or management, is planning to incorporate new technology to make operations more efficient, the potential risk should be analyzed to ensure the e-PHI is reasonably and appropriately protected. If it is determined that existing security measures are not sufficient to protect against the risks associated with the evolving threats or vulnerabilities, a changing business environment, or the introduction of new technology, then the entity must determine if additional security measures are needed. Performing the risk analysis and adjusting risk management processes to address risks in a timely manner will allow the covered entity to reduce the associated risks to reasonable and appropriate levels.8


The Office of the National Coordinator for Health Information Technology (ONC) has produced a risk assessment guide for small health care practices, called Reassessing Your Security Practices in a Health IT Environment.


The Healthcare Information and Management Systems Society (HIMSS), a private consortium of health care information technology stakeholders, created an information technology security practices questionnaire. The questionnaire was developed to collect information about the state of IT security in the health care sector, but could also be a helpful self-assessment tool during the risk analysis process.


The Health Information Trust Alliance (HITRUST) worked with industry to create the Common Security Framework (CSF), a proprietary resource available at -rmf-related-documents. The risk management section of the document, Control Name: 03.0, explains the role of risk assessment and management in overall security program development and implementation. The paper describes methods for implementing a risk analysis program, including knowledge and process requirements, and it links various existing frameworks and standards to applicable points in an information security life cycle.


Out of Scope Tier 2 risks such as operational risks that are not security-related are out of scope. Tier 3 Risks identified by teams across the organization are considered by Security Risk when scoring and/or treating their associated Tier 2 risk (where applicable). Security Risk does not directly facilitate the treatment of Tier 3 risks but may effectively do so through the treatment of a Tier 3 risk's associated Tier 2 risk.


Tone at the Top: GitLab's StORM methodology uses a defined Risk Appetite and Risk Tolerance as the primary drivers to determine what risks GitLab are willing to accept versus what risks we will need to treat. These thresholds are defined by Senior Leadership across the organization to ensure the Tone at the Top is aligned with the StORM program. Risk Appetite and Tolerance are reassessed year-to-year during the annual security operational risk assessment process. This is done through an annual Risk Appetite Survey based on the ISO 31000 Risk Management Methodology. The survey is distributed to individuals operating in a Senior Leadership capacity with direct relations to Security Operations. The responses are averaged to arrive at an overall risk appetite and tolerance.


The Security Risk Team conducts security operational Risk Identification interviews with individuals operating in at least a Manager capacity/level at GitLab in order to identify security operational risks within their respective departments. Risks identified will always be framed in terms of threat sources and threat events, and then assessed against the likelihood of occurrence and the impact to GitLab if the risk event occurs. Additionally, these risks will be assessed against the current internal controls in place to determine the overall residual risk remaining.


There may be times that risks are identified outside of the annual StORM process - such as risks that arise from a security incident, risk identified through regular day-to-day business operations, etc. All security operational risks identified ad-hoc are discussed with the Security Risk Team, an inherent risk score is assigned, and a quantitative analysis done to determine if it should be escalated to the risk register.


When drafting a risk, start with a risk statement. This will represent the title of the Risk in our GRC system and is an attempt to condense the risk into a single sentence. In the spirit of low-context communication, avoid using single words or short phrases for the risk statement (e.g., Supply Chain). As we largely deal with negative risks (vs. positive risks/opportunities), starting the statement with negative language like "Failure to", "Inadequate", "Incomplete", "Lack of", etc. is appropriate, but not required. As risks represent what might happen, use "may" before describing the negative effect it may have on the confidentiality, integrity, availability, security, and privacy of GitLab data. Example: Inadequate physical security controls may result in the loss of GitLab/Customer data and physical assets. The risk description should contain details related to the assets/resources at risk, the event that may occur, the source that would trigger the event (root cause), and the consequence (impact/loss) source.


The Office of the National Coordinator for Health Information Technology (ONC), in collaboration with the HHS Office for Civil Rights (OCR), developed a downloadable Security Risk Assessment (SRA) Tool to help guide you through the process. The tool is designed to help healthcare providers conduct a security risk assessment as required by the HIPAA Security Rule and the Centers for Medicare and Medicaid Service (CMS) Electronic Health Record (EHR) Incentive Program. The target audience of this tool is medium and small providers; thus, use of this tool may not be appropriate for larger organizations.


The SRA Tool is a desktop application that walks users through the security risk assessment process using a simple, wizard-based approach. Users are guided through multiple-choice questions, threat and vulnerability assessments, and asset and vendor management. References and additional guidance are given along the way. Reports are available to save and print after the assessment is completed.


The Security Risk Assessment Tool at HealthIT.gov is provided for informational purposes only. Use of this tool is neither required by nor guarantees compliance with federal, state or local laws. Please note that the information presented may not be applicable or appropriate for all health care providers and organizations. The Security Risk Assessment Tool is not intended to be an exhaustive or definitive source on safeguarding health information from privacy and security risks. For more information about the HIPAA Privacy and Security Rules, please visit the HHS Office for Civil Rights Health Information Privacy website.


January 10, 2023: Today, CISA released the Securing Small and Medium-Sized Business (SMB) Supply Chains: A Resource Handbook to Reduce Information and Communication Technology Risks. Developed by the ICT Supply Chain Risk Management Task Force, the handbook provides an overview of the highest supply chain risk categories commonly faced by ICT SMBs, including cyber risks, and contains several use cases that can assist ICT SMBs in identifying the necessary resources to implement ICT supply chain security practices.


Software Assurance Working Group, which will develop a Buyer's Guide that will help ensure that buyers, suppliers, and acquisition specialists refer to one piece of guidance that includes all important documentation regarding the implementation, security, and reliability of software assurance as well as the risks that can arise.


Verify assurance of third-parties: Verify that your suppliers maintain an adequate security culture and SCRM program to appropriately address the risks that concern your organization. Establish the protocols your organization will use to assess the supply chain practices of your suppliers.


The Risk Management Framework provides a process that integrates security, privacy, and cyber supply chain risk management activities into the system development life cycle. The risk-based approach to control selection and specification considers effectiveness, efficiency, and constraints due to applicable laws, directives, Executive Orders, policies, standards, or regulations. Managing organizational risk is paramount to effective information security and privacy programs; the RMF approach can be applied to new and legacy systems, any type of system or technology (e.g., IoT, control systems), and within any type of organization regardless of size or sector. 041b061a72


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