Regulations and Compliance

An Overview
https://www.youtube.com/watch?
v=ZUrNwo6Rlsc
Motivation

 Regulators have created a large and growing

set of regulations and frameworks aimed at
enforcing protection of information, privacy,
and transparency of information.
 For example, HIPAA for healthcare, GLBA for
financial services, and Sarbanes-Oxley for
public companies.
Motivation
 Questionable accounting practices and poor
management in companies such as Enron and
Worldcom shattered investor confidence and
caused Congress to pass Sarbanes-Oxley Act of
2002 (SOX)
 To protect investors by improving the accuracy and
reliability of corporate disclosures made pursuant to
the securities law.
 All of these systems employ relational databases,
and these projects include database security and
auditing implementations.
 Gramm-Leach-Bliley Act (GLBA)

 Also called Financial Services Modernization Act or Citigroup

Relief Act.
 Enacted 7 months after the merger between Citicorp and
Travelers Group to form CitiGroup.
 Applied to financial holding company (FHC)
 It allows FHC like CitiGroup to own banks, insurance and
securities firms.
 One of main reasons for creating mega-financial companies
is to leverage a knowledge base and be able to do cross-
selling within the FHC.
 insurance company can market products to customers of
the bank if they are in one FHC.
 Individual privacy may be risky.
Gramm-Leach-Bliley Act (GLBA)
 To combat extreme misuse of such cross-selling and
the risks to privacy, Congress adopted Title V of
GLBA, which defines various requirements designed
to protect the privacy of customers financial
institution.
 Title V includes both
 the Financial Privacy Rule discussing operations and
practices
 The safeguard rule with more technical interpretation
▪ Ensure the security and privacy of customer information
▪ Protect against threats to the security and integrity of customer
information
▪ Protect against unauthorized access and/or usage of this
information that could result in harm or inconvenience to the
customer
Sarbanes-Oxley Act of 2002 (SOX or SarBox)

 Applied to public company with over $75

Million revenue
 SOA addresses many areas that affect the
accuracy and transparency of financial
reporting.
 enforces accountability for financial record keeping and
reporting at publicly traded corporations
 Requires that CEO and chief financial officer (CFO)
assume direct and personal accountability for
completeness and accuracy of a publicly traded
organization’s financial reporting and record-keeping
systems
Sarbanes-Oxley Act of 2002 (SOX or SarBox)

 As these executives attempt to ensure that

the systems used to record and report are
sound—often relying upon the expertise of
CIOs and CISOs to do so—the related areas
of availability and confidentiality are also
emphasized
 IT people focus on Section 404, which
requires management to report on the
effectiveness of the company’s internal
control over financial reporting.
Sarbanes-Oxley Act of 2002 (SOX or SarBox)

 It requires management’s development and

monitoring of procedures and controls for
making assertions about the Adequacy of
internal controls over financial reporting.
 It is management’s responsibility and can not
be delegated or abdicated.
 Document and evaluate the design and
operation of its internal control.
California Senate Bill I386 (2003)

 Any business that maintains personal information of

a resident of California must have the appropriate
provisions and capabilities to know when this
information may have been accessed by an
unauthorized person.
 Focus on privacy, not just the need for privacy but
the need for effective controls that will allow one to
know when access controls has been compromised
and data has been accessed in an unauthorized
manner.
Health Insurance Portability and
Accountability Act of 1996 (HIPAA)

 Objective
 Guarantee health insurance coverage of employees
 Reduce health care fraud and abuse
 Protect the health information of individuals against
access without consent or authorization
Health Insurance Portability and
Accountability Act of 1996 (HIPAA)

 Based on 164.520 – Notice of privacy practices for

protected health information, providers must
provide individuals with a notice of privacy practices
in plain language.
 Information about uses and disclosures of protected
health information
 An explanation of privacy rights
 How to file complaints
 The providers have to give it to you and ask you to
sign it, but you do not have to sign the document.
Health Insurance Portability and
Accountability Act of 196 (HIPAA)

 Security requirement outlined in HIPAA require the

following:
 Management involvement in the development and
implementation of HIPAA-compliant security policies and
procedures
 Periodic reviews of these policies and procedures
 Training on policies and procedures for all employees who
come in contact with private patient information
 Technical measures that are integrated into the
organizations’ information systems
HIPPA: two types of confidential
electronic information
ePHI = Electronic Protected Health Information
 Medical record number, account number or SSN
 Patient demographic data, e.g., address, date of birth,
date of death, sex, e-mail / web address
 Dates of service, e.g., date of admission, discharge
 Medical records, reports, test results, appointment dates
PII = Personally Identified Information
 Individual’s name + SSN number + Driver’s License #
and financial credit card account numbers
HIPPA: Definition of “ePHI”
 ePHI or electronic Protected Health Information is patient
health information which is computer based, e.g., created,
received, stored or maintained, processed and/or transmitted
in electronic media.
 Electronic media includes computers, laptops, disks,
memory stick, PDAs, servers, networks, dial-modems, E-Mail,
web-sites, etc.
 Federal Laws: HIPAA Privacy & Security Laws mandate
protection and safeguards for access, use and disclosure of
PHI and/or ePHI with sanctions for violations.
14
HIPPA: Definition of “PII”
 “Personal information” – Unencrypted computerized
information that includes an individual’s name in
combination with any one or more of the following: Social
Security Number, Driver’s license number, or California ID
card #, credit / debit in combination with their access /
security code or password
 State Law: SB-1386 California, Privacy of Personal
Information to Prevent Identity Theft. SB-1386 requires
mandatory notice to the subject of an unauthorized,
unencrypted electronic disclosure of “personal
information”.

15
HIPPA: What are the Information Security
Standards for Protection of ePHI?

 “Information Security” means to ensure the confidentiality,

integrity, and availability of information through safeguards.
 “Confidentiality” – that information will not be disclosed to
unauthorized individuals or processes [164.304]
 “Integrity” – the condition of data or information that has not
been altered or destroyed in an unauthorized manner. Data
from one system is consistently and accurately transferred to
other systems.
 “Availability” – the data or information is accessible and useable
upon demand by an authorized person.

16
HIPPA: What are the Federal Security
Rule - General Requirements
 Ensure the “CIA” (confidentiality, integrity and availability) of all
electronic protected health information (ePHI) that the covered
entity creates, receives, maintains, or transmits.
 Protect against reasonably anticipated threats or hazards to
the security or integrity of ePHI, e.g., hackers, virus, data
back-ups
 Protect against unauthorized disclosures
 Train workforce members (“awareness of good computing
practices”)

17
HIPPA: Who is a “Covered Entity”?
 HIPAA's regulations directly cover three basic groups of
individual or corporate entities: health care providers,
health plans, and health care clearinghouses.
 Health Care Provider means a provider of medical or health
services, and entities who furnishes, bills, or is paid for
health care in the normal course of business
 Health Plan means any individual or group that provides or
pays for the cost of medical care, including employee
benefit plans
 Healthcare Clearinghouse means an entity that either
processes or facilitates the processing of health information,
e.g., billing service, re-pricing company

18
HIPPA:“Isn’t this just an I.T. Problem?”

Good Security Standards follow the “90 / 10” Rule:

 10% of security safeguards are technical
 90% of security safeguards rely on the computer user to
adhere to good computing practices
 Example: The lock on the door is the 10%. remembering to
lock, ensuring others do not prop the door open, and
keeping controls of keys is the 90%. 10% security is
worthless without USER!

19
HIPPA: What are the Consequences for
Security Violations?
 Risk to integrity of confidential information, e.g., data corruption,
destruction, unavailability of patient information in an emergency
 Risk to security of personal information, e.g., identity theft
 Loss of valuable business information
 Loss of confidentiality, integrity & availability of data (and time) due to
poor or untested disaster data recovery plan
 Embarrassment, bad publicity, media coverage, news reports
 Loss of patients’ trust, employee trust and public trust
 Costly reporting requirements for SB-1386 issues
 Internal disciplinary action(s), termination of employment
 Penalties, prosecution and potential for sanctions / lawsuits

20
Payment Card Industry Data Security
Standard
Control Objectives PCI DSS Requirements
Build and Maintain a Secure 1. Install and maintain a firewall configuration to protect
Network cardholder data
2. Do not use vendor-supplied defaults for system
passwords and other security parameters

Protect Cardholder Data 3. Protect stored cardholder data

4. Encrypt transmission of cardholder data across open,
public networks

Maintain a Vulnerability 5. Use and regularly update anti-virus software on all

Management Program systems commonly affected by malware

6. Develop and maintain secure systems and applications

Payment Card Industry Data
Security Standard
Control Objectives PCI DSS Requirements
Implement Strong Access 7. Restrict access to cardholder data by business need-
Control Measures to-know
8. Assign a unique ID to each person with computer
access
9. Restrict physical access to cardholder data

Regularly Monitor and Test 10. Track and monitor all access to network resources
Networks and cardholder data
11. Regularly test security systems and processes

Maintain an Information 12. Maintain a policy that addresses information

Security Policy security
More resources on PCI

 PCI Security Standards Council:

https://www.pcisecuritystandards.org/index.s
html

 PCI and Oracle DB

http://www.oracle.com/technology/deploy/s
ecurity/database-security/oracle-pci.html
Understand Business needs and map to technical
requirements

 Regulations and other privacy requirements do not

typically define precisely what types of technologies
need to be implemented.
 You will often be asked to suggest a set of concrete
implementation options to bring your organization
into compliance with these regulations.
 Comply with regulations
 Is implementable with reasonable cost
Use Reverse Mapping
 Start out with a list of security and auditing provisions that
you have implemented, are implementing, or plan to
implement.
 Check off items in the regulations that these security best
practices cover.
 Couple that with auditing implementations.
 For example
 Implement user-based and role-based privileges in your database, you
may also have some context-related mechanisms. Section 142.308
requires one of three access controls: user-based, role-based, and
context-based
 Role-based access requires identification of the person or class of
person. This maps to authentication and identification.
Timetable, data, and process mappings

 Make sure that the implementation phases

and timetables map to the regulation
timetables.
 Retention period, for example, HIPAA
mandates a retention period of six years.
 Data mapping: identify the data in the
database that maps to the information that
the regulations discuss.
Example: SOX and Excel
 Excel and other spreadsheets have become the focus of
many SOX implementations, because spreadsheets are
extensively used in financial reporting and form the user
interface layer in many financial application.
 Possible techniques
 Monitoring source programs will give you a clear indication of which
applications are accessing the database.
 Baseline accessing will allow you to identify any divergence from
normal access as a result of operations initiated using Excel and can
help with an additional control and audit point in the spreadsheet
macro’s change control process.
The role of auditing
 Audit as a function needs to play a central role in ensuring
compliance. It includes
 Audit trails and other logs (auditing information)
 Security audits: assessments, penetration tests, or
vulnerability scans, and focus on the current state of a
database environment rather than auditing data.
 SQL Server Best Practices Analyzer Tool include and
package a set of best practices, known vulnerabilities, and
items that map well to compliance requirements.
 Continuous assessment evaluates potential flaws in the
database environment – not in how it is configured but how
it is used.
 Auditing is an integral part of security. There is no security
without audit.
The importance of segregation of
duties
 All regulations try to deal with a set of human behaviors such
as untruthfulness, greedy, sloppiness, laziness, and so forth.
 Regulations use two main techniques: (1) guidelines so that
people cannot too loosely interpret the regulations to their
benefit and (2) segregation of duties.
 You can not trust the process to a single individual or a single
group but need to build the process in a way so that you have
multiple layers of audit.
 Auditing should be defined and performed by people other
than those who work within the database every day.
Implement a sustainable solution

 You need to use tools that will do most of the

work for you.
 You need to be able to get information at
multiple levels.
 You must implement a solution that will
sustain change.
 The solution should be well-packaged and
self-maintaining.
“Good Computing Practices”
10 Safeguards for Users

1. User ID or Log-In Name 6. Remote Access

(aka. User Access 7. Recycling Electronic
Controls)
2. Passwords Media & Computers
3. Workstation Security 8. E-Mail
4. Portable Device Security 9. Safe Internet Use
5. Data Management, e.g., 10. Reporting Security
back-up, archive,
restore. Incidents / Breach

31
Safeguard - #1: Unique User Log-In / User
Access Controls
 Access Controls:
 Users are assigned a unique “User ID” for log-in purposes
 Each individual user’s access to ePHI system(s) is
appropriate and authorized
 Access is “role-based”, e.g., access is limited to the minimum
information needed to do your job
 Unauthorized access to ePHI by former employees is
prevented by terminating access
 User access to information systems is logged and audited for
inappropriate access or use.

32
Safeguard-#2: Password Protection

Passwords will be assigned to you for most data systems to

comply with the security rule, but when necessary here are
guidelines for choosing a password:
 Don't use a word that can easily be found in a dictionary —
English or otherwise.
 Use at least eight characters (letters, numbers, symbols)
 Don't share your password — protect it the same as you would
the key to your residence. After all, it is a "key" to your identity.
 Don't let your Web browser remember your passwords. Public
or shared computers allow others access to your password.

33
Safeguard-#3: Workstation Security
– Physical Security

 “Workstations” include any electronic computing device, for

example, a laptop or desktop computer, or any other device
that performs similar functions.
 Physical Security measures include:
 Disaster Controls
▪ Protect workstations from natural and environmental hazards, such as heat,
liquids, water leaks and flooding, disruption of power, conditions exceeding
equipment limits.
 Device & Media Controls:
▪ Auto Log-Off or Automatic Screen Savers

34
Safeguard-#4: Security for Portable
Devices & Laptops with ePHI
 Implement the workstation physical security measures listed in Safeguard #3,
including this Check List:
 Use an Internet Firewall
 Use up-to-date Anti-virus software
 Install computer software updates, e.g., Microsoft patches
 Encrypt and password protect portable devices, e.g. USB memory stick
 Lock-it up!, e.g., Lock office or file cabinet, cable
 Automatic log-off from programs is possible
 Use password protected screen savers
 Back-up critical data and software programs
 De-identify ePHI or delete ePHI from memory stick or PDA
 Disable wireless or use VPN

35
Safeguard-#5: Data Management &
Security
 Data backup and storage
 Backup original data files with ePHI and other essential data and software programs
frequently based on data criticality, e.g., daily, weekly, monthly.
 Consider encrypting back-up disks
 Permanent copies of ePHI should not be stored for archival purposes on portable
device, such as laptop computers, PDAs and memory sticks.
 If necessary, temporary copies could be used on portable devices, only when:
▪ The storage is limited to the duration of the necessary use; and
▪ If protective measures, such as encryption, are used to safeguard the confidentiality, integrity and
availability of the data in the event of theft or loss.
 Transferring and downloading data
 Encryption is an important tool for protection of ePHI in transit across unsecured
networks and communication systems
 Data disposal
 Destroy EPHI data which is no longer needed (professional overwrite)
36
Safeguard-#6: Remote Access
 Need consider authentication such as Radius
 Can adopt Virtual Private Network to encrypt
communication in transit
 Use access control to authorize users
 Audit behavior of remote users
 Safeguard-#7: E-Mail Security
Email is like a “postcard”. Email may potentially be viewed in transit by many
individuals, since it may pass through several switches enroute to its final
destination or never arrive at all! Although the risks to a single piece of email are
small given the volume of email traffic, emails containing ePHI need a higher level
of security.

7-1 Should You Open the E-mail Attachment?

If it's suspicious, don't open it!

What is suspicious?
• Not work-related
• Attachments not expected
• Attachments with a suspicious file extension (*.exe, *.vbs, *.bin, *.com, or *.pif)
• Web link
• Unusual topic lines; “Your car?”; “Oh!” ; “Nice Pic!”; “Family Update!”; “Very Funny!”

38
 7-2. E-Mail Security – Risk Areas
1. Spamming. Unsolicited bulk e-mail, including commercial
solicitations, advertisements, chain letters, pyramid schemes, and
fraudulent offers.
 Do not reply to spam messages. Do not spread spam. Remember,
sending chain letters is against UC policy.
 Do not forward chain letters. It’s the same as spamming!
 Do not open or reply to suspicious e-mails.
2. Phishing Scams. E-Mail pretending to be from trusted names, such
as Citibank or Paypal or Amazon, but directing recipients to rogue
sites. A reputable company will never ask you to send your password
through e-mail.
3. Spyware. Spyware is adware which can slow computer processing
down; hijack web browsers; spy on key strokes and cripple computers

39
7-3. Instant Messaging (IM) - Risks
 Instant messaging (IM) and Instant Relay Chat (IRC) or
chat rooms create ways to communicate or chat in “real-
time” over the Internet.
 Exercise extreme caution when using Instant Messaging on
UC Computers:
 Maintain up-to-date virus protection and firewalls, since
IM may leave networks vulnerable to viruses, spam and
open to attackers / hackers.
 Do not reveal personal details while in a Chat Room
 Be aware that this area of the Internet is not private and
subject to scrutiny

40
Safeguard-#8: Internet Use
 Be careful about providing personal, sensitive or confidential
information to an Internet site or to web-based surveys that
are not from trusted sources.
 Personal information posted to web-pages may not be
protected from unauthorized use.
 Even unlinked web pages can be found by search engines
 Some web sites try to place small files (“cookies”) on your
computer that might help others track the web pages you
access

Remember: The Internet is not private! Access to any site on the

Internet could be traced to your name and location.
41
Safeguard-#9: Report Security Incidents

 Users are responsible to:

 Report and respond to security incidents and security breaches.
 Know what to do in the event of a security breach or incident
related to ePHI and/or Personal Information.
 Security Incident defined:
 "The attempted or successful improper instance of unauthorized
access to, or use of information, or mis-use of information,
disclosure, modification, or destruction of information or
interference with system operations in an information system.“
[45 CFR 164.304]

42
Safeguard-#10: User Responsibility to
Adhere to Information Security Policies
 CIO or CISO may use the following language in their trainings
 “Users of electronic information resources are responsible for complying
with all policies, procedures and standards relating to information security.”
 “Workforce members who violate policies regarding privacy / security of
confidential, restricted and/or protected health information or ePHI are
subject to further corrective and disciplinary actions according to existing
policies.”
 “Actions taken could include:
 Termination of employment
 Possible further legal action
 Violation of local, State and Federal laws may carry additional
consequences of prosecution under the law, costs of litigation, payment
of damages, (or both); or all.
 Knowing, malicious intent  Penalties, fines, jail!”

43
statistical database
statistical database
 A statistical database is a database used for
statistical analysis purposes.
 Statistical databases often incorporate support for
advanced statistical analysis techniques, such as
correlations, which go beyond SQL.
 They also pose unique security concerns, which
were the focus of much research, particularly in the
late 1970s and early to mid 1980s.
Securing statistical database is difficult

 In a statistical database, it is often desired to

allow query access only to aggregate data,
not individual records.
 However, securing such a database is a
difficult problem, since intelligent users can
use a combination of aggregate queries to
derive information about a single individual.
Common Approaches to Secure
Statistical Database
Some common approaches are:
 only allowing aggregate queries (SUM, COUNT, AVG,
STDEV, etc.)
 rather than returning exact values for sensitive data like
income, only return which partition it belongs to (e.g. 35k-
40k)
 return imprecise counts (e.g. rather than 141 records met
query, only indicate 130-150 records met it.)
 don't allow overly selective WHERE clauses
 audit all users queries, so users using system incorrectly can
be investigated
 use intelligent agents to detect automatically inappropriate
system use
Mission Impossible?
 in general, securing statistical databases was an
impossible aim:
 if they were open to legitimate use, they were also open to
abuse; and
 if they were restricted so tightly as to be incapable of
abuse, they would then be useless for practical statistical
purposes.
 statistical databases are almost always subject to
compromise.
 Severe restrictions on allowable query set sizes will render
the database useless as a source of statistical information
but will not secure the confidential records.
References
 doi:10.1145/320613.320616 - Dorothy E. Denning, Secure statistical
databases with random sample queries, ACM Transactions on Database
Systems (TODS), Volume 5, Issue 3 (September 1980), Pages: 291 - 315
 doi:10.1145/319830.319834 - Wiebren de Jonge, Compromising statistical
databases responding to queries about means, ACM Transactions on
Database Systems, Volume 8, Issue 1 (March 1983), Pages: 60 - 80
 doi:10.1145/320128.320138 - Dorothy E. Denning, Jan Schlörer, A fast
procedure for finding a tracker in a statistical database, ACM
Transactions on Database Systems, Volume 5, Issue 1 (March 1980) .
Pages: 88 - 102
 Information is from wikipedia