Purpose

This document establishes guidelines for risk analysis and management of ePHI (Electronic Personal Health Information). Risk management is an ongoing process to determine the value of assets and the corresponding exposure to threats and vulnerabilities. Information produced during the risk assessment will be used to determine and manage security controls for our ePHI resources.

Scope

This risk management program applies to resources with ePHI that are managed by the NCSA Health Care Component, including those in the Advanced Computational Health Enclave.

Standards

Risk Assessment Frequency

A risk assessment will be performed every year with coordination of the NCSA Security Office and the NCSA HIPAA Liaison. Exceptions to this include (i) substantial infrastructure/environment changes that would require a new impact analysis and (ii) a security incident that warrants reevaluation of risks.

Risk Assessment Components

A risk assessment contains the following components: asset identification, data/service criticality analysis, threat assessment, risk determination, and a mitigation strategy. Risks will be recorded in the NCSA risks register, and risk assessments will be saved for 6 years or from the inception of the NCSA Health Care Component.

Risk Management Process

The risk assessment is part of an on-going process to understand and manage risk. The broader process contains the following steps.

1. A risk assessment performed.
2. Findings are submitted to the NCSA Security Office within 30 days, and the Security Office forwards it to the HIPAA Liaison.
3. The NCSA Security Office works with the project(s) to remediate vulnerabilities and mitigate risks within 90 days of finishing the assessment. If this is not possible for all risks, an exemption must be requested in writing to the Security Office and HIPAA Liaison.
4. Remediation activities are documented in a remediation plan.
5. The remediation plan is sent to the Security Office, who sends it to the HIPAA Liaison.

Privacy

All data from the risk assessment is kept confidential and not shared without written approval from the NCSA Security Office and HIPAA Liaison.

Consequences

Violations can result in disciplinary action as described in the University of Illinois HIPAA policies.