Project: Situation: Your Team Represents IT Leadership ✓ Solved

Project: Situation: Your team represents the IT leadership

Your team represents the IT leadership of a large healthcare organization that is preparing to purchase a smaller hospital group consisting of: 2 Metro hospitals (1 is a learning hospital, which means students are in scope), 3 Rural hospitals, 2 Shared data centers (located within 5 miles of each other), 25 Physician practices, 1 Lab, and 1 Coordinated business office. Your objective is to evaluate the sites prior to purchase from a risk and compliance standpoint, with a focus on access controls at both the logical and physical standpoint.

Part of the agreement allows for your organization to thoroughly test the systems, which includes: 1 Electronic medical record (EMR) system, 2 Mobile applications (1 has the ability to accept credit card payments), 5 External websites (1 has the ability to accept credit card payments), 3 Cloud based systems (1 Infrastructure as a service, 2 Software as a service), 75 Patient care applications (25 developed internally), and 500 Patient care devices. See individual assignments for deliverables (1 - 8).

Expected Work: 1) Team Details - Document your roles in the organization (e.g., CIO, CISO, Architect, etc.) (each team member) - Develop job descriptions for each role, include a salary range. 2. Information Security Policy - Select a best practice framework, review the control family recommendations and document a policy for the existing organization with the expectation that the new sites will follow the policy. Note: Still follow APA for this assignment, which may not be appropriate in an organization.

3. Testing Methodology Policy and Procedure - Research and document preferred testing methodologies for: EMR, Mobile Apps, Patient Care devices, External websites, SDLC (hint: vulnerability scanning, penetration testing, medical device scanning, static code analysis, dynamic code analysis, etc.). (each team member) - Research and document preferred remediation cycles for the in-scope systems (hint: HIPAA, PCI, FERPA) - Research and document preferred reporting cycles / methods for the in-scope systems (hint: vulnerability metrics, such as CVSS, NVD). Note: Still follow APA for this assignment, which may not be appropriate in an organization.

4. Network Diagram - Develop a proposed network diagram for after the purchase to aid in security and administration (reference required security controls in your policy). 5. Physical Security Assessment Procedure - Develop a physical security assessment plan for the new entity (reference this in your policy). Note: This can be a checklist. 6. Project Plan - Include timelines, expected level of efforts, RACI model, remediation expectations (if you decide to also use third-party resources, you’ll need to estimate those costs since you have already created your own hourly rate).

7. Risk Acceptance / Risk Tolerance Procedure - Develop a method for leadership to receive risk details and determine appropriate risk actions. 8. Final Presentation - Summarize items to present to the class.

Paper For Above Instructions

The healthcare landscape is increasingly competitive, necessitating robust IT leadership capable of integrating new acquisitions seamlessly. The forthcoming acquisition of a smaller hospital group by a larger healthcare organization presents both opportunities and challenges, requiring a thorough risk and compliance evaluation. This paper outlines the framework of risk management in the context of IT leadership in healthcare, focusing on access controls—both logical and physical—across various healthcare facilities.

Team Roles and Responsibilities

In any organizational structure, a clear delineation of roles is crucial for effective management. Our IT leadership team comprises a Chief Information Officer (CIO), Chief Information Security Officer (CISO), IT Architect, Compliance Manager, and Operations Manager. The CIO oversees the IT strategy and ensures alignment with organizational goals, while the CISO is responsible for establishing and maintaining the enterprise vision, strategy, and security programs. Each member's job description includes essential skills and competencies based on national benchmarks for salaries within the healthcare IT sector:

• CIO: Responsible for strategic planning and leadership in IT; Salary: $180,000 - $250,000.
• CISO: Oversees information security efforts and manages risk; Salary: $150,000 - $220,000.
• IT Architect: Designs IT systems and infrastructure; Salary: $120,000 - $180,000.
• Compliance Manager: Ensures adherence to regulatory standards; Salary: $90,000 - $130,000.
• Operations Manager: Manages daily IT operations; Salary: $95,000 - $140,000.

Information Security Policy

Adopting a best practice framework, such as the NIST Cybersecurity Framework, is vital for our organization as it sets guidelines for managing cybersecurity risks. The policy will encompass standard operating procedures (SOPs) for new installations, updates, and access controls that new sites will adhere to. Additionally, training staff on security awareness forms an integral part of the compliance strategy.

Testing Methodology Policy

The testing methodology for the IT systems will focus on essential areas such as Electronic Medical Record (EMR) systems, mobile applications, patient care devices, and external websites. Proposed methodologies include:

• Vulnerability Scanning: To identify weaknesses in systems.
• Pentration Testing: To evaluate security by simulating attacks.
• Static Code Analysis: To detect security flaws in software code before it runs.
• Dynamic Code Analysis: To identify vulnerabilities while the application is running.

Compliance considerations such as HIPAA and PCI guidelines will dictate the remediation cycles necessary for identified vulnerabilities, ensuring timely reporting and rectification of security gaps.

Network Diagram

The proposed network diagram for post-acquisition introduces a multi-tier infrastructure that segments sensitive data and systems. Security controls will include firewalls, intrusion detection systems (IDS), and encrypted connections for remote access.

Physical Security Assessment Procedure

A thorough physical security assessment will incorporate an audit checklist assessing entry points, surveillance systems, and access control mechanisms to ensure that both patient data and medical devices are protected from unauthorized access.

Project Plan

The project plan will integrate a RACI model (Responsible, Accountable, Consulted, Informed) to ensure clarity in task delegation. Estimated timelines for completion of each component will focus on critical path analysis, aiming for a structured rollout that minimizes disruptions. Regular budget reviews will account for third-party resources and staffing costs.

Risk Acceptance and Tolerance Procedure

A systematic method for leadership to assess and accept risk will be established, including detailed reporting of risk metrics and potential impacts. This ensures informed decision-making at the executive level.

Conclusion

The acquisition of a smaller hospital group presents a timely opportunity for expansion, albeit with significant risks necessitating diligent planning and execution from IT leadership. The outlined frameworks and strategies provide a comprehensive approach to ensuring compliance, security, and operational efficiency in integration.

References

• Clark, J. (2020). "Cybersecurity in Healthcare: A Guide to Compliance." Journal of Health Information Management.
• National Institute of Standards and Technology. (2018). "Framework for Improving Critical Infrastructure Cybersecurity."
• HealthIT.gov. (2021). "The Role of Health IT in Consumer Engagement." U.S. Department of Health & Human Services.
• HIMSS. (2019). "Cybersecurity: Protecting Patient Information and Health Data."
• HIPAA Journal. (2020). "Understanding the HIPAA Security Rule."
• PCI Security Standards Council. (2020). "Payment Card Industry Data Security Standard."
• ISACA. (2021). "COBIT 2019 Framework: Introduction and Methodology."
• Weber, L. (2019). "Compliance and Risk Management in Healthcare: Balancing Act." Healthcare Quarterly.
• Sharma, S., & McCoy, A. (2021). "Mobile Application Security in Health: Challenges and Opportunities." International Journal of Medical Informatics.
• Security and Privacy in Healthcare. (2019). "Best Practices for Healthcare Cybersecurity."