hipaa-policies

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7. System Access Policy

Access to CIRG 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:

7.1 Applicable Standards

7.1.1 Applicable Standards from the HITRUST Common Security Framework

7.1.2 Applicable Standards from the HIPAA Security Rule

7.2 Access Establishment and Modification

  1. Requests for access to CIRG Platform systems and applications is made formally using the following process:
  2. The CIRG workforce member, or their manager, initiates the access request by creating an Issue in the Trello Compliance Review Activity (CRA) Project.
    • 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.
  3. 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.
  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. The Security Officer then grants requested access.
    • New accounts will be created with a temporary secure password that meets all requirements from §7.12, which must be changed on the initial login.
    • All password exchanges must occur over an authenticated channel.
    • For production systems, access grants are accomplished by adding the appropriate user account to the corresponding LDAP group.
    • For non-production systems, access grants are accomplished by leveraging the access control mechanisms built into those systems. Account management for non-production systems may be delegated to a CIRG employee at the discretion of the Security Officer.
  6. Access is not granted until receipt, review, and approval by the CIRG Security Officer;
  7. The request for access is retained for future reference.
  8. All access to CIRG systems and services are reviewed and updated on a bi-annual 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 Trello Compliance Review Activity (CRA) Project.
    2. The Security Officer, or a Privacy Officer, is assigned to review levels of access for each CIRG 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 Trello reporting to assess compliance with above policy.
  9. Any CIRG workforce member can request change of access using the process outlined in §7.2 paragraph 1.
  10. Access to production systems is controlled using centralized user management and authentication.
  11. Temporary accounts are not used unless absolutely necessary for business purposes.
    • Accounts are reviewed every 90 days to ensure temporary accounts are not left unnecessarily.
    • Accounts that are inactive for over 90 days are removed.
  12. In the case of non-personal information, such as generic educational content, identification and authentication may not be required. This is the responsibility of CIRG Clients to define, and not CIRG.
  13. 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 §7.2 paragraph 1.
  14. 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.
  15. Generic accounts are not allowed on CIRG systems.
  16. Access is granted through encrypted, VPN tunnels.
    • VPN connections use 256-bit AES 256 encryption, or equivalent.
    • VPN sessions are automatically disconnected after 30 minutes of inactivity.
  17. 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.
  18. Direct system to system, system to application, and application to application authentication and authorization are limited and controlled to restrict access.

7.3 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. CIRG maintains a minimum necessary approach to access to Client data.

7.4 Access Authorization

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

7.5 Person or Entity Authentication

  1. Each CIRG workforce member has and uses a unique user ID and password that identifies him/her as the user of the information system. This credential is provisioned and managed by the University of Washington’s central IT group.
  2. Each Client and Partner has and uses a unique user ID and password that identifies him/her as the user of the information system.
  3. All Client support desk interactions must be verified before CIRG support personnel will satisfy any request having information security implications.

7.6 Unique User Identification

  1. Access to CIRG systems and applications is controlled by requiring unique User Login IDs and passwords for each individual user and developer.
  2. Passwords requirements mandate strong password controls (see below).
  3. Passwords are not displayed at any time 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 CIRG systems or networks.
  6. Automated log-on configurations that store user passwords or bypass password entry are not permitted for use with CIRG workstations or production systems.

7.7 Logoff

  1. Users are required to make information systems inaccessible by any other individual when unattended by the users (ex. by using a password protected screen saver or logging off the system).

7.8 Employee Workstation Use

All workstations at CIRG are company owned.

  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 FileVault 2.0 or equivalent.
  8. All workstations have firewalls enabled to prevent unauthorized access unless explicitly granted.

7.9 Wireless Access Use

  1. CIRG 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 CIRG non-production facilities (offices, etc.) are secured with the following configurations:
    • All data in transit over wireless is encrypted using WPA2 encryption;

7.10 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, users, and supervisors are required to notify the Security Officer 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 CIRG 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.

7.11 Paper Records

CIRG does not use paper records for any sensitive information. Use of paper for recording and storing sensitive data is against CIRG policies.

7.12 Password Management

  1. User IDs and passwords are used to control access to CIRG systems and may not be disclosed to anyone for any reason.
  2. Users may not allow anyone, for any reason, to have access to any information system using another user’s unique user ID and password.
  3. Operating systems tie in with a backend LDAP server ( CIRG LDAP ), which shadows UW Active Directory (“AD”). Passwords are stored in either the CIRG LDAP server or the UW AD ( kerberos ). Users are granted access to systems based on their role.
  4. Web applications use local accounts which are unique to each user (not shared). Access to specific functionality and data is controlled via roles (e.g.: patient, staff, staff-admin, admin), and organizational affiliation (e.g. clinical site). They have a configurable inactivity timeout that expires inactive login sessions (currently set to 60 minutes standard, and 5 minutes in kiosk environments).
  5. 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).
    • Passwords that must be stored in non-hashed format must be encrypted at rest pursuant to the requirements in §17.8.
    • Transmitted passwords must be encrypted in flight pursuant to the requirements in §17.9.
  6. Passwords are inactivated immediately upon an employee’s termination (refer to the Employee Termination Procedures in §7.10).
  7. All default system, application, and Partner passwords are changed before deployment to production.
  8. Upon initial login, users must change any passwords that were automatically generated for them.
  9. Password change methods must use a confirmation method to correct for user input errors.
  10. All passwords used in configuration scripts are secured and encrypted.
  11. If a user believes their user ID has been compromised, they are required to immediately report the incident to the Security Office.
  12. 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 cirg-adm@uw.edu. The request should include the system to which the user has lost access and needs the password reset.
    • An administrator with password reset privileges is notified and connects directly with 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.

The password-reset email inbox is used to track and store password reset requests. The Security Officer is the owner of this group and modifies membership as needed.

7.13 Access to ePHI

  1. Employees may not download ePHI to any workstations used to connect to production systems.