Security and Privacy Assessment Report – Evaluating ABC Hospital’s Protocols, Gaps, and Industry-Specific Cyber Laws
Security issues play an important role in the healthcare business, especially for the hospitals that deal with the personal information of their patients. Compliance with these laws is important because it ensures that ABC Hospital is in line with developed regulations and minimizes or eradicates probable legal implications that relate to data infringement. This report elaborates on areas that are crucial in compliance and development of sound cybersecurity status.
Components of IT Governance Frameworks
To address the compliance issues within ABC Hospital, it is important to reflect on the components of the IT Governance frameworks. Thus, IT governance frameworks are aimed at providing a structured approach to managing and controlling IT processes and activities in terms of objectives and compliance with a firm’s standards and norms. Below are some of the core components that are employed in the formulation of IT governance frameworks.
Policies are one of the key aspects of IT governance that regulate the organization’s organized activities. They have the right to determine the code of conduct and policies governing IT activities. This is a way of standardizing organizational processes and IT plans and aligning them with the hospital’s strategic plans and goals. Further, procedures are understood as instructions that describe how particular policies are to be put into practice. They also give a precise structure of how the IT will function, and they articulate that all the operations will be properly aligned with the rules and regulations. Activities should include essential fields like managing the IT service, managing IT projects, and managing risks.
Overarching Guidance and Laws for Industry Compliance
The healthcare industry has to meet several general guidelines and laws that govern its functioning. Below are some of the critical guidance and laws of ABC Hospital: The Health Insurance Portability and Accountability Act of 1996, also known as HIPAA. HIPAA has guidelines that establish the privacy of patient’s health information and its implementation across electronic health records (Edemekong et al., 2024). HIPAA guidelines have to be adhered to protect the privacy of the patient and to avoid leakage of information. According to the Cybersecurity Act of 2015, the Department of Health and Human Services is supposed to establish a framework for the Cybersecurity of the healthcare sector (Panetta & Andrew Schroth, 2020). There is also the General Data Protection Regulation (GDPR). Nevertheless, as per the GDPR of the European Union, such a guideline can be implemented in healthcare organizations that may have a connection with the handling of the personal data of EU residents (Van Alsenoy, 2019).
Requisite Set of Standards, Frameworks, Policies, and Best Practices
Pertaining to cybersecurity management at ABC Hospital, it is highly recommended that the hospital incorporates and applies standards, frameworks, policies, and best practices for cybersecurity. The most common of these is the National Institute of Standards and Technology (NIST) Cybersecurity Framework (Sargent, 2022). It is very useful in trying to give a sound roadmap on how to handle the issue of cybersecurity risks. It includes five core functions. The five different preparedness elements that can be identified are identification, protection, detection, reaction, and recovery.
Another influential framework is ISO 27001, which defines international requirements for information security. It has a structure that outlines how one is to protect company information, outlines procedures in risk evaluation and security measures, and illuminates how to handle security breaches. HIPAA is another standard specific to the healthcare business. It outlines the standards for the confidentiality of the patient’s health information and contains provisions for the handling of data, security, access, and breach reporting.
Requirements Analysis and Business Information Systems Solutions
In the implementation of business information systems solutions, the recommendations state that ABC Hospital should first define its needs and provide solutions that address these needs through administrative requirements analyses. They include data categorization, encryptions, and authorization of data. In data classification, the data is sorted according to their levels of sensitivity and criticality in order to facilitate the required security measures. Data encryption entails the process of encoding all the ePHI information in a manner that cannot be accessed by unauthorized persons (Rahul et al., 2022). Security policies include applying role-based access control to restrict dignified access to patient records.
Critical Data Infrastructure Assets
Understanding what needs protection is equally important in building up the cybersecurity strength of an industry’s infrastructure. The hospital’s network infrastructure comprises routers, switches, firewalls, and WAPs and is an important organizational asset. ABC Hospital’s telecommunication systems, including voice and data communication channels, should be secured to prevent interception and unauthorized access to sensitive information. Critical utilities include power and water supply systems. Various applications in the hospital include electronic health record systems, patient management systems, and billing systems. All hold patients’ data, which is sensitive information, and should not be exposed to unauthorized personnel, or else the hospital will be the next big health scandal. All computers within ABC Hospital’s infrastructure, including workstations, servers, and mobile devices, should be protected against malware, unauthorized access, and data exfiltration. Client data types include client health information, financial details, and demographic information. In the same manner, each category may require certain compliance issues to be dealt with.
Human Resources for Technical, Management, and Legal Operations
Determining key human factors in technical, management, and legal domains is critical to compliance and cybersecurity preparedness. Technical operations employ IT professionals with knowledge of network management or working on Microsoft developments and security threats. Management operations contain supervisors with skills in IT project management, risk, and legal compliance. Legal operations contain legal personnel with a specialty in the law of health care, data protection, and cyber security.
Law Enforcement Entities
In the event of a cybersecurity breach, ABC Hospital should be aware of the requisite law enforcement entities for reporting. The specific entities may vary depending on the organization’s operating jurisdiction but typically include local, state, and federal authorities. Local law enforcement is local police departments or sheriff’s offices. State law enforcement agencies, such as the state attorney general’s office, are state-level law enforcement agencies. Federal law enforcement agencies include the Federal Bureau of Investigation (FBI), the Department of Health and Human Services (HHS), and the Office for Civil Rights (OCR).
Cybersecurity Policies
Therefore, the framework of ABC Hospital’s cybersecurity policies should adhere to laws, regulations, and standards in the USA. These are measures for addressing cybersecurity threats while protecting the digital business components of an organization. The Policy of Data Protection explains the process and procedure for safeguarding the patient’s record. This policy is to make sure that all data is well sorted, archived, and transmitted to avoid cases of unauthorized persons accessing it or breaching it. The policy also prescribes how breaches of data will be and all the necessary measures to dispose of data that is not required anymore.
The incident response policy outlines the response plan in the case of an IT security incident. This policy guarantees that the hospital coordinates ways of managing and correcting a specific incident in a concerted manner at different stages, such as identification, containment, eradication, recovery, and post-recovery work.
The Cybersecurity Awareness Policy provides comprehensive details on how the employees’ awareness of cybersecurity measures will be enhanced. This policy makes it possible to ensure that the employees are fully aware of the need to promote cybersecurity and to report any issue that may be a cybersecurity threat.
References
Edemekong, P. F., Annamaraju, P., & Haydel, M. J. (2024). Health Insurance Portability and Accountability Act. Encyclopedia of Information Assurance, 1299–1309. https://doi.org/10.1081/e-eia-120046838
Panetta, J. J., & Andrew Schroth, R. (2020). CYBERSECURITY ACT OF 2015 REVIEW What it Means for Cybersecurity Governance. http://www.american.edu/kogod/cybergov/upload/kogod-kcgc_cybersecurity-act-of-2015-review_panetta-schroth-2016.pdf
Rahul, Bommareddy, S., Monika, Khan, J. A., & Anand, R. (2022). A review on healthcare data privacy and security. In Networking Technologies in Smart Healthcare (pp. 165–187). CRC Press. https://doi.org/10.1201/9781003239888-8
Sargent, J. F. (2022). The National Institute of Standards and Technology: An Appropriations Overview.
Van Alsenoy, B. (2019). General Data Protection Regulation. In Data Protection Law in the EU: Roles, Responsibilities and Liability (pp. 279–324). https://doi.org/10.1017/9781780688459.021
ORDER A PLAGIARISM-FREE PAPER HERE
We’ll write everything from scratch
Question 
In the attached “Benchmark – Impact Analysis Part 1 Information Acquisition” document, you wrote a compliance report to the CIO from a legal standpoint. In this part of the impact analysis, you will gauge and evaluate ABC Hospital’s current state of security and protection protocols and mechanisms.
Security and Privacy Assessment Report – Evaluating ABC Hospital’s Protocols, Gaps, and Industry-Specific Cyber Laws
Write a 1,300- to 1,500-word report that will be reviewed by the CIO and System Security Authority (SSA), addressing the following:
- Identify gaps when security measures fail, challenges, and opportunities for improvement by conducting a thorough audit.
- Examine concepts of privacy and the effects the internet has on privacy.
- Identify the industry-specific cyber laws about inquiries and incidents to obtain data and evidence.
- Assess the critical information infrastructure and determine the configuration of physical assets, logical controls, data storage and encryption, firewalls, servers, routers, switches, hubs, and so forth to be compliant.
- Identify at least ten key auditable elements that would help determine the current state of the organization’s cybersecurity posture. Explain the relevance of each element to the security and protection protocols and mechanisms.
- Indicate the legal elements and liability (costs) that the industry may encounter for noncompliance.