Description

This curriculum spans the design and operationalization of health information security programs comparable to multi-workshop advisory engagements, covering governance, risk management, and technical controls across clinical, administrative, and third-party systems in complex healthcare environments.

Module 1: Establishing the Governance Framework for Health Information Security

Define the scope of ISO 27799 applicability across clinical, administrative, and research systems within a multi-facility healthcare network.
Select governance roles (e.g., Data Protection Officer, Clinical Information Security Lead) and assign accountability for security controls in hybrid cloud environments.
Align ISO 27799 policies with existing regulatory mandates such as HIPAA, GDPR, and local health privacy laws without creating redundant compliance obligations.
Determine escalation paths for security incidents that involve both IT and clinical leadership, ensuring timely clinical risk assessment.
Integrate privacy impact assessments (PIAs) into system procurement processes for new EHR modules or medical devices.
Document decision criteria for retaining versus retiring legacy health information systems that cannot meet current ISO 27799 control baselines.
Negotiate authority boundaries between central IT governance and decentralized clinical departments regarding local system configuration.
Establish a formal process for reviewing and updating governance policies annually or after major organizational changes (e.g., mergers).

Module 2: Risk Assessment and Management Specific to Health Data

Conduct threat modeling for connected medical devices (e.g., infusion pumps, MRI systems) using ISO 27799 Annex A controls as a baseline.
Assign risk ownership to clinical department heads for systems they operate, ensuring accountability for risk treatment plans.
Quantify residual risk tolerance levels for patient data exposure in emergency care scenarios where encryption may be temporarily bypassed.
Implement risk assessment templates customized for different health data types (e.g., genomic data vs. billing records).
Validate third-party risk assessments from cloud service providers hosting electronic health records against ISO 27799 control requirements.
Document exceptions for high-risk systems where compensating controls are implemented instead of direct compliance.
Use risk heat maps to prioritize remediation efforts across geographically distributed clinics with varying security maturity.
Integrate risk treatment outcomes into capital planning cycles for security technology refresh projects.

Module 3: Designing Organizational Security Policies for Healthcare Settings

Draft role-based access policy definitions that reflect clinical workflows (e.g., rapid access during codes) while maintaining auditability.
Specify encryption standards for data at rest and in transit across mobile devices used by home health nurses.
Define acceptable use policies for personal devices accessing patient portals in bring-your-own-device (BYOD) environments.
Establish data retention schedules that comply with legal requirements while minimizing unnecessary data storage.
Develop incident response communication protocols that include legal, public relations, and clinical leadership.
Implement policy exception management procedures with time-bound approvals and mandatory review triggers.
Localize policy language for multinational healthcare providers to reflect jurisdictional differences in consent and disclosure.
Embed policy references directly into system configuration baselines to ensure technical enforceability.

Module 4: Access Control Governance in Clinical Environments

Design role hierarchies in identity management systems that mirror clinical credentialing and privileging processes.
Implement just-in-time access for external consultants or researchers with time-limited data access requirements.
Enforce multi-factor authentication for remote access to EHR systems without disrupting clinical workflow efficiency.
Monitor and audit access patterns for anomalous behavior, such as after-hours record access by non-on-call staff.
Integrate single sign-on (SSO) solutions with clinical workstation workflows while maintaining session timeout safeguards.
Manage shared account usage in emergency departments with automated logging and real-time monitoring.
Establish deprovisioning workflows that trigger automatically upon employee termination or role change.
Validate access control configurations during system upgrades to prevent unintended privilege escalation.

Module 5: Asset Management and Data Classification in Healthcare

Classify health data into sensitivity tiers (e.g., psychotherapy notes, HIV status) to determine encryption and handling requirements.
Tag electronic records with metadata indicating data classification and retention deadlines for automated enforcement.
Map data flows for patient information across departments to identify unsecured transfer points (e.g., fax, USB).
Maintain an asset register that includes medical devices with embedded operating systems requiring patch management.
Implement data loss prevention (DLP) rules based on classification levels to block unauthorized email transmissions.
Define ownership of data assets at the departmental level to ensure accountability for protection measures.
Conduct periodic data minimization sweeps to identify and securely delete obsolete patient records.
Extend classification policies to research datasets that combine clinical and genomic information.

Module 6: Incident Management and Breach Response Coordination

Activate incident response playbooks specific to ransomware attacks on hospital systems with clinical impact assessment steps.
Coordinate forensic data collection while preserving patient care operations during active incidents.
Report breaches to regulatory authorities within mandated timeframes, incorporating clinical impact analysis.
Conduct post-incident reviews that include clinical stakeholders to evaluate workflow-related root causes.
Manage patient notification processes for data breaches with input from legal and patient relations teams.
Preserve logs and system images from medical devices involved in security incidents for legal admissibility.
Integrate tabletop exercises into clinical staff training to test response readiness without disrupting operations.
Update incident response plans based on lessons learned from actual events or industry peer disclosures.

Module 7: Third-Party and Vendor Risk Management

Assess business associate agreements (BAAs) for compliance with ISO 27799 control requirements and audit rights.

Conduct on-site security assessments of cloud hosting providers storing sensitive patient data.

Require vendors of medical devices to disclose software bill of materials (SBOM) for vulnerability management.

Enforce encryption requirements for data processed by third-party billing and transcription services.

Monitor vendor patch management performance for critical systems like radiology information systems (RIS).

Terminate contracts based on repeated failure to meet security SLAs or audit findings.

Validate that subcontractors used by vendors are bound by equivalent security obligations.

Implement continuous monitoring of vendor access to internal systems using privileged access management tools.

Module 8: Security in System Development and Medical Device Integration

Incorporate security requirements into software development life cycle (SDLC) for custom clinical applications.
Perform security testing on EHR upgrades before deployment to production environments.
Validate that medical devices comply with IEC 62304 and ISO 27799 control mappings for network connectivity.
Establish secure configuration baselines for imaging systems (e.g., PACS) before clinical deployment.
Manage patching schedules for embedded systems in medical devices with manufacturer coordination.
Conduct threat modeling during the design phase of patient portal development.
Implement code review processes that include checks for hard-coded credentials or insecure APIs.
Document security acceptance criteria for system go-live decisions involving clinical leadership sign-off.

Module 9: Monitoring, Audit, and Continuous Improvement

Configure SIEM rules to detect unauthorized access to high-sensitivity patient records in real time.
Schedule regular internal audits of ISO 27799 control implementation across clinical and administrative units.
Generate executive dashboards showing control effectiveness, incident trends, and remediation status.
Conduct log retention reviews to ensure compliance with legal and regulatory requirements.
Perform penetration testing on externally facing health information systems annually or after major changes.
Use audit findings to prioritize security investments in areas with highest control gaps.
Integrate automated compliance checking tools into cloud infrastructure provisioning workflows.
Update governance metrics based on changes in threat landscape or organizational structure.

Module 10: Strategic Alignment and Executive Engagement

Present security risk posture to the board using clinical impact scenarios rather than technical metrics.
Align security initiatives with enterprise digital transformation goals such as telehealth expansion.
Secure budget approval for security projects by demonstrating risk reduction in financial and clinical terms.
Coordinate cybersecurity strategy with clinical safety programs to address converging risks.
Engage C-suite executives as champions for security awareness campaigns targeting clinical staff.
Report on regulatory compliance status to audit and risk committees using standardized frameworks.
Integrate security KPIs into performance objectives for IT and clinical leadership roles.
Facilitate cross-functional governance committees with representation from legal, clinical, and IT domains.