Personnel
NACHC employs an information technology (IT) team of experienced and appropriately credentialed personnel to monitor and maintain data security and privacy. For selected security functions, NACHC partners with various information security vendors and subject matter experts. The executive sponsor for NACHC data security and privacy is the CFO. Outside of the IT team, NACHC shares the responsibility to ensure that data is protected and treated with the utmost respect with all NACHC staff and contractors. NACHC is exploring hiring a compliance officer. For staff and contractors handling health data, NACHC expects those individuals to understand and abide by the additional requirements defined in the HIPAA Privacy and Security Rules.
Future Improvements: NACHC staff will receive training that begins with an annual baseline training and expands to additional training that is defined based on job and access to protected health information and personally identifiable information.
Compliance
Currently, NACHC does not undergo regular compliance reviews. For health data, NACHC recognizes that HIPAA compliance begins with organizational policies, procedures, and practices that are reinforced through appropriately secured technology and training of staff. As a steward of health data from other organizations, NACHC recognizes the requirement to fully comply with HIPAA, HITECH, and the data sharing agreements in place with partners. NACHC requires a data sharing agreement to be executed between any organization with whom data is shared in order to clearly define the expectations of the data provider and recipient. NACHC requested an audit of AWS assets by CloudNexa to assess their alignment with the 'Well Architected' framework (WA) that defines best practices for security, reliability, performance efficiency, cost optimization, operational excellence, and serverless lens.
Future Improvements: NACHC will continue to make progress adopting and aligning with the WA framework.
Cybersecurity Standard
NACHC adopts the NIST cybersecurity framework and standard. As the NIST framework and standard is always evolving, NACHC regularly updates their security and privacy practices accordingly.
Cybersecurity Insurance
Future Improvements: NACHC is seeking cybersecurity insurance and is in the process of putting in place the infrastructure to meet the requirements to secure a cybersecurity policy.
Multi-factor Authentication (MFA)
Mutli-factor authentication is managed by NACHC's IT team. NACHC has implemented multi-factor authentication across platforms and systems. Multi-factor authentication is in place to access internal servers, Confluence, Office 365, and cloud applications.
Disaster Recovery and Back-Up
Disaster recovery is managed by NACHC's IT team. NACHC is developing a disaster recovery plan that is compliant with HIPAA and industry standards. NACHC has three backups using Microsoft Azure of all internal and cloud servers including all elements of Office 365 on a daily and weekly basis. For some applications like AWS, supplementary back up functions within those applications are enabled.
Incident Management and Breach Notification
Incident management is the responsibility of NACHC’s security IT vendor. When a security incident includes a breach, NACHC will notify affected partners of the security event and remediation efforts. Applicable NACHC systems run a breach detection software tool to identify and report a breach in real time. To provide an added layer of protection against breaches, NACHC also runs Microsoft End Point Protection. NACHC developed breach notification policy and procedure based on industry best practices. NACHC delivered a required training on breach procedures to all staff. Every new NACHC employee must complete this training as part of onboarding.
Vulnerability Assessment
Vulnerability Assessment is the responsibility of NACHC’s security IT vendor. All applicable systems are assessed for vulnerabilities every three months and upon completion of each assessment, recommendations are implemented prior to the subsequent assessment, which verifies that those changes were made.
Auditing
NACHC performs auditing of critical internal and cloud systems as part of the vulnerability assessment. All system audit functions are enabled and audit information is reported to the IT team. Multiple tools log all user activity and performance within AWS. Thresholds for alarms are configured to identify suboptimal performance and notify NACHC in real time for remediation.
Encryption and Transmission
We protect your data with encryption in transit and at rest and provide administrative controls to enforce organization-wide protection such as SAML SSO, enforced 2FA, and SCIM.