Description

This curriculum spans the design and operationalization of an ISO 27799-aligned governance structure across clinical, technical, and compliance functions, comparable in scope to a multi-phase advisory engagement supporting enterprise-wide health information governance in a regulated healthcare environment.

Module 1: Establishing the Governance Framework for Health Information

Define scope boundaries for health information governance across clinical, administrative, and research systems within a multi-facility organization.
Select governance roles and responsibilities for data stewards, system custodians, and clinical leads based on regulatory accountability.
Map existing organizational policies to ISO 27799 control objectives to identify coverage gaps in privacy and security practices.
Determine reporting lines for information governance decisions between IT, compliance, legal, and clinical leadership.
Develop escalation protocols for data breaches involving protected health information (PHI) that align with both HIPAA and ISO 27799.
Integrate risk appetite statements into governance charters to guide decision-making on data access and retention.
Establish a governance review cycle for periodic evaluation of control effectiveness across electronic health record (EHR) platforms.
Implement a centralized register of information assets to support classification and ownership assignment.

Module 2: Aligning with Regulatory and Legal Requirements

Conduct jurisdictional analysis to reconcile conflicting data residency laws when operating across state or national borders.
Document legal basis for processing sensitive health data under GDPR, HIPAA, or PIPEDA within shared care environments.
Negotiate data processing agreements with third-party vendors that enforce ISO 27799-aligned security obligations.
Implement audit trails to demonstrate compliance with mandatory retention periods for clinical records.
Design data subject access request (DSAR) workflows that balance patient rights with clinical operational continuity.
Develop policies for handling law enforcement data requests while preserving patient confidentiality.
Update governance controls in response to new regulatory interpretations, such as OCR guidance on ransomware and PHI.
Coordinate with legal counsel to assess implications of using AI-generated clinical documentation on data accountability.

Module 3: Risk Assessment and Management Integration

Perform health-specific risk assessments using ISO 27799 guidance to prioritize threats to patient data confidentiality.
Assign ownership for risk treatment plans involving legacy clinical systems lacking modern encryption capabilities.
Integrate clinical safety considerations into information risk evaluations for connected medical devices.
Quantify residual risk levels for data sharing initiatives with external research partners.
Define thresholds for risk acceptance based on clinical impact, not just technical exposure.
Implement risk treatment plans that address insecure default configurations in medical imaging systems.
Use risk assessment outcomes to justify investment in access control upgrades for EHRs.
Ensure risk registers are updated following system decommissioning or integration of new health information exchanges.

Module 4: Information Classification and Handling

Define classification levels for health data (e.g., public, internal, confidential, highly sensitive) based on clinical impact of disclosure.
Implement automated tagging of clinical documents at point of creation using EHR metadata.
Configure secure printing policies for documents containing mental health or genetic information.
Enforce encryption requirements for removable media used in mobile clinical workflows.
Develop handling rules for de-identified datasets used in population health analytics.
Train clinical staff on proper handling of screenshots containing PHI during telehealth consultations.
Restrict email transmission of classified health data using DLP policies integrated with clinical messaging systems.
Establish procedures for secure destruction of physical health records in decentralized clinics.

Module 5: Access Control Governance

Define role-based access control (RBAC) models for clinicians, billing staff, and researchers based on minimum necessary principles.
Implement just-in-time access for third-party contractors supporting EHR maintenance.
Enforce privileged access management (PAM) for database administrators with access to patient records.
Conduct quarterly access reviews for users with elevated privileges in clinical systems.
Integrate identity lifecycle management with HR systems to automate access revocation upon staff termination.
Configure context-aware access policies that restrict logins from non-trusted locations during off-hours.
Address override access (e.g., emergency override in EHRs) with mandatory justification and audit logging.
Manage shared account usage in clinical kiosks while maintaining individual accountability.

Module 6: Third-Party and Vendor Risk Oversight

Conduct security assessments of cloud service providers hosting patient portals using ISO 27799 criteria.
Enforce contractual SLAs requiring vendors to report security incidents involving health data within one hour.
Verify subcontractor controls when a cloud provider uses additional data centers in unapproved jurisdictions.
Perform on-site audits of medical billing vendors with access to full patient datasets.
Implement continuous monitoring of vendor access to internal health information systems.
Require penetration test results from SaaS providers before integrating with EHR infrastructure.
Establish governance processes for terminating vendor relationships with data transition requirements.
Manage risks associated with open-source software components used in clinical applications.

Module 7: Incident Management and Breach Response

Define incident severity levels based on patient impact, such as delayed care due to system unavailability.
Coordinate response between IT security, legal, communications, and clinical leadership during a ransomware event.
Preserve forensic evidence from clinical workstations while minimizing disruption to patient care.
Report breaches to regulatory authorities within 72 hours as required by HIPAA or GDPR.
Conduct root cause analysis for insider threats involving clinicians accessing unauthorized patient records.
Implement automated alerting for anomalous data exports from health data warehouses.
Test incident response plans with realistic scenarios involving loss of backup tapes or cloud misconfigurations.
Document lessons learned from incidents to update governance policies and access controls.

Module 8: Audit and Compliance Monitoring

Design audit log specifications for capturing access to sensitive health data in EHRs and PACS systems.
Configure log retention periods to meet both legal requirements and forensic investigation needs.
Implement automated log correlation rules to detect suspicious access patterns across multiple systems.
Conduct unannounced audits of access logs for high-risk clinical departments such as oncology or psychiatry.
Respond to internal audit findings by updating governance controls for data export functionality.
Prepare for external certification audits against ISO 27799 by compiling evidence of control implementation.
Use audit findings to refine user training content on secure data handling practices.
Integrate compliance dashboards into executive reporting to track control effectiveness over time.

Module 9: Continuous Governance Improvement

Establish key performance indicators (KPIs) for governance effectiveness, such as time to revoke access after role change.
Conduct post-implementation reviews after deploying new health information systems to assess control adherence.
Update governance policies in response to changes in clinical workflows, such as adoption of remote patient monitoring.
Facilitate governance forums for clinicians to report usability issues with security controls.
Benchmark governance maturity against ISO 27799 best practices using structured assessment models.
Integrate governance feedback into system procurement criteria for future technology acquisitions.
Manage version control of governance policies to ensure all staff reference the current edition.
Align governance improvement initiatives with organizational strategic objectives in digital health transformation.