A HIPAA security risk analysis identifies risks and vulnerabilities to patient data by evaluating threats, vulnerabilities, and existing controls. It is a foundational part of a HIPAA compliance program and helps prioritize security improvements. Key preparation steps include selecting a vendor, allocating time and resources, and gathering documentation. Common pitfalls to avoid are failing to address actual risks, assuming compliance means security, and using checklists without context. The goal is a transparent view of security to guide effective risk management.

1. How to Prepare Your Organization for a
HIPAA Security Risk Analysis
Presented by:
John Abraham
Founder & Chief Security Evangelist
Redspin

2. About Redspin
• Penetration Testing
– External Infrastructure
– Internal Infrastructure
– Web Applications
• IT Security Controls
– HIPAA
– FFIEC/GLBA
– PCI
– NERC
• Social Engineering

3. About The Speaker
John Abraham
Founder & Chief Security Evangelist
As Redspin's founder and Chief Security Evangelist, John is
passionate about the importance of a structured
information security program that enables management to
focus IT resources on the most pressing security risk.
John's belief is that addressing subtle issues within an
organization's IT environment can yield significant business
impact, so an ounce of prevention is the key operative
behavior of successful risk management programs. John is
one of Redspin's health IT security specialists, is a regular
speaker on topics of security and healthcare ePHI risk
management, and enjoys working with IT teams,
compliance officers and executives on practical approaches
to data security mitigation strategies.

4. Preparing Your Organization for a
HIPAA Security Risk Analysis
What we’ll cover today:
 What is it?
 How does it fit into my security program?
 What are the preparation steps?
 How can I avoid pitfalls & maximize value?

5. Why now?
 Meaningful use core objective (protecting ePHI)
 HIPAA Compliance
 Risk management

6. Part 1
HIPAA Security Risk Analysis
1. What is it?
2. How does it fit into my security program?
3. What are the preparation steps?
4. How can I avoid pitfalls & maximize value?

8. HIPAA Security Rule
§ 164.308(a)(1)(ii)(A)
“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 covered entity.”

9. What is a Risk Analysis?
(Also called: Risk Assessment)
 Assessment of risk
 CIA: confidentiality, availability and integrity
 EPHI: created, received, maintained, transmitted

10. How is it performed?
- It’s an evaluation
1. Where is ePHI, what are critical apps
2. Threats
3. Vulnerabilities
4. Existing controls (effective?)
5. Determine risk (= probability * impact)

11. Flexibility on RA Approach
 “Security Rule does not prescribe a specific risk analysis
methodology”
 “Methods will vary dependent on the size, complexity, and
capabilities of the organization”
 “There are numerous methods of performing risk analysis”
 “There is no single method or 'best practice' that guarantees
compliance with the Security Rule”
Guidance on Risk Analysis Requirements under the HIPAA Security Rule, July 14, 2010
-http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/rafinalguidancepdf.pdf

12. Goals and Objectives
Identify (and prioritize) risk
Ensure controls are working
Recommend improvements
Foundation for robust security program
Achieve compliance
- HIPAA Security Rule & Meaningful Use

13. Expected Outcomes
IT transparency
Executive understanding of current state of security
Prioritized view of risk
Provide data needed to create IT action plan

14. Part 2
HIPAA Security Risk Analysis
1. What is it?
2. How does it fit into my security program?
3. What are the preparation steps?
4. How can I avoid pitfalls & maximize value?

15. Source: ISO 27001, NIST SP 800-39, PCI DSS, FFIEC, COBIT,
HIPAA - Administrative Safeguards (§164.308), ...

18. Risk Analysis
 “Conducting a risk analysis is the first step in identifying
and implementing safeguards that comply with and carry
out the standards and implementation specifications in
the Security Rule.”
 “A risk analysis is foundational”
 “The Security Rule requires entities to evaluate risks and
vulnerabilities... and to implement reasonable and
appropriate security measures... Risk analysis is the first
step in that process.”
Guidance on Risk Analysis Requirements under the HIPAA Security Rule, July 14, 2010
http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/rafinalguidancepdf.pdf

19. Part 3
HIPAA Security Risk Analysis
1. What is it?
2. How does it fit into my security program?
3. What are the preparation steps?
4. How can I avoid pitfalls & maximize value?

20. Organizational Resources
• Vendor selection (2-8 weeks)
Time • Risk Analysis timeline (1-4 weeks)
• Vendor selection (IT, compliance,
People executive)
• During RA (1 liaison)
Budget • Varies depending on size/complexity

21. What about cost?
Variables
– Depends on complexity, satellite locations, …
– Web application and network penetration testing
– Social engineering
– Business associate risk

22. What is needed for a proposal?
What is size & complexity of IT environment
Key criteria...
RFP Template

23. What is needed for analysis?
Liaison
ePHI inventory
Critical business associates
ISO – person responsible for security
Security policy
Documentation (whatever is available)
- Network diagrams, audit results, system docs

24. Part 4
HIPAA Security Risk Analysis
1. What is it?
2. How does it fit into my security program?
3. What are the preparation steps?
4. How can I avoid pitfalls & maximize value?

25. 1
Pitfall
Waiting for network to stabilize
It Never Does!

26. 2
Pitfall
Assuming control addresses risk
Existence
does not equal
Effective

30. 3
Pitfall
Thinking compliance is security
Compliance
does not equal
Security

32. 4
Pitfall
Waiting until you implement ____
It may not be a high priority

33. 5
Pitfall
Using a check-box approach to RA
 False positives make you look bad
 Creates focus on less important issues, while
missing critical risk
 Expensive mitigation
 Lack of context

34. HIPAA Security Rule
 Covered entities may use any security measures that
allow the covered entity to reasonably and appropriately
implement the standards and implementation
specifications as specified in this subpart.

35. HIPAA Security Rule
 In deciding which security measures to use, a covered
entity must take into account the following factors:
– (i) The size, complexity, and capabilities of the covered entity.
– (ii) The covered entity's technical infrastructure, hardware, and
software security capabilities.
– (iii) The costs of security measures.
– (iv) The probability and criticality of potential risks to electronic
protected health information.

36. Summary
HIPAA Security Risk Analysis
What is it?
How does it fit into my security program?
What are the preparation steps?
How can I avoid pitfalls & maximize value?