Summary of Data Security and Privacy Practices

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.  NACHC continues to expand workforce training content and tools to ensure data privacy and security.

Regulations

For approved projects, NACHC receives limited datasets (LDS) containing minimal amounts of protected health information (PHI) from health centers. Those LDS are subject to the Health Insurance Portability and Accountability Act (HIPAA), specifically the Privacy Rule. As such, NACHC ensures that LDS are kept safe using appropriate physical and electronic safeguards and executes a data use agreement before a LDS is shared. Additionally, NACHC commits to timely breach notification terms. 

Compliance 

NACHC recognizes that 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 appreciates the requirement to fully comply with HIPAA, HITECH, and the data use agreements in place with data sharing partners. NACHC requires a data use 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. 

For security compliance, NACHC completed an audit of AWS assets by Cloudnexa to assess alignment with the 'Well Architected' framework (WA) that defines best practices for security, reliability, performance efficiency, cost optimization, operational excellence, and serverless lens.    

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 

NACHC carries cybersecurity insurance to protect against the impacts of a cybersecurity event.   

Multi-factor Authentication  

Multi-factor (MFA) authentication is managed by NACHC's IT team. NACHC has implemented MFA 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.