Risk Assessment, Business Impact Analysis, and Business Continuity Plan for Augusta Medical Hospital

Risk Assessment, Business Impact Analysis, and Business Continuity Plan for Augusta Medical Hospital

With the growing dependence on digital systems in an interdependent world, Augusta Medical Hospital, like any healthcare organization, must prepared to handle a myriad of risks that may have profound implications on operations. Given Augusta Medical Hospital’s recent history regarding cybersecurity incidents, more so with ransomware attacks, there is a critical need to develop an effective risk assessment, business impact analysis, and business continuity plan to guarantee resilience within the hospital. This essay is aimed at conducting a qualitative risk assessment, creating a business impact analysis (BIA) and a business continuity plan that identifies critical systems, determines weaknesses, and ensures continuity of service if an event occurs that disrupts Augusta Medical Hospital.

Part 1: Qualitative Risk Assessment

Identification of Critical Systems and Their Impact on the Organization

Some systems are indispensable in a healthcare setting, ensuring patient care, legal compliance, and operational continuity. The following are critical systems identified at Augusta Medical Hospital:

1. Electronic Medical Records System: It is the backbone of patient information management. It carries the patient history, treatment plans, drug prescriptions, and test results from medical imaging. Any disturbance to the system could lead to extreme circumstances entailing delays in care, misdiagnosis, and even non-compliance with health and other regulations, not to mention HIPAA.
2. Radiology and Medical Imaging Systems: These are crucial for the accuracy and speed of diagnosis. They include CT, MRI, and X-ray, which are all extremely vital in diagnosing life issues such as cancer, fractures, and cardiovascular diseases. Downtime may delay treatment and be related to poor health outcomes.
3. Pharmacy and Laboratory Systems: Pharmacy systems maintain and coordinate medication dispensing in accordance with prescriptions issued to patients. Laboratory systems interpret the results of blood tests, biopsies, and other important diagnostic tests conducted on patients. Disruption in such systems can mean medication errors and delayed diagnostics, issues that can compromise patient safety.
4. Billing and Insurance Systems: These manage financial transactions, insurance claims, and billing for services rendered. If these systems are not working properly, the hospital may suffer financial losses, delays in receiving payments, and deteriorating relationships with insurers and patients.
5. Patient Portals: These are accessed for patient records, appointment requests, and payments. A breach or disruption in this would permit intrusion into patients’ privacy and reduce trust in the institution (Okafor et al., 2023).

Should any of these systems fail, the impact will be disastrous, as not only patient care but also the general reputation and financial stability of the hospital will be at stake.

High-Risk Findings and Mitigation Strategies

Following the vulnerability scanning, several high-risk findings became apparent and needed to be fixed immediately. These include:

Outdated EMR Software

Risk. Augusta Medical Hospital’s EMR system has not seen an upgrade since 2000 and remains vulnerable to cyberattacks, especially ransomware.

Mitigation. The EMR needs to be migrated to a more modern and secure version that allows for encryption, has 2FA, and has the latest software updates. The backup systems also need to be improved so that the data can be recovered in case of an attack (Spence et al., 2018).

Lack of Multi-Factor Authentication (MFA)

Risk. This exposes access of critical systems to unauthorized access due to a lack of MFA for access.

Mitigation. Implement MFA for all staff access to the EMRs, pharmacy information systems, and patient portals. This provides a layer of security and requires users to furnish additional verification (Suleski et al., 2023).

Unencrypted Data Transmission

Risk. Data in transit from one system to another is in plain text and can be hijacked by any cybercriminal.

Mitigation. Establish industry-standard protocols for in-transit encryption, like Transport Layer Security, to ensure that, even if the data is intercepted, it cannot be read by any entity other than the participating parties; Matt (2020) proposed this risk mitigation measure.

Inadequate Backup and Recovery Processes

Risk. The hospital’s present backup procedures are inadequate, and this may lead to data loss or extended downtime in case of a cyberattack or system failure.

Mitigation. Backing up all data to on- and off-site locations with strong encryption and faster recovery capabilities shall be implemented to reduce dependency on having to pay a ransom by the hospital as a last resort in the case of ransomware attacks.

Vulnerable Patient Portals

Risk. Weak security in patient portals is a sure way for a system to be hacked and data breached.

Mitigation. Use stronger passwords, add multi-factor authentication, and ensure that all data stored or transferred is encrypted.

Compensating Controls

Where the implementation of some of the security measures involves high costs or some operational constraints that cannot be applied fully, then compensating controls should be introduced. For example, for legacy systems that cannot be upgraded or replaced immediately, network segmentation has to be implemented. This involves isolating these systems from the main network, hence reducing the risk of malware propagation through the entire hospital infrastructure. In the case of data, encryption is not possible in all systems; keep tracking for any abnormal behavior and raise the alarm to the security team in real-time. This will facilitate a prompt response during a breach and contain the damage. These compensating controls shall minimize the risks and ensure Augusta Medical Hospital retains a risk-free operation environment while complete mitigation techniques cannot be enforced within a short period.

Part 2: Business Impact Analysis and Business Continuity Plan

Business Continuity Plan

A business continuity plan (BCP) is articulated to ensure that core functions and services are sustained during and after disruptions. The goal is to reduce business time loss by protecting against the compromise of patient information and adherence to healthcare regulations. Augusta Medical Hospital’s BCP will focus on maintaining patient care, preserving financial stability, and restoring critical systems in case of a disaster.

Contingency Plan

A contingency plan for Augusta Medical Hospital should place emphasis on the following:

1. Critical System Restoration: Restore the EMR first, followed by radiology, pharmacy, and billing systems. These systems are related to diagnosis, treatment, and financial operations with direct contact with patients.
2. Manual Workflows: In the event that the system fails completely, Augusta Medical Hospital should establish manual procedures. For example, paper charting of patient records with lab and pharmacy orders done manually should be initiated until digital systems are restored (Cao et al., 2017).
3. Data Backup and Redundancy: The hospital should periodically back up relevant data, locally and remotely. Backups through the cloud add an extra element of redundancy that allows faster system re-establishment in case of a disaster. The hospital should periodically exercise its disaster recovery capacity for seamless transitions during disruptions (Fulmer, 2018).

Cost/Benefit Analysis

An organization implementing a comprehensive business continuity and disaster recovery plan needs huge investment in technology and personnel. The cost/benefit analysis below reveals the following:

Costs

• IT cost to upgrade critical systems: EMRs, Radiology: $1 million
• Cost of MFA and encryption implementation = $250,000
• Disaster recovery site and redundancy infrastructure = $500,000 per annum
• Cybersecurity awareness training and regular disaster recovery drills = $100,000 per annum

Benefits

• Reduced risk of ransomware remittance and litigation: $1 million per incident
• Reduced downtime: Preserves patient care services and compliance with regulatory standards: Priceless in patient safety and hospital reputation
• Protection from regulatory fines and penalties: Avoid potential fines in excess of $1 million for a breach, depending on its seriousness.

While such systems and controls may be costly at the front end, the pros—especially in terms of avoided costs, improved patient safety, and enhanced reputation—outweigh the initial expenditure.

Incident Response Plan (IRP)

The incident response plan is an inherent component of the BCP, primarily concerned with the minimization of damage caused by security-related incidents. The incident response plan will have the following provisions:

1. Identification of the Incident: Security teams should monitor systems continuously in search of unauthorized access, malware, and data breaches. In case of any such suspicious activity, the system should generate an automatic alert for teams to respond promptly (Suleski et al., 2023).
2. Containment: Proper containment must be done immediately after an incident is identified. This might involve isolating affected systems from the network, stopping unauthorized data transfers, and suspending user accounts portraying suspicious behavior (Spence et al., 2018).
3. Eradication and Recovery: After containing the threat, eradication processes should be initiated by eliminating malware, patching vulnerabilities, and restoring data from backup. This recovery needs to be initiated so that the impact of the event is minimal through minimum downtime and ensuring continuity in patient care (Cao et al., 2017).
4. Lessons Learned: This should be ensured after an incident, and a post-incident review should be conducted to find out the root cause of the breach and improve future security measures. This will ensure that lessons learned from the incident and that security policies are updated (Matt, 2020).

Compensating Controls and Compliance Gaps

In some cases, the implementation of security controls will be impossible either due to budget implications or disruptions of operations. In such cases, compensating controls can be applied to ensure that a non-compliant system still runs securely. For example, if full encryption cannot be implemented, strict access controls must be implemented, and non-compliant systems must be constantly monitored.

Network segmentation—if upgrading legacy systems is delayed. This provides a lower risk of propagation of an attack across a network. A delayed upgrading of such has the risk of propagation across a network. The presence of these compensating controls enables Augusta Medical Hospital to remain in compliance with healthcare regulations and reduce risk.

Likelihood and Impact of a Cybersecurity Breach

The risk of a breach in cybersecurity is still considerably large, especially considering that cyberattacks are growing more and more complex by the day. Indeed, according to various recent studies, the healthcare sector has been assessed as one of the top five most commonly targeted ones due to the sheer value that medical records hold on the black market (Newaz et al., 2021). This could mean disastrous consequences for the hospital if this happened, including:

• Data Theft: Unauthorized patient medical records may be used for identity theft and invasion of privacy (Newaz et al., 2021).
• Financial Loss: Costly litigation, regulatory fines, and loss of patient trust may bring financial ruin to a hospital.
• Operational Disruption: A hospital may suspend its operations due to a breach of its duty to protect its patients. The care given to the patients will be affected, and eventually, reputational damage will occur.

By designing an in-depth BCP, DRP, and IRP, Augusta Medical Hospital can mitigate the impact of a potential breach on the health system and allow it to continue operations in the face of severe cyber threats.

Part 3: System Configuration Requirements Based on the NIST Cybersecurity Framework

The NIST Cybersecurity Framework can be reduced to system configuration requirements and test cases to enhance Augusta Medical Hospital’s cybersecurity posture. These controls will make sure that critical systems are protected and compliant with industry standards.

Access Control (AC-2)

• Configuration: Role-based access control on all critical systems is implemented.
• Test Case: Unauthorized access of EMRs to verify that only authorized users have access to the system. Pass/Fail

Data Encryption (SC-13)

• Configuration: The TLS and AES-256 protocols have to be configured for rest and transit data, respectively.
• Testing Case: The testing will simulate the interception of data and will check that the information is still encrypted and not readable. Pass/Fail

Incident Response (IR-4)

• Configuration: An incident response plan has to be developed, and all employees must know their role in incident handling.
• Testing Case: Simulation of a ransomware attack and compute response time and effectiveness of containment and recovery process.

Data Backup (CP-9)

• Configuration: Set up an automated daily backup of critical systems; store the media at an off-site location.
• Test Case: Test restoration of backup data within 24 hours to quickly recover. Pass/Fail.

Continuous Monitoring (CA-7)

• Configuration: Continuous monitoring tools shall be installed to highlight unusual activity in real time.
• Test Case: Conduct a simulation for unauthorized access or data transfer. Check that the alerts are generated in a reasonable timeframe. Pass/Fail

By implementing such NIST controls, Augusta Medical Hospital would enhance its cybersecurity defenses and compliance with industry standards.

Conclusion

The implementation of a qualitative risk assessment, business impact analysis, and business continuity plan is paramount for the survival of Augusta Medical Hospital amidst impending risks. It will enable the organization to identify critical systems against high-risk vulnerabilities and implement compensating controls wherever necessary to avert the risks. Complying with healthcare regulations, the NIST Cybersecurity Framework acts as a guiding principle that keeps Augusta Medical Hospital on the right course toward the delivery of quality patient care. In this regard, hospitals can maintain operational resiliency in the face of cyber threats by keeping pace with constant monitoring, incident response planning, and system testing.

References

Cao, F., Huang, H. K., & Zhou, X. Q. (2017). Medical image security in a HIPAA-mandated PACS environment. Computerized Medical Imaging and Graphics, 27(2-3), 185-196.

Fulmer, K. L. (2018). Business continuity planning: A step-by-step guide with planning forms. Rothstein Publishing.

Matt, B. (2020). Computer security: Art and science (2nd ed.). Pearson.

Newaz, A. I., Sikder, A. K., Rahman, M. A., & Uluagac, A. S. (2021). A survey on security and privacy issues in modern healthcare systems: Attacks and defenses. ACM Transactions on Computing for Healthcare, 2(3), 1-44.

Okafor, C. M., Kolade, A., Onunka, T., Daraojimba, C., Eyo-Udo, N. L., Onunka, O., & Omotosho, A. (2023). Mitigating cybersecurity risks in the US healthcare sector. International Journal of Research and Scientific Innovation (IJRSI), 10(9), 177-193.

Spence, N., Niharika Bhardwaj, M. B. B. S., & Paul III, D. P. (2018). Ransomware in healthcare facilities: A harbinger of the future? Perspectives in Health Information Management, 1-22.

Suleski, T., Ahmed, M., Yang, W., & Wang, E. (2023). A review of multi-factor authentication in the Internet of Healthcare Things. Digital health, p. 9, 20552076231177144.

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

Conduct a Risk Assessment, Develop a Business Impact Analysis and Business Continuity Plan.

Organizations exist in a globally competitive environment where there are threats such as natural disasters, geopolitical threats, and cybersecurity risks. As such, organization leaders must develop a business continuity plan to ensure the successful continuation of the organization during a period of disruption. Conduct a risk assessment, business impact analysis, and create a business continuity plan for Augusta Medical Hospital. Use the virtual system and vulnerability assessment tools to simulate systems security vulnerabilities within the organization’s business application systems.

Part 1:
In 750-900 words, conduct a qualitative risk assessment and assess the impact the risk will have on the organization after conducting a vulnerability scanning of the provided systems. Address the following:

• Identify critical systems and their impact on the organization.
• Highlight high-risk findings and recommend mitigation strategies.
• Explain what is to be done in each case identified above to compensate for controls that cannot be implemented (an alternate control).

Part 2:
In 750-900 words, develop a contingency plan to include: business continuity, disaster recovery, and incident response. This will not be a technical risk assessment, but an assessment of Augusta Medical Hospital. Address the following:

• Explain the contingency plan to address and prioritize compliance gaps.
• Provide a cost/benefit analysis.
• Describe when some controls cannot be implemented (because implementing these controls will reduce business functionality or endanger human lives).
• Demonstrate how compensating controls can ensure the noncompliant system can continue to operate within the secured and compliant environment.
• Differentiate the likelihood of a cybersecurity breach within the compliant environment and its impact on the organization (make sure to consider emerging risks, threats, and vulnerabilities).

Part 3:

• For Augusta Medical Hospital, take the NIST cybersecurity framework controls and reduce them to system configuration requirements and system test cases with pass/fail criteria.