Information Security Management Policy

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1. Introduction

RxRevu, Inc (“RxRevu”) is committed to ensuring the confidentiality, privacy, integrity, and availability of all electronic protected health information (ePHI) it receives, maintains, processes and/or transmits on behalf of its Customers. As providers of a compliant, hosted software used by health technology vendors, developers, designers, agencies, custom development shops, and enterprises, RxRevu strives to maintain compliance, proactively address information security, mitigate risk for its Customers, and assure known breaches are completely and effectively communicated in a timely manner. The following documents address core policies used by RxRevu, and executed by the CTO, to maintain compliance and assure the proper protections of infrastructure used to store, process, and transmit ePHI for RxRevu Customers.

RxRevu provides secure and compliant cloud-based software.

1.1 Compliance Inheritance

RxRevu provides compliant hosted software for its Customers. RxRevu’s service offerings are hosted on AWS; current production systems on these platforms are included in RxRevu’s third-party audits.

RxRevu signs business associate agreements (BAAs) with its Customers. These BAAs outline RxRevu obligations and Customer obligations, as well as liability in the case of a breach. In providing infrastructure and managing security configurations that are a part of the technology requirements that exist in HIPAA and HITRUST, as well as future compliance frameworks, RxRevu manages various aspects of compliance for Customers. The aspects of compliance that RxRevu manages for Customers are inherited by Customers, and RxRevu assumes the risk associated with those aspects of compliance. In doing so, RxRevu helps Customers achieve and maintain compliance, as well as mitigates Customers risk.

RxRevu does not act as a covered entity. When RxRevu does operate as a business associate (not a subcontractor), RxRevu does not interface with users to provide access to ePHI. Only ePHI that was part of the request is included in the response, and only to the requesting party.

Certain aspects of compliance cannot be inherited. Because of this, RxRevu Customers, in order to achieve full compliance or HITRUST Certification, must implement certain organizational policies. These policies and aspects of compliance fall outside of the services and obligations of RxRevu.

Mappings of HIPAA Rules to RxRevu controls and a mapping of what Rules are inherited by Customers are covered in §2.

1.2 RxRevu Organizational Concepts

The physical infrastructure environment, where all ePHI is processed and stored, is hosted at Amazon Web Services (AWS). The network components and supporting network infrastructure are contained within the AWS infrastructure and managed by AWS, which also supports integrated control mechanisms to manage, monitor, and address threats to information security. RxRevu does not have physical access into the network components. The RxRevu environment consists of nginx web servers; Ruby application servers; MySQL database servers; CloudWatch monitoring servers; Falco IDS services; Docker containers; and developer tool servers running on Linux Ubuntu.

Within the RxRevu Platform on AWS, all data transmission is encrypted and all hard drives are encrypted so data at rest is also encrypted; this applies to all servers - those hosting Docker containers, databases, APIs, log servers, etc. Automatic failover is supported through the use of containerized web services and Multi-AZ database deployments. RxRevu assumes all data may contain ePHI, even though our Risk Assessment does not indicate this is the case, and provides appropriate protections based on that assumption.

There is data and network segmentation in place for the RxREVU Platform. Hosted load balancers segment data across a dedicated Virtual Private Cloud.

The result of segmentation strategies employed by RxREVU effectively create RFC 1918, or dedicated, private segmented and separated networks and IP spaces, for the RxREVU Platform.

Additionally, AWS security groups are used on each each server for logical segmentation. The security groups are configured to restrict access to only justified ports and protocols. RxREVU has implemented strict logical access controls so that only authorized personnel are given access to the internal management servers. The environment is configured so that data is transmitted from the load balancers to the application servers over a TLS encrypted session.

The bastion hosts are externally facing and accessible via the Internet. The nginx web servers and the database servers, where the ePHI resides, are located on the internal RxREVU network and can only be accessed directly over an SSH connection through the nginx web servers. The access to the internal database is restricted to a limited number of personnel and strictly controlled to only those personnel with a business justified reason. Remote access to the internal servers is not accessible except through the load balancers and nginx web servers.

1.3 Requesting Audit and Compliance Reports

RxRevu, at its sole discretion, shares audit reports, including its HITRUST reports and Corrective Action Plans (CAPs), with customers on a case by case basis. All audit reports are shared under explicit NDA in RxRevu format between RxRevu and party to receive materials. Audit reports can be requested by RxRevu workforce members for Customers or directly by RxRevu Customers.

The following process is used to request audit reports:

  1. Email is sent to security@rxrevu.com. In the email, please specify the type of report being requested and any required timelines for the report.
  2. RxRevu staff will log an Issue with the details of the request into the RxRevu Compliance Review Activities Project on Asana. Asana is used to track requests’ status and outcomes.
  3. RxRevu will confirm if a current NDA is in place with the party requesting the audit report. If there is no NDA in place, RxRevu will send one for execution.
  4. Once it has been confirmed that an NDA is executed, RxRevu staff will move the Asana Issue to “Under Review”.
  5. The RxRevu Security Officer or Privacy Officer must Approve or Reject the Issue. If the Issue is rejected, RxRevu will notify the requesting party that we cannot share the requested report.
  6. If the Issue has been Approved, RxRevu will send the customer the requested audit report and complete the Asana Issue for the request.

1.4 Version Control

A GitHub repository contains the full version history of these policies.

2. HIPAA Inheritance

Administrative Controls HIPAA Rule RxRevu Control Inherited
Security Management Process - 164.308(a)(1)(i) Risk Management Policy Yes
Assigned Security Responsibility - 164.308(a)(2) Roles Policy Partially
Workforce Security - 164.308(a)(3)(i) Employee Policies Partially
Information Access Management - 164.308(a)(4)(i) System Access Policy Yes
Security Awareness and Training - 164.308(a)(5)(i) Employee Policy No
Security Incident Procedures - 164.308(a)(6)(i) IDS Policy Yes
Contingency Plan - 164.308(a)(7)(i) Disaster Recovery Policy Yes
Evaluation - 164.308(a)(8) Auditing Policy Yes
Physical Safeguards HIPAA Rule RxRevu Control Inherited
Facility Access Controls - 164.310(a)(1) Facility and Disaster Recovery Policies Yes
Workstation Use - 164.310(b) System Access, Approved Tools, and Employee Policies Partially
Workstation Security - 164.310(‘c’) System Access, Approved Tools, and Employee Policies Partially
Device and Media Controls - 164.310(d)(1) Disposable Media and Data Management Policies Yes
Technical Safeguards HIPAA Rule RxRevu Control Inherited
Access Control - 164.312(a)(1) System Access Policy Partially
Audit Controls - 164.312(b) Auditing Policy Yes (optional)
Integrity - 164.312(‘c’)(1) System Access, Auditing, and IDS Policies Yes (optional)
Person or Entity Authentication - 164.312(d) System Access Policy Yes
Transmission Security - 164.312(e)(1) System Access and Data Management Policy Yes
Organizational Requirements HIPAA Rule RxRevu Control Inherited
Business Associate Contracts or Other Arrangements - 164.314(a)(1)(i) Business Associate Agreements and 3rd Parties Policies Partially
Policies and Procedures and Documentation Requirements HIPAA Rule RxRevu Control Inherited
Policies and Procedures - 164.316(a) Policy Management Policy Partially
Documentation - 164.316(b)(1)(i) Policy Management Policy Partially
HITECH Act - Security Provisions HIPAA Rule RxRevu Control Inherited
Notification in the Case of Breach - 13402(a) and (b) Breach Policy Partially
Timelines of Notification - 13402(d)(1) Breach Policy Partially
Content of Notification - 13402(f)(1) Breach Policy Partially

3. Policy Management Policy

RxRevu implements policies and procedures to maintain compliance and integrity of data. The Security Officer and Privacy Officer are responsible for maintaining policies and procedures and assuring all RxRevu workforce members, business associates, customers, and partners are adherent to all applicable policies. Previous versions of policies are retained to assure ease of finding policies at specific historic dates in time.

3.1 Applicable Standards

3.1.1 Applicable Standards from the HITRUST Common Security Framework

3.1.2 Applicable Standards from the HIPAA Security Rule

3.2 Maintenance of Policies

  1. All policies are stored and updated to maintain RxRevu compliance with HIPAA, HITRUST, and other relevant standards. Updates and version control are done similarly to source code control.
  2. Policy update requests can be made by any workforce member at any time. Furthermore, all policies are reviewed quarterly by both the Security and Privacy Officer to assure they are accurate and up-to-date.
  3. RxRevu employees may request changes to policies using the following process:
    1. The RxRevu employee initiates a policy change request by initiating a Policy Change Request Process in Asana. The change request may optionally include a GitHub pull request from a separate branch or repository containing the desired changes.
    2. The Security Officer or the Privacy Officer is assigned to review the policy change request.
    3. Once the review is completed, the Security Officer or Privacy Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
    4. If the review is approved, the Security Officer or Privacy Officer then marks the Issue as Done, adding any pertinent notes required.
    5. If the policy change requires technical modifications to production systems, those changes are carried out by authorized personnel using RxRevu’s change management process (§9.4).
  4. All policies are made accessible to all RxRevu workforce members. The current master policies are published at https://policies.rxrevu.com.
    • Changes are automatically communicated to all RxRevu team members through integrations between GitHub and Slack that log all GitHub policy channels to a dedicated RxRevu Slack Channel.
    • The Security Officer also communicates policy changes to all employees via email. These emails include a high-level description of the policy change using terminology appropriate for the target audience.
  5. All critical records, including policies, with associated documentation, are retained for 6 years from the date of its creation or the date when it last was in effect, whichever is later
    1. Version history of all RxRevu policies is done via GitHub.
  6. The policies and information security policies are reviewed and audited quarterly, or after significant changes occur to RxRevu’s organizational environment. Issues that come up as part of this process are reviewed by RxRevu management to assure all risks and potential gaps are mitigated and/or fully addressed. The process for reviewing polices is outlined below:
    1. The Security Officer initiates a policy change request by initiating a Policy Change Request Process in Asana.
    2. The Security Officer or the Privacy Officer is assigned to review the current RxRevu policies (https://policies.rxrevu.com/).
    3. If changes are made, the above process is used. All changes are documented in the Issue.
    4. Once the review is completed, the Security Officer or Privacy Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
    5. If the review is approved, the Security Officer or Privacy Officer then marks the Issue as Done, adding any pertinent notes required.
    6. Policy review is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.
  7. RxRevu utilizes the HITRUST MyCSF framework to track compliance with the HITRUST CSF on an annual basis. RxRevu also tracks compliance with HIPAA and publishes results at http://wiki.rxrevu.com/xwiki. In order to track and measure adherence on an annual basis, RxRevu uses the following process to track HITRUST audits, both full and interim:
    1. The Security Officer initiates the HITRUST audit activity by initiating a HITRUST Audit Process in Asana.
    2. The Security Officer or the Privacy Officer is assigned to own and manage the HITRUST activity.
    3. Once the HITRUST activity is completed, the Security Officer approves or rejects the Issue.
    4. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
    5. Document the recommendations and results, for approval by management.
    6. Compliance with annual compliance assessments, utilizing the HITRUST CSF as a framework, is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.

Additional documentation related to maintenance of policies is outlined in §5.3.1.

4. Risk Management Policy

This policy establishes the scope, objectives, and procedures of RxRevu’s information security risk management process. The risk management process is intended to support and protect the organization and its ability to fulfill its mission.

4.1 Applicable Standards

4.1.1 Applicable Standards from the HITRUST Common Security Framework

4.1.2 Applicable Standards from the HIPAA Security Rule

4.2 Risk Management Policies

  1. It is the policy of RxRevu to conduct thorough and timely risk assessments of the potential threats and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI) (and other confidential and proprietary electronic information) it stores, transmits, and/or processes for its Customers and to develop strategies to efficiently and effectively mitigate the risks identified in the assessment process as an integral part of the RxRevu’s information security program.
  2. Risk analysis and risk management are recognized as important components of RxRevu’s corporate compliance program and information security program in accordance with the Risk Analysis and Risk Management implementation specifications within the Security Management standard and the evaluation standards set forth in the HIPAA Security Rule, 45 CFR 164.308(a)(1)(ii)(A), 164.308(a)(1)(ii)(B), 164.308(a)(1)(i), and 164.308(a)(8).
    1. Risk assessments are done throughout product life cycles:
    2. Before the integration of new system technologies and before changes are made to RxRevu physical safeguards; and
      • These changes do not include routine updates to existing systems, deployments of new systems created based on previously configured systems, deployments of new Customers, or new code developed for operations and management of the RxRevu Platform.
    3. While making changes to RxRevu physical equipment and facilities that introduce new, untested configurations.
    4. RxRevu performs periodic technical and non-technical assessments of the security rule requirements as well as in response to environmental or operational changes affecting the security of ePHI.
  3. The risk assessment process should consider the value and sensitivity of the relevant data, physical and logical access controls, network connectivity, the location where the work will be performed, who will be doing the work and how they will be authenticated, and their procedures for handling sensitive data. In addition, legal considerations, business continuity and potential impact on stakeholders should be evaluated.
  4. RxRevu implements security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to:
    1. Ensure the confidentiality, integrity, and availability of all ePHI RxRevu receives, maintains, processes, and/or transmits for its Customers;
    2. Protect against any reasonably anticipated threats or hazards to the security or integrity of Customer ePHI;
    3. Protect against any reasonably anticipated uses or disclosures of Customer ePHI that are not permitted or required; and
    4. Ensure compliance by all workforce members.
  5. Any risk remaining (residual) after other risk controls have been applied, requires sign off by the senior management and RxRevu’s Security Officer.
  6. All RxRevu workforce members are expected to fully cooperate with all persons charged with doing risk management work, including contractors and audit personnel. Any workforce member that violates this policy will be subject to disciplinary action based on the severity of the violation, as outlined in the RxRevu Roles Policy.
  7. The implementation, execution, and maintenance of the information security risk analysis and risk management process is the responsibility of RxRevu’s Security Officer (or other designated employee), and the identified Risk Management Team.
  8. All risk management efforts, including decisions made on what controls to put in place as well as those to not put into place, are documented and the documentation is maintained for six years.
  9. The details of the Risk Management Process, including risk assessment, discovery, and mitigation, are outlined in detail below. The process is tracked, measured, and monitored using the following procedures:
    1. The Security Officer or the Privacy Officer initiates the Risk Management Procedures by initiating a Risk Assessment Process or Risk Mitigation Process in Asana.
    2. The Security Officer or the Privacy Officer is assigned to carry out the Risk Management Procedures.
    3. All findings are documented in an approved spreadsheet that is linked to the Issue.
    4. Once the Risk Management Procedures are complete, along with corresponding documentation, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
    5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
  10. The Risk Management Procedure is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.

4.3 Risk Management Procedures

4.3.1 Risk Assessment

The intent of completing a risk assessment is to determine potential threats and vulnerabilities and the likelihood and impact should they occur. The output of this process helps to identify appropriate controls for reducing or eliminating risk.

4.3.2 Risk Mitigation

Risk mitigation involves prioritizing, evaluating, and implementing the appropriate risk-reducing controls recommended from the Risk Assessment process to ensure the confidentiality, integrity and availability of RxRevu Platform ePHI. Determination of appropriate controls to reduce risk is dependent upon the risk tolerance of the organization consistent with its goals and mission.

4.3.3 Risk Management Schedule

The two principle components of the risk management process - risk assessment and risk mitigation - will be carried out according to the following schedule to ensure the continued adequacy and continuous improvement of RxRevu’s information security program:

4.4 Process Documentation

Maintain documentation of all risk assessment, risk management, and risk mitigation efforts for a minimum of six years.

5. Roles Policy

RxRevu has a Security Officer [164.308(a)(2)], who also serves as the Data Protection Officer, and Privacy Officer [164.308(a)(2)] appointed to assist in maintaining and enforcing safeguards towards compliance. The responsibilities associated with these roles are outlined below.

5.1 Applicable Standards

5.1.1 Applicable Standards from the HITRUST Common Security Framework

5.1.2 Applicable Standards from the HIPAA Security Rule

5.2 Privacy Officer

The Privacy Officer is responsible for assisting with compliance and security training for workforce members, assuring organization remains in compliance with evolving compliance rules, and helping the Security Officer in his responsibilities.

  1. Provides annual training to all workforce members of established policies and procedures as necessary and appropriate to carry out their job functions, and documents the training provided.
  2. Assists in the administration and oversight of business associate agreements.
  3. Manage relationships with customers and partners as those relationships affect security and compliance of ePHI.
  4. Assist Security Officer as needed.

The current RxRevu Privacy Officer is Joel Longtine (joel.longtine@rxrevu.com).

5.2.1 Workforce Training Responsibilities

  1. The Privacy Officer facilitates the training of all workforce members as follows:
    1. New workforce members within their first month of employment;
    2. Existing workforce members annually;
    3. Existing workforce members whose functions are affected by a material change in the policies and procedures, within a month after the material change becomes effective;
    4. Existing workforce members as needed due to changes in security and risk posture of RxRevu.
  2. The Security Officer or designee maintains documentation of the training session materials and attendees for a minimum of six years.
  3. The training session focuses on, but is not limited to, the following subjects defined in RxRevu’s security policies and procedures:
    1. HIPAA Privacy, Security, and Breach notification rules;
    2. HITRUST Common Security Framework;
    3. NIST Security Rules;
    4. Risk Management procedures and documentation;
    5. Auditing. RxRevu may monitor access and activities of all users;
    6. Workstations may only be used to perform assigned job responsibilities;
    7. Users may not download software onto RxRevu’s workstations and/or systems without prior approval from the Security Officer;
    8. Users are required to report malicious software to the Security Officer immediately;
    9. Users are required to report unauthorized attempts, uses of, and theft of RxRevu’s systems and/or workstations;
    10. Users are required to report unauthorized access to facilities
    11. Users are required to report noted log-in discrepancies (i.e. application states users last log-in was on a date user was on vacation);
    12. Users may not alter ePHI maintained in a database, unless authorized to do so by a RxRevu Customer;
    13. Users are required to understand their role in RxRevu’s contingency plan;
    14. Users may not share their user names nor passwords with anyone;
    15. Requirements for users to create and change passwords, including avoidance of commonly used passwords;
    16. Users must set all applications that contain or transmit ePHI to automatically log off after 15 minutes of inactivity;
    17. Supervisors are required to report terminations of workforce members and other outside users;
    18. Supervisors are required to report a change in a users title, role, department, and/or location;
    19. Procedures to backup ePHI;
    20. Procedures to move and record movement of hardware and electronic media containing ePHI;
    21. Procedures to dispose of discs, CDs, hard drives, and other media containing ePHI;
    22. Procedures to re-use electronic media containing ePHI;
    23. SSH key and sensitive document encryption procedures.

5.3 Security Officer

The Security Officer is responsible for facilitating the training and supervision of all workforce members [164.308(a)(3)(ii)(A) and 164.308(a)(5)(ii)(A)], investigation and sanctioning of any workforce member that is in violation of RxRevu security policies and non-compliance with the security regulations [164.308(a)(1)(ii)(c)], and writing, implementing, and maintaining all polices, procedures, and documentation related to efforts toward security and compliance [164.316(a-b)].

The current RxRevu Security Officer is Joel Longtine (joel.longtine@rxrevu.com).

5.3.1 Organizational Responsibilities

The Security Officer, in collaboration with the Privacy Officer, is responsible for facilitating the development, testing, implementation, training, and oversight of all activities pertaining to RxRevu’s efforts to be compliant with the HIPAA Security Regulations, HITRUST CSF, and any other security and compliance frameworks. The intent of the Security Officer Responsibilities is to maintain the confidentiality, integrity, and availability of ePHI. The Security Officer is appointed by and reports to the Board of Directors and the CEO.

These organizational responsibilities include, but are not limited to the following:

  1. Oversees and enforces all activities necessary to maintain compliance and verifies the activities are in alignment with the requirements.
  2. Helps to establish and maintain written policies and procedures to comply with the Security rule and maintains them for six years from the date of creation or date it was last in effect, whichever is later.
  3. Reviews and updates policies and procedures as necessary and appropriate to maintain compliance and maintains changes made for six years from the date of creation or date it was last in effect, whichever is later.
  4. Facilitates audits to validate compliance efforts throughout the organization.
  5. Documents all activities and assessments completed to maintain compliance and maintains documentation for six years from the date of creation or date it was last in effect, whichever is later.
  6. Provides copies of the policies and procedures to management, customers, and partners, and has them available to review by all other workforce members to which they apply.
  7. Annually, and as necessary, reviews and updates documentation to respond to environmental or operational changes affecting the security and risk posture of ePHI stored, transmitted, or processed within RxRevu infrastructure.
  8. Develops and provides periodic security updates and reminder communications for all workforce members.
  9. Implements procedures for the authorization and/or supervision of workforce members who work with ePHI or in locations where it may be accessed.
  10. Maintains a program promoting workforce members to report non-compliance with policies and procedures.
    • Promptly, properly, and consistently investigates and addresses reported violations and takes steps to prevent recurrence.
    • Applies consistent and appropriate sanctions against workforce members who fail to comply with the security policies and procedures of RxRevu.
    • Mitigates, to the extent practicable, any harmful effect known to RxRevu of a use or disclosure of ePHI in violation of RxRevu’s policies and procedures, even if effect is the result of actions of RxRevu business associates, customers, and/or partners.
  11. Reports security efforts and incidents to administration immediately upon discovery. Responsibilities in the case of a known ePHI breach are documented in the RxRevu Breach Policy.
  12. The Security Officer facilitates the communication of security updates and reminders to all workforce members to which it pertains. Examples of security updates and reminders include, but are not limited to:
    • Latest malicious software or virus alerts;
    • RxRevu’s requirement to report unauthorized attempts to access ePHI;
    • Changes in creating or changing passwords;
    • Additional security-focused training is provided to all workforce members by the Security Officer. This training includes, but is not limited to:
    • Data backup plans;
    • System auditing procedures;
    • Redundancy procedures;
    • Contingency plans;
    • Virus protection;
    • Patch management;
    • Media Disposal and/or Re-use;
    • Documentation requirements.
  13. The Security Officer works with the COO to ensure that any security objectives have appropriate consideration during the budgeting process.
    • In general, security and compliance are core to RxRevu’s technology and service offerings; in most cases this means security-related objectives cannot be split out to separate budget line items.
    • For cases that can be split out into discrete items, such as licenses for commercial tooling, the Security Officer follows RxRevu’s standard corporate budgeting process.
      • At the beginning of every fiscal year, the COO contacts the Security Officer to plan for the upcoming year’s expenses.
      • The Security Officer works with the COO to forecast spending needs based on the previous year’s level, along with changes for the upcoming year such as additional staff hires.
      • During the year, if an unforeseen security-related expense arises that was not in the budget forecast, the Security Officer works with the COO to reallocate any resources as necessary to cover this expense.

5.3.2 Supervision of Workforce Responsibilities

Although the Security Officer is responsible for implementing and overseeing all activities related to maintaining compliance, it is the responsibility of all workforce members (i.e. team leaders, supervisors, managers, directors, co-workers, etc.) to supervise all workforce members and any other user of RxRevu’s systems, applications, servers, workstations, etc. that contain ePHI.

  1. Monitor workstations and applications for unauthorized use, tampering, and theft and report non-compliance according to the Security Incident Response policy.
  2. Assist the Security and Privacy Officers to ensure appropriate role-based access is provided to all users.
  3. Take all reasonable steps to hire, retain, and promote workforce members and provide access to users who comply with the Security regulation and RxRevu’s security policies and procedures.

5.3.3 Sanctions of Workforce Responsibilities

All workforce members report non-compliance of RxRevu’s policies and procedures to the Security Officer or other individual as assigned by the Security Officer. Individuals that report violations in good faith may not be subjected to intimidation, threats, coercion, discrimination against, or any other retaliatory action as a consequence.

  1. The Security Officer promptly facilitates a thorough investigation of all reported violations of RxRevu’s security policies and procedures. The Security Officer may request the assistance from others.
    • Within 24 hours of beginning the sanctions process, notify the employees and relevant supervisors of the investigation.
    • Complete an audit trail/log to identify and verify the violation and sequence of events.
    • Interview any individual that may be aware of or involved in the incident.
    • All individuals are required to cooperate with the investigation process and provide factual information to those conducting the investigation.
    • Provide individuals suspected of non-compliance of the Security rule and/or RxRevu’s policies and procedures the opportunity to explain their actions.
    • The investigator thoroughly documents the investigation as the investigation occurs. This documentation must include a list of all employees involved in the violation.
  2. Violation of any security policy or procedure by workforce members may result in corrective disciplinary action, up to and including termination of employment. Violation of this policy and procedures by others, including business associates, customers, and partners may result in termination of the relationship and/or associated privileges. Violation may also result in civil and criminal penalties as determined by federal and state laws and regulations.
    • A violation resulting in a breach of confidentiality (i.e. release of PHI to an unauthorized individual), change of the integrity of any ePHI, or inability to access any ePHI by other users, requires immediate termination of the workforce member from RxRevu.
  3. The Security Officer facilitates taking appropriate steps to prevent recurrence of the violation (when possible and feasible).
  4. In the case of an insider threat, the Security Officer and Privacy Officer are to set up a team to investigate and mitigate the risk of insider malicious activity. RxRevu workforce members are encouraged to come forward with information about insider threats, and can do so anonymously.
  5. The Security Officer maintains all documentation of the investigation, sanctions provided, and actions taken to prevent reoccurrence for a minimum of six years after the conclusion of the investigation.

6. Asset Management Policy

The management and backup of information assets is an important part of the day-to-day operations of RxRevu. All important records are stored either in AWS or Dropbox and protected from loss or misuse through user authentication and encryption, both in transit and at rest.

To protect the confidentiality, integrity, and availability of ePHI, both for RxRevu and RxRevu Customers, complete backups are done at least daily to assure that data remains available when it needed and in compliance with any relevant contractual, legal, regulatory and business requirements. An inventory of system and information assets is maintained, for the purpose of classification and documenting ownership, handling.

Violation of this policy and its procedures by workforce members may result in corrective disciplinary action, up to and including termination of employment.

6.1 Applicable Standards

6.1.1 Applicable Standards from the HITRUST Common Security Framework

6.1.2 Applicable Standards from the HIPAA Security Rule

6.2 Backup Policy and Procedures

6.2.1 AWS Assets

  1. Perform daily snapshot backups of all databases that process, store, or transmit ePHI for RxRevu Customers, and retain for 7 days.
  2. Version all static assets, and retain previous versions for 7 days.
  3. The RxRevu Systems Engineering Team is designated to be in charge of backups.
  4. The Systems Engineering Team members are trained and assigned to complete backups and manage the backup media.
  5. Backups are automatically tagged with a name, timestamp and relevant location (AWS region).
  6. Securely encrypt stored backups in a manner that protects them from loss or environmental damage.
  7. Backups should be stored in a secure, remote location.
  8. Test backups and document that files have been completely and accurately restored from the backup media.

6.2.1 Dropbox Assets

Information assets stored in Dropbox are backed up, and retained, in accordance with the policies and mechansisms described in the Dropbox Security Whitepaper. Restoration is available through the Dropbox user interface.

6.3 System Asset Inventory

RxRevu maintains an inventory of system assets and classifies them based on type, sensitivity, backup frequency, backup retention, and backup restoration process.

In addition, RxRevu uses the AWS Console to manage, and track, system assets in real-time. Classification is supported through tagging of AWS resources. ePHI may only be stored using RDS, S3, and CloudTrail.

Local access points are also tracked, as dedicated points of entry for in-scope systems.

The Security Officer is responsible for maintaining this inventory and reviewing the information, at least quarterly.

6.4 Information Asset Inventory

RxRevu maintains an inventory of information assets and classifies them based on ownership, sensitivity, format, and appropriate use.

The Security Officer is responsible for maintaining this inventory and reviewing the information, at least quarterly, to ensure that only the minimum necessary information is retained.

The CTO must approve changes to the appropriate use of information assets.

6.5 Workstation Inventory

RxRevu maintains an inventory of labeled workstations and classifies them based on risk profile. The Security Officer is responsible for maintaining this inventory and reviewing the information, at least, quarterly.

7. System Access Policy

Access to RxRevu systems and application is limited for all users, including but not limited to workforce members, volunteers, business associates, contracted providers, and consultants. Access by any other entity is allowable only on a minimum necessary basis. All users are responsible for reporting an incident of unauthorized user or access of the organization’s information systems. These safeguards have been established to address the HIPAA Security regulations including the following:

7.1 Applicable Standards

7.1.1 Applicable Standards from the HITRUST Common Security Framework

7.1.2 Applicable Standards from the HIPAA Security Rule

7.2 Access Establishment and Modification

  1. Requests for access to RxRevu Platform systems and applications is made formally using the following process:
    1. A RxRevu workforce member initiates the access request by initiating an Access Request Process in Asana..
      • User identities must be verified prior to granting access to new accounts.
      • Identity verification must be done in person where possible; for remote employees, identities must be verified over the phone.
      • For new accounts, the method used to verify the user’s identity must be recorded on the Issue.
    2. The Security Officer or Privacy Officer will grant access to systems as dictated by the employee’s job title. If additional access is required outside of the minimum necessary to perform job functions, the requester must include a description of why the additional access is required as part of the access request.
    3. Once the review is completed, the Security Officer or Privacy Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
    4. If the review is approved, the Security Officer or Privacy Officer then marks the Issue as Done, adding any pertinent notes required. The Security Officer or Privacy Officer then grants requested access.
      • New accounts will be created with a temporary secure password that is unique and meets all requirements from §7.12, which must be changed on the initial login.
      • All password exchanges must occur over an authenticated channel.
      • For production systems, access grants are accomplished by adding the appropriate user account to the corresponding JumpCloud or IAM Groups, which each correspond with multiple functions.
      • For non-production systems, access grants are accomplished by leveraging the access control mechanisms built into those systems. Account management for non-production systems may be delegated to a RxRevu employee at the discretion of the Security Officer or Privacy Officer .
  2. Access is not granted until receipt, review, and approval by the RxRevu Security Officer or Privacy Officer ;
  3. The request for access is retained for future reference.
  4. Access to RxRevu systems and services is reviewed and updated on a quarterly basis, or when a workforce member’s position has changed, to ensure proper authorizations are in place commensurate with job functions. The process for conducting reviews is outlined below:
    1. The Security Officer initiates the review of user access by initiating a System Access Review Process in Asana.
    2. The Security Officer is assigned to review levels of access for each RxRevu workforce member in the scope of the review.
    3. If user access is found during review that is not in line with the least privilege principle, the process below is used to modify user access and notify the user of access changes. Once those steps are completed, the Issue is then reviewed again.
    4. Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
    5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
    6. Review of user access is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.
  5. Any RxRevu workforce member can request change of access using the process outlined in §7.2 paragraph 1. When approved, the Security Officer and CTO will be notified.
  6. Access to production systems is controlled using centralized user management and authentication.
  7. Temporary accounts are not used unless absolutely necessary for business purposes.
    • Accounts are reviewed every 90 days to ensure temporary accounts are not left unnecessarily.
    • Accounts that are inactive for over 90 days are removed.
  8. In the case of non-personal information, such as generic educational content, identification and authentication may not be required. This is the responsibility of RxRevu Customers to define, and not RxRevu.
  9. Direct access to production systems is only available to privileged users, and for performing privileged tasks, as granted by the Security Officer or Privacy Officer using the process outlined in §7.2 paragraph 1. Separate accounts are used for privileged access on production systems, and should be used sparingly. RxRevu promotes the use of programs that support limiting the need for granting privileged access.
  10. Security configuration, and other privileged tasks, must be done through separate privileged accounts.
  11. All application to application communication using service accounts is restricted and not permitted unless absolutely needed. Automated tools are used to limit account access across applications and systems.
  12. Generic accounts are not allowed on RxRevu systems.
  13. In cases of increased risk or known attempted unauthorized access, immediate steps are taken by the Security and Privacy Officer to limit access and reduce risk of unauthorized access.
  14. Direct system to system, system to application, and application to application authentication and authorization are limited and controlled to restrict access.

7.3 Workforce Clearance

  1. The level of security assigned to a user to the organization’s information systems is based on the minimum necessary amount of data access required to carry out legitimate job responsibilities assigned to a user’s job classification and/or to a user needing access to carry out treatment, payment, or healthcare operations.
  2. All access requests are treated on a “least-access principle.”
  3. RxRevu maintains a minimum necessary approach to access to Customer data. As such, RxRevu, including all workforce members, does not readily have access to any ePHI.

7.4 Access Authorization

  1. Role based access categories for each RxRevu system and application are pre-approved by the Security Officer, or an authorized delegate of the Security Officer.
  2. RxRevu utilizes hardware and software firewalls to segment data, prevent unauthorized access, and monitor traffic for denial of service attacks.
  3. When available, menu items are limited to only those that are necessary for authorized access.

7.5 Person or Entity Authentication

  1. Each workforce member has and uses a unique user ID and password that identifies him/her as the user of the information system.
  2. Each Customer and Partner has and uses a unique user ID and password that identifies him/her as the user of the information system.
  3. All Customer support desk interactions must be verified before RxRevu support personnel will satisfy any request having information security implications.
    • Support issues submitted by email must be verified by RxRevu personnel using a known email that has been registered with the corresponding account.

7.6 Unique User Identification

  1. Access to the RxRevu Platform systems and applications is controlled by requiring unique User Login IDs and passwords for each individual user and developer.
  2. Passwords requirements mandate strong password controls (see below).
  3. Passwords are not displayed at any time and are not transmitted or stored in plain text.
  4. Default accounts on all production systems, including root, are disabled.
  5. Shared, group, or generic accounts are not allowed for access of production systems.
  6. Automated log-on configurations that store user passwords or bypass password entry are not permitted for use with RxRevu workstations or production systems.

7.7 Automatic Logoff

  1. Users are required to make information systems inaccessible by any other individual when unattended by the users (ex. by using a password protected screen saver or logging off the system).
  2. Information systems automatically log users off the systems after 30 minutes of inactivity.
  3. The Security Officer pre-approves exceptions to automatic log off requirements.

7.8 Employee Workstation Use

All workstations at RxRevu are company-owned Apple laptops, labeled based on classification, running OS X.

  1. Workstations may not be used to engage in any activity that is illegal or is in violation of organization’s policies.
  2. Access may not be used for transmitting, retrieving, or storage of any communications of a discriminatory or harassing nature or materials that are obscene or “X-rated”. Harassment of any kind is prohibited. No messages with derogatory or inflammatory remarks about an individual’s race, age, disability, religion, national origin, physical attributes, sexual preference, or health condition shall be transmitted or maintained. No abusive, hostile, profane, or offensive language is to be transmitted through organization’s system.
  3. Information systems/applications also may not be used for any other purpose that is illegal, unethical, or against company policies or contrary to organization’s best interests. Messages containing information related to a lawsuit or investigation may not be sent without prior approval.
  4. Solicitation of non-company business, or any use of organization’s information systems/applications for personal gain is prohibited.
  5. Transmitted messages may not contain material that criticizes the organization, its providers, its employees, or others.
  6. Users may not misrepresent, obscure, suppress, or replace another user’s identity in transmitted or stored messages.
  7. Workstation hard drives will be encrypted using FileVault 2.0 or equivalent.
  8. All workstations have firewalls enabled to prevent unauthorized access unless explicitly granted.
  9. All workstations are to have the following messages added to the lock screen and login screen: This computer is owned by RxRevu, Inc. By logging in, unlocking, and/or using this computer you acknowledge you have seen, and follow, the information security policies and have completed the security training. Please contact security@rxrevu.com if you have problems.

7.9 Wireless Access Use

  1. RxRevu production systems are not accessible directly over wireless channels.
  2. Wireless access is disabled on all production systems.
  3. When accessing production systems via remote wireless connections, the same system access policies and procedures apply to wireless as all other connections, including wired.
  4. Production systems should not be accessed from open public, or less trusted, networks.
  5. Wireless networks managed within RxRevu non-production facilities (offices, etc.) are secured with the following configurations:
    • Routers and physical firewalls must be stored in a secure location;
    • Wireless access points are never left with default configurations;
    • All data in transit over wireless is encrypted using WPA2 encryption;
    • Connections are monitored to restrict unauthorized access;
    • Passwords are rotated on a regular basis, presently quarterly. This process is managed by the RxRevu Security Officer.

7.10 External Connections

  1. External connections to the network must go through the bastion host and use multi-factor authentication.
  2. Dial-up connections are not permitted.

7.11 Employee Termination Procedures

  1. The Human Resources Department (or other designated department), users, and their supervisors are required to notify the Security Officer upon completion and/or termination of access needs and facilitating completion of the “Offboarding Process”.
  2. The Human Resources Department, users, and supervisors are required to notify the Security Officer to terminate a user’s access rights if there is evidence or reason to believe the following (these incidents are also reported on an incident report and is filed with the Privacy Officer):
    • The user has been using their access rights inappropriately;
    • A user’s password has been compromised (a new password may be provided to the user if the user is not identified as the individual compromising the original password);
    • An unauthorized individual is utilizing a user’s User Login ID and password (a new password may be provided to the user if the user is not identified as providing the unauthorized individual with the User Login ID and password).
  3. The Security Officer will terminate users’ access rights immediately upon notification, and will coordinate with the appropriate RxRevu employees to terminate access to any non-production systems managed by those employees.
  4. The Security Officer audits and may terminate access of users that have not logged into organization’s information systems/applications for an extended period of time.

7.12 Password Management

  1. User IDs and passwords are used to control access to RxRevu systems and may not be disclosed to anyone for any reason.
  2. Users may not allow anyone, for any reason, to have access to any information system using another user’s unique user ID and password. They must sign a statement their responsibility to keep passwords confidential.
  3. On all production systems in the RxRevu environment, password configurations are set to require:
    • a minimum length of 8 characters;
    • a mix of upper case characters, lower case characters, and numbers or special characters;
    • a 90-day password expiration, or 60-day password expiration for administrative accounts;
    • prevention of password reuse using a history of the last 6 passwords;
    • where supported, modifying at least 4 characters when changing passwords;
    • account lockout after 5 invalid attempts.
  4. All system and application passwords must be stored and transmitted securely.
    • Where possible, passwords should be stored in a hashed format using a salted cryptographic hash function (SHA-256 or equivalent).
    • Passwords that must be stored in non-hashed format must be encrypted at rest pursuant to the requirements in §17.8.
    • Transmitted passwords must be encrypted in flight pursuant to the requirements in §17.9.
  5. Each information system automatically requires users to change passwords at a pre-determined interval as determined by the organization, based on the criticality and sensitivity of the ePHI contained within the network, system, application, and/or database.
  6. Passwords are inactivated immediately upon an employee’s termination (refer to the Employee Termination Procedures in §7.10).
  7. All default system, application, and Partner passwords are changed before deployment to production.
  8. Clear text transmission of any temporary passwords should be avoided. Upon initial login, users must immediately change such passwords.
  9. For applications that contain ePHI, temporary credentials must be encrypted and sent through an encrypted channel. Confirmation of receipt is required.
  10. Password change methods must use a confirmation method to correct for user input errors.
  11. All passwords used in configuration scripts are secured and encrypted.
  12. If a user believes their user ID has been compromised, they are required to immediately report the incident to the Security Office.
  13. In cases where a user has forgotten their password, the following procedure is used to reset the password.
    • The user submits a password reset request to security@rxrevu.com. The request should include the system to which the user has lost access and needs the password reset.
    • An administrator with password reset privileges is notified and connects directly with the user requesting the password reset.
    • The administrator verifies the identity of the user either in-person or through a separate communication channel such as phone or Slack.
    • Once verified, the administrator resets the password.

The password-reset email inbox is used to track and store password reset requests. The Security Officer is the owner of this group and modifies membership as needed.

7.13 Access to Production Systems

Employees may not download ePHI from AWS to any local workstation. This is enforced through technical measures, including the configuration of bastion hosts and privileged workstations. These systems will be kept in the referenced configuration, except as necessary to obtain documentation or records in the ordinary course of business. Such excepts are at the sole discretion of the CTO, and no such exceptions will be made unless expressly provided for in writing and approved by the CTO.

7.13.2 Bastion Hosts

7.13.2 Privileged Workstations

7.14 Sharing of Storage of ePHI

Paper: RxRevu does not use paper records, or fax, for any sensitive information. Use of paper for recording and storing sensitive data is against RxRevu policies.

Oral: Oral communication of ePHI should be limited, and be by-product of an otherwise permitted use.

Email: Emailing of ePHI is not permitted. Data-loss prevention tools must be in place to monitor compliance.

Chat: ePHI should not be sent via chat or instant message.

In the case of data migration, RxRevu does, on a case by case basis, and commensurate with our legal and contractual obligations, and commensurate with our legal and contractual obligations, support business partners in importing and exporting of data. In these cases RxRevu requires that all data is secured and encrypted in transit, using SFTP for transferring files.

In the case of an investigation, RxRevu will assist customers, at RxRevu’s discretion, and law enforcement in forensics. When legally required, consent is obtained prior to sharing of ePHI.

8. Auditing Policy

RxRevu shall audit access and activity of electronic protected health information (ePHI) applications and systems in order to ensure compliance. The Security Rule requires healthcare organizations to implement reasonable hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use ePHI. Audit activities may be limited by application, system, and/or network auditing capabilities and resources. RxRevu shall make reasonable and good-faith efforts to safeguard information privacy and security through a well-thought-out approach to auditing that is consistent with available resources.

It is the policy of RxRevu to safeguard the confidentiality, integrity, and availability of applications, systems, and networks. To ensure that appropriate safeguards are in place and effective, RxRevu shall audit access and activity to detect, report, and guard against:

This policy applies to all RxRevu systems that store, transmit, or process ePHI.

8.1 Applicable Standards

8.1.1 Applicable Standards from the HITRUST Common Security Framework

8.1.2 Applicable Standards from the HIPAA Security Rule

8.2 Auditing Policies

  1. Responsibility for auditing information system access and activity is assigned to RxRevu’s Security Officer. The Security Officer shall:
    • Assign the task of generating reports for audit activities to the workforce member responsible for the application, system, or network, in compliance with all legal requirements;
    • Assign the task of reviewing the audit reports to the workforce member responsible for the application, system, or network, the Privacy Officer, or any other individual determined to be appropriate for the task;
    • Organize and provide oversight to a team structure charged with audit compliance activities (e.g., parameters, frequency, sample sizes, report formats, evaluation, follow-up, etc.).
    • All connections to RxRevu are monitored. Access is limited to certain services, ports, and destinations. Exceptions to these rules, if created, are reviewed on an annual basis.
  2. RxRevu’s auditing processes shall address access and activity at the following levels listed below. Auditing processes may address date and time of each log-on attempt, date and time of each log-off attempt, devices used, functions performed, etc.
    • User: User level audit trails generally monitor and log all commands directly initiated by the user, all identification and authentication attempts, and data and services accessed.
    • Application: Application level audit trails generally monitor and log all user activities, including data accessed and modified and specific actions.
    • System: System level audit trails generally monitor and log user activities, applications accessed, and other system defined specific actions. RxRevu utilizes file system monitoring from Falco to assure the integrity of file system data and ClamAV to ensure malicious code is not present on the instance.
    • Network: Network level audit trails generally monitor information on what is operating, penetrations, and vulnerabilities.
  3. RxRevu shall log all incoming and outgoing traffic to into and out of its environment. This includes all successful and failed attempts at data access and editing. Data associated with this data will include origin, destination, time, and other relevant details that are available to RxRevu.
  4. RxRevu utilizes Falco to scan all systems for malicious and unauthorized software every 2 hours and at reboot of systems.
  5. RxRevu leverages process monitoring tools throughout its environment, and aggregates these logs into CloudWatch for analysis and review.
  6. RxRevu uses Falco to monitor the integrity of log files.
  7. RxRevu uses ClamAV to ensure malicious code is not present on the server.
  8. RxRevu shall identify “trigger events” or criteria that raise awareness of questionable conditions or viewing of confidential information. The “events” may be applied to the entire RxRevu Platform or may be specific to a Customer, partner, business associate, or application (See Listing of Potential Trigger Events below).
  9. Logs are reviewed weekly by the Security Officer.
  10. RxRevu’s Security Officer and Privacy Officer are authorized to select and use auditing tools that are designed to detect network vulnerabilities and intrusions. Such tools are explicitly prohibited by others, including Customers and Partners, without the explicit authorization of the Security Officer. These tools may include, but are not limited to:
    • Scanning tools and devices;
    • Password cracking utilities;
    • Network “sniffers.”
    • Passive and active intrusion detection systems.
  11. The process for review of audit logs, trails, and reports shall include:
    • Description of the activity as well as rationale for performing the audit.
    • Identification of which RxRevu workforce members will be responsible for review (workforce members shall not review audit logs that pertain to their own system activity).
    • Frequency of the auditing process.
    • Determination of significant events requiring further review and follow-up.
    • Identification of appropriate reporting channels for audit results and required follow-up.
  12. Vulnerability testing software may be used to probe the network to identify what is running (e.g., operating system or product versions in place), whether publicly-known vulnerabilities have been corrected, and evaluate whether the system can withstand attacks aimed at circumventing security controls.
    • Testing may be carried out internally or provided through an external third-party vendor. Whenever possible, a third party auditing vendor should not be providing the organization IT oversight services (e.g., vendors providing IT services should not be auditing their own services - separation of duties).
    • Testing shall be done on an ongoing basis.
  13. Software patches and updates will be applied to all systems in a timely manner.

8.3 Audit Requests

  1. A request may be made for an audit for a specific cause. The request may come from a variety of sources including, but not limited to, Privacy Officer, Security Officer, Customer, Partner, or an Application owner or application user.
  2. A request for an audit for specific cause must include time frame, frequency, and nature of the request. The request must be reviewed and approved by RxRevu’s Privacy or Security Officer.
  3. A request for an audit must be approved by RxRevu’s Privacy Officer and/or Security Officer before proceeding. Under no circumstances shall detailed audit information be shared with parties without proper permissions and access to see such data.
    • Should the audit disclose that a workforce member has accessed ePHI inappropriately, the minimum necessary/least privileged information shall be shared with RxRevu’s Security Officer to determine appropriate sanction/corrective disciplinary action.
    • Only de-identified information shall be shared with Customer or Partner regarding the results of the investigative audit process. This information will be communicated to the appropriate personnel by RxRevu’s Privacy Officer or designee. Prior to communicating with customers and partners regarding an audit, it is recommended that RxRevu consider seeking risk management and/or legal counsel.

8.4 Review and Reporting of Audit Findings

  1. Audit information that is routinely gathered must be reviewed in a timely manner, currently weekly, by the responsible workforce member(s). On a weekly basis, logs are reviewed to assure the proper data is being captured and retained. The following process details how log reviews are done at RxRevu:
    1. The Security Officer initiates the log review by initiating an Audit Log Review Process in Asana.
    2. The Security Officer, or a RxRevu Security Engineer assigned by the Security Officer, is assigned to review the logs.
    3. Relevant audit log findings are added to the Issue; these findings are investigated in a later step. Once those steps are completed, the Issue is then reviewed again.
    4. Once the review is completed, the Security Officer approves or rejects the Issue. Relevant findings are reviewed at this stage. If the Issue is rejected, it goes back for further review and documentation. The communications protocol around specific findings are outlined below.
    5. If the Issue is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
  2. The reporting process shall allow for meaningful communication of the audit findings to those workforce members, Customers, or Partners requesting the audit.
    • Significant findings shall be reported immediately in a written format. RxRevu’s security incident response form may be utilized to report a single event.
    • Routine findings shall be reported to the sponsoring leadership structure in a written report format.
  3. Reports of audit results shall be limited to internal use on a minimum necessary/need-to-know basis. Audit results shall not be disclosed externally without administrative and/or legal counsel approval.
  4. Security audits constitute an internal, confidential monitoring practice that may be included in RxRevu’s performance improvement activities and reporting. Care shall be taken to ensure that the results of the audits are disclosed to administrative level oversight structures only and that information which may further expose organizational risk is shared with extreme caution. Generic security audit information may be included in organizational reports (individually-identifiable e PHI shall not be included in the reports).
  5. Whenever indicated through evaluation and reporting, appropriate corrective actions must be undertaken. These actions shall be documented and shared with the responsible workforce members, Customers, and/or Partners.
  6. Log review activity is monitored on a weekly basis using Asana reporting to assess compliance with above policy.

8.5 Auditing Customer and Partner Activity

  1. Periodic monitoring of Customer and Partner activity shall be carried out to ensure that access and activity is appropriate for privileges granted and necessary to the arrangement between RxRevu and the 3rd party. RxRevu will make every effort to assure Customers and Partners do not gain access to data outside of their own Environments.
  2. If it is determined that the Customer or Partner has exceeded the scope of access privileges, RxRevu’s leadership must remedy the problem immediately.
  3. If it is determined that a Customer or Partner has violated the terms of the HIPAA business associate agreement or any terms within the HIPAA regulations, RxRevu must take immediate action to remediate the situation. Continued violations may result in discontinuation of the business relationship.

8.6 Audit Log Security Controls and Backup

  1. Audit logs shall be protected from unauthorized access or modification, so the information they contain will be made available only if needed to evaluate a security incident or for routine audit activities as outlined in this policy.
  2. All audit logs are protected in transit and encrypted at rest to control access to the content of the logs.
  3. Audit logs shall be stored on a separate system to minimize the impact auditing may have on the privacy system and to prevent access to audit trails by those with system administrator privileges.
    • Separate systems are used to apply the security principle of “separation of duties” to protect audit trails from hackers.
    • Audit logs are stored in CloudTrail, CloudWatch and S3 Buckets, and are used to store system integrity, anti-virus and usage logs.

8.7 Workforce Training, Education, Awareness and Responsibilities

  1. RxRevu workforce members are provided training, education, and awareness on safeguarding the privacy and security of business and ePHI. RxRevu’s commitment to auditing access and activity of the information applications, systems, and networks is communicated through new employee orientation, ongoing training opportunities and events, and applicable policies. RxRevu workforce members are made aware of responsibilities with regard to privacy and security of information as well as applicable sanctions/corrective disciplinary actions should the auditing process detect a workforce member’s failure to comply with organizational policies.
  2. RxRevu Customers are provided with necessary information to understand RxRevu auditing capabilities.

8.8 External Audits of Information Access and Activity

  1. Prior to contracting with an external audit firm, RxRevu shall:
    • Outline the audit responsibility, authority, and accountability;
    • Choose an audit firm that is independent of other organizational operations;
    • Ensure technical competence of the audit firm staff;
    • Require the audit firm’s adherence to applicable codes of professional ethics;
    • Obtain a signed HIPAA business associate agreement;
    • Assign organizational responsibility for supervision of the external audit firm.

8.9 Retention of Audit Data

  1. Audit logs shall be maintained based on organizational needs. There is no standard or law addressing the retention of audit log/trail information. Retention of this information shall be based on:
    • Organizational history and experience.
    • Available storage space.
  2. Reports summarizing audit activities shall be retained for a period of six years.
  3. Audit log data is retained locally on the audit log server for a one-month period. Beyond that, log data is encrypted and moved to warm storage (currently S3) using automated scripts, and is retained for a minimum of one year.

8.10 Potential Trigger Events

9. Configuration Management Policy

RxRevu standardizes and automates configuration management through the use of CloudFormation templates and Ansible playbooks as well as documentation of all changes to production systems and networks. CloudFormation templates and Ansible playbooks automatically configure all RxRevu systems according to established and tested policies, and are used as part of our Disaster Recovery plan and process.

9.1 Applicable Standards

9.1.1 Applicable Standards from the HITRUST Common Security Framework

9.1.2 Applicable Standards from the HIPAA Security Rule

9.2 Configuration Management Policies

  1. CloudFormation templates and Ansible playbooks are used to standardize and automate configuration management.
  2. No systems are deployed into RxRevu environments without approval of the RxRevu CTO.
  3. All changes to production systems, network devices, and firewalls are approved by the RxRevu CTO before they are implemented to assure they comply with business and security requirements.
  4. All changes to production systems are tested before they are implemented in production, and can be rolled back if necessary.
  5. Implementation of approved changes are only performed by authorized personnel.
  6. Tooling to generate an up-to-date inventory of systems is managed through the AWS Console.
    • All systems are categorized as production and staging to differentiate based on criticality.
    • The Security Officer maintains scripts to generate inventory lists on demand using APIs provided by each cloud provider.
    • These scripts are used to generate the diagrams and asset lists required by the Risk Assessment phase of RxRevu’s Risk Management procedures (§4.3.1).
    • After every use of these scripts, the Security Officer will verify their accuracy by reconciling their output with recent changes to production systems. The Security Officer will address any discrepancies immediately with changes to the scripts.
  7. All frontend functionality (developer dashboards and portals) is separated from backend (database and app servers) systems by being deployed on separate servers or containers.
  8. All software is tested using unit tests and feature tests before they are implemented, and can be rolled back if necessary.
  9. All committed code is reviewed using pull requests to assure software code quality and proactively detect potential security issues in development.
  10. RxRevu utilizes development and staging environments that mirror production to assure proper function.
  11. Only authorized software is allowed to run on production systems.
  12. All formal change requests require unique ID and authentication.
  13. RxRevu uses the Security Technical Implementation Guides (STIGs) published by the Defense Information Systems Agency as a baseline for hardening systems.
    • Linux-based systems use an Ansible Hardening playbook.
  14. Clocks are continuously synchronized to an authoritative source across all systems using NTP or a platform-specific equivalent. Modifying time data on systems is restricted.

9.3 Provisioning Production Systems

  1. Before provisioning any systems, Systems Engineering Team members must file a request in the System Provisioning Process within Asana.
  2. The CTO, or an authorized delegate of the CTO, must approve the provisioning request before any new system can be provisioned.
  3. Once provisioning has been approved, the Systems Engineering Team member must configure the new system according to the standard baseline chosen for the system’s role.
    • For Linux systems, this means adding the appropriate roles and running the appropriate Ansible playbooks.
  4. If the system will be used to house production data (ePHI), the Systems Engineering Team member must ensure the data will be encrypted at rest.
  5. Once the system has been provisioned, the Systems Engineering Team member must contact the security team to inspect the new system. A member of the security team will verify that the secure baseline has been applied to the new system, including (but not limited to) verifying the following items:
    • Removal of default users used during provisioning.
    • Network configuration for system.
    • Data volume encryption settings.
    • Intrusion detection and virus scanning software installed.
    • All items listed below in the operating system-specific subsections below.
  6. Once the security team member has verified the new system is correctly configured, the team member must add that system to the list of vulnerability scanning targets.
  7. The new system may be rotated into production once the CTO verifies all the provisioning steps listed above have been correctly followed and has marked the issue approved, within Asana.

9.3.1 Provisioning Linux Systems

  1. Linux systems have their baseline security configuration applied via base AMIs and Ansible playbooks. These baseline configurations cover:
    • Ensuring that the machine is up-to-date with security patches and is configured to apply patches in accordance with our policies.
    • Stopping and disabling any unnecessary OS services.
    • Removing programs and executable code that have not been approved.
    • Installing and configuring the Falco IDS agent.
    • Configuring 15-minute session inactivity timeouts.
    • Installing and configuring the ClamAV virus scanner.
    • Installing and configuring the NTP daemon, including ensuring that modifying system time cannot be performed by unprivileged users.
    • Configuring authentication to the centralized LDAP servers.
    • Configuring audit logging as described in the Auditing Policy section.
  2. Any additional Ansible playbooks applied to the Linux system must be clearly documented by the Systems Engineering Team member in the request by specifying the purpose of the new system.

9.3.2 Provisioning Management Systems

  1. Provisioning management systems such as Ansible playbooks, LDAP servers, or VPN appliances follows the same procedure as provisioning a production system.
  2. Provisioning the first AMI for a production instance requires bootstrapping. An authorized member of the Systems Engineering Team team will oversee provisioning a new AMI.
    • Once the AMI has been provisioned, the Systems Engineering Team member will apply the baseline configuration to the AMI through the Ansible Hardening role..
  3. Critical infrastructure services such as logging, monitoring, or LDAP servers must be configured with appropriate states.
    • These states have been approved by the CTO, or an authorized delegate of the CTO, to be in accordance with all RxRevu policies, including setting appropriate:
      • Audit logging requirements.
      • Password size, strength, and expiration requirements.
      • Transmission encryption requirements.
      • Network connectivity timeouts.
  4. Critical infrastruture roles applied to new systems must be clearly documented by the Systems Engineering Team member in the DT request.

9.4 Changing Existing Systems

  1. Subsequent changes to already-provisioned systems are handled by one of the following methods:
    • Changes to the base AMIs.
    • Changes to the Ansible Hardening playbook.
    • Changes to the CloudFormation template.
    • For configuration changes that cannot be handled by AMI configuration or the Ansible Hardening playbook, a runbook describing exactly what changes will be made and by whom.
  2. Configuration changes to the Ansible Hardening playbook must be initiated by creating a Pull Request in GitHub.
    • The Systems Engineering Team member must test their configuration change locally when possible, or on a development and/or staging sandbox otherwise.
    • At least one other Systems Engineering Team member must review the change before being dpeloyed to produciton.
  3. In all cases, before rolling out the change to production, the Systems Engineering Team member must file an Issue in the DT project describing the change. This Issue must link to the reviewed Merge Request and/or include a link to the runbook.
  4. Once the request has been approved by the CTO, the Systems Engineering Team member may roll out the change into production environments.

9.5 Patch Management Procedures

  1. RxRevu uses automated tooling to ensure systems are up-to-date with the latest security patches.
  2. If systems or system components are no longer supported, and they need to be replaced, the System Provisioning Process is used to ensure consideration is given to security constraints and alignment with business neeeds.

9.6 Software Development Procedures

  1. All development uses feature branches based on the main branch used for the current release. Any changes required for a new feature or defect fix are committed to that feature branch.
    • All changes to code interacting with ePHI must be covered under 1) a unit test where possible, or 2) integration tests.
  2. When writing software, coding best practices must be followed.
    • Input validation is required to protect against code and/or SQL injection.
  3. Developers are strongly encouraged to follow the commit message conventions suggested by GitHub.
    • Commit messages should be wrapped to 72 characters.
    • Commit messages should be written in the present tense. This convention matches up with commit messages generated by commands like git merge and git revert.
  4. Once the feature and corresponding tests are complete, a pull request will be created using the GitHub/GitLab web interface. The pull request should indicate which feature or defect is being addressed and should provide a high-level description of the changes made.
  5. Code reviews are performed as part of the pull request procedure. Once a change is ready for review, the author(s) will notify other engineers using an appropriate mechanism, typically via automated Slack notifications or emails from GitHub.
    • Other engineers will review the changes, using the guidelines above.
    • Engineers should note all potential issues with the code; it is the responsibility of the author(s) to address those issues or explain why they are not applicable.
  6. If the feature or defect interacts with ePHI, or controls access to data potentially containing ePHI, the code changes must be reviewed by one member of RxRevu’s Blue Team (software security team) before the feature is marked as complete.
    • The Blue Team members will provide a security analysis of features to ensure they satisfy RxRevu’s compliance and security commitments.
    • This review must include a security analysis for potential vulnerabilities such as those listed in the OWASP Top 10 or the CWE top 25.
    • This review must also verify that any actions performed by authenticated users will generate appropriate audit log entries.
    • Blue Team members are required to undergo annual training on identifying the most common software vulnerabilities and will receive ongoing training on RxRevu’s compliance and security requirements.
  7. Once the review process finishes, the original author(s) may merge their change into the release, or develop, branch.
  8. Development procedures are reviewed quarterly.
  9. The code base is reviewed quarterly, through manual and automated mechanisms, to ensure compliance with secure software development best practices.

9.7 Software Release Procedures

  1. Software releases are treated as changes to existing systems and thus follow the procedure described in §9.4.

10. Facility Access Policy

RxRevu works with Subcontractors to assure restriction of physical access to systems used as part of the RxRevu Platform. RxRevu and its Subcontractors control access to the physical buildings/facilities that house these systems/applications, or in which RxRevu workforce members operate, in accordance to the HIPAA Security Rule 164.310 and its implementation specifications. Physical Access to all of RxRevu facilities is limited to only those authorized in this policy. In an effort to safeguard ePHi from unauthorized access, tampering, and theft, access is allowed to areas only to those persons authorized to be in them and with escorts for unauthorized persons. All workforce members are responsible for reporting an incident of unauthorized visitor and/or unauthorized access to RxRevu’s facility.

Of note, RxRevu does not have ready access to ePHI, it provides cloud-based, compliant software, primarily to covered entities. RxRevu does not physically house any systems used by its Platform in RxRevu facilities. Physical security of our Platform servers is outlined in §1.4.

10.1 Applicable Standards

10.1.1 Applicable Standards from the HITRUST Common Security Framework

10.1.2 Applicable Standards from the HIPAA Security Rule

10.2 RxRevu-controlled Facility Access Policies

  1. Visitor and third party support access is supervised. All visitors are escorted.
  2. Repairs are documented and the documentation is retained.
  3. Fire extinguishers and detectors are installed according to applicable laws and regulations.
  4. Maintenance is controlled and conducted by authorized personnel in accordance with supplier-recommended intervals, insurance policies and the organization’s maintenance program.
  5. Electronic and physical media containing covered information is securely destroyed (or the information securely removed) prior to disposal.
  6. The organization securely disposes media with sensitive information.
  7. Physical access is restricted using smart locks that track all access.
    • Restricted areas and facilities are locked when unattended (where feasible).
    • Only authorized workforce members receive access to restricted areas (as determined by the Security Officer).
    • Access and keys are revoked upon termination of workforce members.
    • Workforce members must report a lost and/or stolen key(s) to the Security Officer.
    • The Security Officer facilitates the changing of the lock(s) within 7 days of a key being reported lost/stolen
  8. Enforcement of Facility Access Policies
    • Report violations of this policy to the restricted area’s department team leader, supervisor, manager, or director, or the Privacy Officer.
    • Workforce members in violation of this policy are subject to disciplinary action, up to and including termination.
    • Visitors in violation of this policy are subject to loss of vendor privileges and/or termination of services from RxRevu.
  9. Workstation Security
    • Workstations may only be accessed and utilized by authorized workforce members to complete assigned job/contract responsibilities.
    • All workforce members are required to monitor workstations and report unauthorized users and/or unauthorized attempts to access systems/applications as per the System Access Policy.
    • All workstations purchased by RxRevu are the property of RxRevu and are distributed to users by the company.

11. Incident Response Policy

RxRevu implements an information security incident response process to consistently detect, respond, and report incidents, minimize loss and destruction, mitigate the weaknesses that were exploited, and restore information system functionality and business continuity as soon as possible.

The incident response process addresses:

Note: These policies were adapted from work by the HIPAA Collaborative of Wisconsin Security Networking Group. Refer to the linked document for additional copyright information.

11.1 Applicable Standards

11.1.1 Applicable Standards from the HITRUST Common Security Framework

11.1.2 Applicable Standards from the HIPAA Security Rule

11.2 Incident Management Policies

The RxRevu incident response process follows the process recommended by SANS, an industry leader in security. Process flows are a direct representation of the SANS process which can be found in this document. The Security Officer has the authority to direct actions required in all phases of the incident response process.

RxRevu’s incident response classifies security-related events into the following categories:

RxRevu employees must report any unauthorized or suspicious activity seen on production systems or associated with related communication systems (such as email or Slack). In practice this means keeping an eye out for security events, and letting the Security Officer know about any observed precursors or indications as soon as they are discovered.

11.2.1 Identification Phase

  1. Immediately upon observation RxRevu members report suspected and known Events, Precursors, Indications, and Incidents in one of the following ways:
    1. Direct report to management, the Security Officer, Privacy Officer, or other;
    2. Email;
    3. Phone call;
    4. Online incident response form located here;
    5. Secure Chat.
    6. Anonymously through workforce members desired channels.
  2. The individual receiving the report facilitates completion of an Incident Identification form and notifies the Security Officer (if not already done).
  3. The Security Officer determines if the issue is an Event, Precursor, Indication, or Incident.
    1. If the issue is an event, indication, or precursor the Security Officer forwards it to the appropriate resource for resolution.
      1. Non-Technical Event (minor infringement): the Security Officer completes a SIR Form and investigates the incident.
      2. Technical Event: Assign the issue to an IT resource for resolution. This resource may also be a contractor or outsourced technical resource, in the event of a small office or lack of expertise in the area.
    2. If the issue is a security incident the Security Officer activates the Security Incident Response Team (SIRT) and notifies senior management.
      1. If a non-technical security incident is discovered the SIRT completes the investigation, implements preventative measures, and resolves the security incident.
      2. Once the investigation is completed, progress to Phase V, Follow-up.
      3. If the issue is a technical security incident, commence to Phase II: Containment.
      4. The Containment, Eradication, and Recovery Phases are highly technical. It is important to have them completed by a highly qualified technical security resource with oversight by the SIRT team.
      5. Each individual on the SIRT and the technical security resource document all measures taken during each phase, including the start and end times of all efforts.
      6. The lead member of the SIRT team facilitates initiation of a SIR Form or an Incident Survey Form. The intent of the SIR form is to provide a summary of all events, efforts, and conclusions of each Phase of this policy and procedures.
  4. The Security Officer, Privacy Officer, or RxRevu representative appointed notifies any affected Customers, Partners, relevant CERTs and law enforcement agencies. If no Customers and Partners are affected, notification is at the discretion of the Security and Privacy Officer.
  5. In the case of a threat identified, the Security Officer is to form a team to investigate and involve necessary resources, both internal to RxRevu and potentially external.

11.2.2 Containment Phase (Technical)

In this Phase, RxRevu’s IT department attempts to contain the security incident. It is extremely important to take detailed notes during the security incident response process. This provides that the evidence gathered during the security incident can be used successfully during prosecution, if appropriate.

  1. The SIRT reviews any information that has been collected by the Security Officer or any other individual investigating the security incident.
  2. The SIRT secures the network perimeter.
  3. The IT department performs the following:
    1. Securely connect to the affected system over a trusted connection.
    2. Retrieve any volatile data from the affected system.
    3. Determine the relative integrity and the appropriateness of backing the system up.
    4. If appropriate, back up the system.
    5. Change the password(s) to the affected system(s).
    6. Determine whether it is safe to continue operations with the affect system(s).
    7. If it is safe, allow the system to continue to function;
      1. Complete any documentation relative to the security incident on the SIR Form.
      2. Move to Phase V, Follow-up.
    8. If it is NOT safe to allow the system to continue operations, discontinue the system(s) operation and move to Phase III, Eradication.
    9. The individual completing this phase provides written communication to the SIRT.
  4. Continuously apprise Senior Management of progress.
  5. Continue to notify affected Customers and Partners with relevant updates as needed

11.2.3 Eradication Phase (Technical)

The Eradication Phase represents the SIRT’s effort to remove the cause, and the resulting security exposures, that are now on the affected system(s).

  1. Determine symptoms and cause related to the affected system(s).
  2. Strengthen the defenses surrounding the affected system(s), where possible (a risk assessment may be needed and can be determined by the Security Officer). This may include the following:
    1. An increase in network perimeter defenses.
    2. An increase in system monitoring defenses.
    3. Remediation (“fixing”) any security issues within the affected system, such as removing unused services/general host hardening techniques.
  3. Conduct a detailed vulnerability assessment to verify all the holes/gaps that can be exploited have been addressed.
    1. If additional issues or symptoms are identified, take appropriate preventative measures to eliminate or minimize potential future compromises.
  4. Complete the Eradication Form.
  5. Update the documentation with the information learned from the vulnerability assessment, including the cause, symptoms, and the method used to fix the problem with the affected system(s).
  6. Apprise Senior Management of the progress.
  7. Continue to notify affected Customers and Partners with relevant updates as needed.
  8. Move to Phase IV, Recovery.

11.2.4 Recovery Phase (Technical)

The Recovery Phase represents the SIRT’s effort to restore the affected system(s) back to operation after the resulting security exposures, if any, have been corrected.

  1. The technical team determines if the affected system(s) have been changed in any way.
    1. If they have, the technical team restores the system to its proper, intended functioning (“last known good”).
    2. Once restored, the team validates that the system functions the way it was intended/had functioned in the past. This may require the involvement of the business unit that owns the affected system(s).
    3. If operation of the system(s) had been interrupted (i.e., the system(s) had been taken offline or dropped from the network while triaged), restart the restored and validated system(s) and monitor for behavior.
    4. If the system had not been changed in any way, but was taken offline (i.e., operations had been interrupted), restart the system and monitor for proper behavior.
    5. Update the documentation with the detail that was determined during this phase.
    6. Apprise Senior Management of progress.
    7. Continue to notify affected Customers and Partners with relevant updates as needed.
    8. Move to Phase V, Follow-up.

11.2.5 Follow-up Phase (Technical and Non-Technical)

The Follow-up Phase represents the review of the security incident to look for “lessons learned” and to determine whether the process that was taken could have been improved in any way. It is recommended all security incidents be reviewed shortly after resolution to determine where response could be improved. Timeframes may extend to one to two weeks post-incident.

  1. Responders to the security incident (SIRT Team and technical security resource) meet to review the documentation collected during the security incident.
  2. If workforce sanctions are necessary, initiate the process for taking disciplinary action and/or limiting access, using the formal sanctions process.
  3. Create a “lessons learned” document and attach it to the completed SIR Form.
    1. Evaluate the cost and impact of the security incident to RxRevu using the documents provided by the SIRT and the technical security resource.
    2. Determine what could be improved.
    3. Communicate these findings to Senior Management for approval and for implementation of any recommendations made post-review of the security incident.
    4. Carry out recommendations approved by Senior Management; sufficient budget, time and resources should be committed to this activity.
    5. Ensure the Incident Response Process, training materials, testing, and monitoring protocols are updated, if appropriate.
    6. Close the security incident.

11.2.6 Periodic Evaluation

It is important to note that the processes surrounding security incident response should be periodically reviewed and evaluated for effectiveness. This also involves appropriate training of resources expected to respond to security incidents, as well as the training of the general population regarding RxRevu’s expectation for them, relative to security responsibilities. The incident response plan is tested annually.

11.3 Security Incident Response Team (SIRT)

Current members of the RxRevu SIRT:

12. Breach Policy

To provide guidance for breach notification when impressive or unauthorized access, acquisition, use and/or disclosure of the ePHI occurs. Breach notification will be carried out in compliance with the American Recovery and Reinvestment Act (ARRA)/Health Information Technology for Economic and Clinical Health Act (HITECH) as well as any other federal or state notification law.

The Federal Trade Commission (FTC) has published breach notification rules for vendors of personal health records as required by ARRA/HITECH. The FTC rule applies to entities not covered by HIPAA, primarily vendors of personal health records. The rule is effective September 24, 2009 with full compliance required by February 22, 2010.

The American Recovery and Reinvestment Act of 2009 (ARRA) was signed into law on February 17, 2009. Title XIII of ARRA is the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH significantly impacts the Health Insurance Portability and Accountability (HIPAA) Privacy and Security Rules. While HIPAA did not require notification when patient protected health information (PHI) was inappropriately disclosed, covered entities and business associates may have chosen to include notification as part of the mitigation process. HITECH does require notification of certain breaches of unsecured PHI to the following: individuals, Department of Health and Human Services (HHS), and the media. The effective implementation for this provision is September 23, 2009 (pending publication HHS regulations).

In the case of a breach, RxRevu shall notify all affected Customers. It is the responsibility of the Customers to notify affected individuals.

12.1 Applicable Standards

12.1.1 Applicable Standards from the HITRUST Common Security Framework

12.1.2 Applicable Standards from the HIPAA Security Rule

12.2 RxRevu Breach Policy

  1. Discovery of Breach: A breach of ePHI shall be treated as “discovered” as of the first day on which such breach is known to the organization, or, by exercising reasonable diligence would have been known to RxRevu (includes breaches by the organization’s Customers, Partners, or subcontractors). RxRevu shall be deemed to have knowledge of a breach if such breach is known or by exercising reasonable diligence would have been known, to any person, other than the person committing the breach, who is a workforce member or Partner of the organization. Following the discovery of a potential breach, the organization shall begin an investigation (see organizational policies for security incident response and/or risk management incident response) immediately, conduct a risk assessment, and based on the results of the risk assessment, begin the process to notify each Customer affected by the breach. RxRevu shall also begin the process of determining what external notifications are required or should be made (e.g., Secretary of Department of Health & Human Services (HHS), media outlets, law enforcement officials, etc.)
  2. Breach Investigation: The RxRevu Security Officer shall name an individual to act as the investigator of the breach (e.g., privacy officer, security officer, risk manager, etc.). The investigator shall be responsible for the management of the breach investigation, completion of a risk assessment, and coordinating with others in the organization as appropriate (e.g., administration, security incident response team, human resources, risk management, public relations, legal counsel, etc.) The investigator shall be the key facilitator for all breach notification processes to the appropriate entities (e.g., HHS, media, law enforcement officials, etc.). All documentation related to the breach investigation, including the risk assessment, shall be retained for a minimum of six years. A template breach log is located here.
  3. Risk Assessment: For an acquisition, access, use or disclosure of ePHI to constitute a breach, it must constitute a violation of the HIPAA Privacy Rule. A use or disclosure of ePHI that is incident to an otherwise permissible use or disclosure and occurs despite reasonable safeguards and proper minimum necessary procedures would not be a violation of the Privacy Rule and would not qualify as a potential breach. To determine if an impermissible use or disclosure of ePHI constitutes a breach and requires further notification, the organization will need to perform a risk assessment to determine if there is significant risk of harm to the individual as a result of the impermissible use or disclosure. The organization shall document the risk assessment as part of the investigation in the incident report form noting the outcome of the risk assessment process. The organization has the burden of proof for demonstrating that all notifications to appropriate Customers or that the use or disclosure did not constitute a breach. Based on the outcome of the risk assessment, the organization will determine the need to move forward with breach notification. The risk assessment and the supporting documentation shall be fact specific and address:
    • Consideration of who impermissibly used or to whom the information was impermissibly disclosed;
    • The type and amount of ePHI involved;
    • The cause of the breach, and the entity responsible for the breach, either Customer, RxRevu, or Partner.
    • The potential for significant risk of financial, reputational, or other harm.
  4. Timeliness of Notification: Upon discovery of a breach, notice shall be made to the affected RxRevu Customers no later than 4 hours after the discovery of the breach. It is the responsibility of the organization to demonstrate that all notifications were made as required, including evidence demonstrating the necessity of delay.
  5. Delay of Notification Authorized for Law Enforcement Purposes: If a law enforcement official states to the organization that a notification, notice, or posting would impede a criminal investigation or cause damage to national security, the organization shall:
    • If the statement is in writing and specifies the time for which a delay is required, delay such notification, notice, or posting of the timer period specified by the official; or
    • If the statement is made orally, document the statement, including the identify of the official making the statement, and delay the notification, notice, or posting temporarily and no longer than 30 days from the date of the oral statement, unless a written statement as described above is submitted during that time.
  6. Content of the Notice: The notice shall be written in plain language and must contain the following information:
    • A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if known;
    • A description of the types of unsecured protected health information that were involved in the breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, disability code or other types of information were involved), if known;
    • Any steps the Customer should take to protect Customer data from potential harm resulting from the breach.
    • A brief description of what RxRevu is doing to investigate the breach, to mitigate harm to individuals and Customers, and to protect against further breaches.
    • Contact procedures for individuals to ask questions or learn additional information, which may include a toll-free telephone number, an e-mail address, a web site, or postal address.
  7. Methods of Notification: RxRevu Customers will be notified via email and phone within the timeframe for reporting breaches, as outlined above.
  8. Maintenance of Breach Information/Log: As described above and in addition to the reports created for each incident, RxRevu shall maintain a process to record or log all breaches of unsecured ePHI regardless of the number of records and Customers affected. The following information should be collected/logged for each breach (see sample Breach Notification Log):
    • A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
    • A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
    • A description of the action taken with regard to notification of patients regarding the breach.
    • Resolution steps taken to mitigate the breach and prevent future occurrences.
  9. Workforce Training: RxRevu shall train all members of its workforce on the policies and procedures with respect to ePHI as necessary and appropriate for the members to carry out their job responsibilities. Workforce members shall also be trained as to how to identify and report breaches within the organization.
  10. Complaints: RxRevu must provide a process for individuals to make complaints concerning the organization’s patient privacy policies and procedures or its compliance with such policies and procedures.
  11. Sanctions: The organization shall have in place and apply appropriate sanctions against members of its workforce, Customers, and Partners who fail to comply with privacy policies and procedures.
  12. Retaliation/Waiver: RxRevu may not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against any individual for the exercise by the individual of any privacy right. The organization may not require individuals to waive their privacy rights under as a condition of the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits.

12.3 RxRevu Platform Customer Responsibilities

  1. The RxRevu Customer that accesses, maintains, retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses unsecured ePHI shall, without unreasonable delay and in no case later than 60 calendar days after discovery of a breach, notify RxRevu of such breach. The Customer shall provide RxRevu with the following information:
    • A description of what happened, including the date of the breach, the date of the discovery of the breach, and the number of records and Customers affected, if known.
    • A description of the types of unsecured protected health information that were involved in the breach (such as full name, Social Security number, date of birth, home address, account number, etc.), if known.
    • A description of the action taken with regard to notification of patients regarding the breach.
    • Resolution steps taken to mitigate the breach and prevent future occurrences.
  2. Notice to Media: RxRevu Customers are responsible for providing notice to prominent media outlets at the Customer’s discretion.
  3. Notice to Secretary of HHS: RxRevu Customers are responsible for providing notice to the Secretary of HHS at the Customer’s discretion.

12.4 Sample Letter to Customers in Case of Breach

[Date]

[Name] [Name of Customer] [Address 1] [Address 2] [City, State Zip Code]

Dear [Name of Customer]:

I am writing to you from RxRevu, Inc., with important information about a recent breach that affects your account with us. We became aware of this breach on [Insert Date] which occurred on or about [Insert Date]. The breach occurred as follows:

Describe event and include the following information:

Other Optional Considerations:

We will assist you in remedying the situation.

Sincerely,

Peregrin Marshall Co-founder - RxRevu, Inc.
peregrin.marshall@rxrevu.com 720-839-3893

13. Disaster Recovery Policy

The RxRevu Contingency Plan establishes procedures to recover RxRevu following a disruption resulting from a disaster. This Disaster Recovery Policy is maintained by the RxRevu Security Officer and Privacy Officer.

The following objectives have been established for this plan:

  1. Maximize the effectiveness of contingency operations through an established and distributed plan that consists of the following phases:
    • Notification/Activation phase to detect and assess damage and to activate the plan;
    • Recovery phase to restore temporary IT operations and recover damage done to the original system;
    • Reconstitution phase to restore IT system processing capabilities to normal operations.
  2. Identify the activities, resources, and procedures needed to carry out RxRevu processing requirements during prolonged interruptions to normal operations.
  3. Identify and define the impact of interruptions to RxRevu systems.
  4. Assign responsibilities to designated personnel and provide guidance for recovering RxRevu during prolonged periods of interruption to normal operations.
  5. Ensure coordination with other RxRevu staff who will participate in the contingency planning strategies.
  6. Ensure coordination with external points of contact and vendors who will participate in the contingency planning strategies.

This RxRevu Contingency Plan has been developed as required under the Office of Management and Budget (OMB) Circular A-130, Management of Federal Information Resources, Appendix III, November 2000, and the Health Insurance Portability and Accountability Act (HIPAA) Final Security Rule, Section §164.308(a)(7), which requires the establishment and implementation of procedures for responding to events that damage systems containing electronic protected health information.

This RxRevu Contingency Plan is created under the legislative requirements set forth in the Federal Information Security Management Act (FISMA) of 2002 and the guidelines established by the National Institute of Standards and Technology (NIST) Special Publication (SP) 800-34, titled “Contingency Planning Guide for Information Technology Systems” dated June 2002.

The RxRevu Contingency Plan also complies with the following federal and departmental policies:

Example of the types of disasters that would initiate this plan are natural disaster, political disturbances, man made disaster, external human threats, internal malicious activities.

RxRevu defined two categories of systems from a disaster recovery perspective.

  1. Critical Systems. These systems host application servers and database servers or are required for functioning of systems that host application servers and database servers. These systems, if unavailable, affect the integrity of data and must be restored, or have a process begun to restore them, immediately upon becoming unavailable.
  2. Non-critical Systems. These are all systems not considered critical by definition above. These systems, while they may affect the performance and overall security of critical systems, do not prevent Critical systems from functioning and being accessed appropriately. These systems are restored at a lower priority than critical systems.

13.1 Applicable Standards

13.1.1 Applicable Standards from the HITRUST Common Security Framework

13.1.2 Applicable Standards from the HIPAA Security Rule

13.2 Line of Succession

The following order of succession to ensure that decision-making authority for the RxRevu Contingency Plan is uninterrupted. The Chief Technology Officer (CTO) is responsible for ensuring the safety of personnel and the execution of procedures documented within this RxRevu Contingency Plan. If the CTO is unable to function as the overall authority or chooses to delegate this responsibility to a successor, the CEO or COO shall function as that authority. To provide contact initiation should the contingency plan need to be initiated, please use the contact list below.

13.3 Responsibilities

The following teams have been developed and trained to respond to a contingency event affecting the IT system.

  1. The Systems Engineering Team is responsible for recovery of the RxRevu hosted environment, network devices, and all servers. Members of the team include personnel who are also responsible for the daily operations and maintenance of RxRevu. The team leader is the CTO and directs the Systems Engineering Team.
  2. The Software Development Team is responsible for assuring all application servers, web services, and platform features are working. It is also responsible for testing redeployments and assessing damage to the environment. The team leader is the CTO and directs the Software Development Team.

Members of the Systems Engineering Team and Software Development Team must maintain local copies of the contact information from §13.2. Additionally, the CTO must maintain a local copy of this policy in the event Internet access is not available during a disaster scenario.

13.4 Testing and Maintenance

The CTO shall establish criteria for validation/testing of a Contingency Plan, an annual test schedule, and ensure implementation of the test. This process will also serve as training for personnel involved in the plan’s execution. At a minimum the Contingency Plan shall be tested annually (within 365 days). The types of validation/testing exercises include tabletop and technical testing. Contingency Plans for all application systems must be tested at a minimum using the tabletop testing process. However, if the application system Contingency Plan is included in the technical testing of their respective support systems that technical test will satisfy the annual requirement.

13.4.1 Tabletop Testing

Tabletop Testing is conducted in accordance with the the CMS Risk Management Handbook, Volume 2. The primary objective of the tabletop test is to ensure designated personnel are knowledgeable and capable of performing the notification/activation requirements and procedures as outlined in the CP, in a timely manner. The exercises include, but are not limited to:

13.4.2 Technical Testing

The primary objective of the technical test is to ensure the communication processes and data storage and recovery processes can function at an alternate site to perform the functions and capabilities of the system within the designated requirements. Technical testing shall include, but is not limited to:

13.5 Disaster Recovery Procedures

13.5.1 Notification and Activation Phase

This phase addresses the initial actions taken to detect and assess damage inflicted by a disruption to RxRevu. Based on the assessment of the Event, sometimes according to the RxRevu Incident Response Policy, the Contingency Plan may be activated by either the CTO.

The notification sequence is listed below:

13.5.2 Recovery Phase

This section provides procedures for recovering the application at an alternate site, whereas other efforts are directed to repair damage to the original system and capabilities.

The following procedures are for recovering the RxRevu infrastructure at the alternate site. Procedures are outlined per team required. Each procedure should be executed in the sequence it is presented to maintain efficient operations.

Recovery Goal: The goal is to rebuild RxRevu infrastructure to a production state.

The tasks outlined below are not sequential and some can be run in parallel.

  1. Contact Partners and Customers affected - Client Services
  2. Assess damage to the environment - AWS/Systems Engineering
  3. Begin replication of new AWS environment using automated and tested scripts, currently CloudFormation templates and Ansible playbooks. - Systems Engineering
  4. Test new environment using pre-written tests - Software Development
  5. Test logging, security, and alerting functionality - Systems Engineering
  6. Assure systems are appropriately patched and up to date. - Systems Engineering
  7. Deploy environment to production - Systems Engineering
  8. Update DNS to new environment. - Systems Engineering

13.5.3 Reconstitution Phase

This section discusses activities necessary for restoring RxRevu operations at the original or new site. The goal is to restore full operations within 24 hours of a disaster or outage. When the hosted data center at the original or new site has been restored, RxRevu operations at the alternate site may be transitioned back. The goal is to provide a seamless transition of operations from the alternate site to the computer center.

  1. Original or New Site Restoration
    • Begin replication of new environment using automated and tested scripts, currently CloudFormation templates and Ansible playbooks. - Systems Engineering
    • Test new environment using pre-written tests. - Software Development
    • Test logging, security, and alerting functionality. - Systems Engineering
    • Deploy environment to production - Systems Engineering
    • Assure systems are appropriately patched and up to date. - Systems Engineering
    • Update DNS to new environment. - Systems Engineering
  2. Plan Deactivation
    • If the RxRevu environment is moved back to the original site from the alternative site, all hardware used at the alternate site should be handled and disposed of according to the RxRevu Media Disposal Policy.
  3. Create a “lessons learned” document and attach it to the completed SIR Form.
    • Determine what could be improved.
    • Communicate these findings to Senior Management for approval and for implementation of any recommendations made post-review of the security incident.
    • Ensure the Disaster Recovery Process, training materials, testing, and monitoring protocols are updated, if appropriate.

14. Disposable Media Policy

RxRevu recognizes that media containing ePHI may be reused when appropriate steps are taken to ensure that all stored ePHI has been effectively rendered inaccessible. Destruction/disposal of ePHI shall be carried out in accordance with federal and state law. The schedule for destruction/disposal shall be suspended for ePHI involved in any open investigation, audit, or litigation.

RxRevu utilizes dedicated hardware from Subcontractors. ePHI is only stored on SSD volumes in our hosted environment. All SSD volumes utilized by RxRevu and RxRevu Customers are encrypted. RxRevu does not use, own, or manage any mobile devices, SD cards, or tapes that have access to ePHI.

14.1 Applicable Standards

14.1.1 Applicable Standards from the HITRUST Common Security Framework

14.1.2 Applicable Standards from the HIPAA Security Rule

14.2 Disposable Media Policy

  1. All removable media is restricted, audited, and is encrypted.
  2. RxRevu assumes all disposable media in its Platform may contain ePHI, so it treats all disposable media with the same protections and disposal policies.
  3. All destruction/disposal of ePHI media will be done in accordance with federal and state laws and regulations and pursuant to the RxRevu’s written retention policy/schedule. Records that have satisfied the period of retention will be destroyed/disposed of in an appropriate manner.
  4. Records involved in any open investigation, audit or litigation should not be destroyed/disposed of. If notification is received that any of the above situations have occurred or there is the potential for such, the record retention schedule shall be suspended for these records until such time as the situation has been resolved. If the records have been requested in the course of a judicial or administrative hearing, a qualified protective order will be obtained to ensure that the records are returned to the organization or properly destroyed/disposed of by the requesting party.
  5. Before reuse of any media, for example all ePHI is rendered inaccessible, cleaned, or scrubbed. All media is formatted to restrict future access.
  6. All RxRevu Subcontractors provide that, upon termination of the contract, they will return or destroy/dispose of all patient health information. In cases where the return or destruction/disposal is not feasible, the contract limits the use and disclosure of the information to the purposes that prevent its return or destruction/disposal.
  7. Any media containing ePHI is disposed using a method that ensures the ePHI could not be readily recovered or reconstructed.
  8. The methods of destruction, disposal, and reuse are reassessed periodically, based on current technology, accepted practices, and availability of timely and cost-effective destruction, disposal, and reuse technologies and services.
  9. In the cases of a RxRevu Customer terminating a contract with RxRevu and no longer utilizing RxRevu Services, the following actions will be taken depending on the RxRevu Services in use. In all cases it is solely the responsibility of the RxRevu Customer to maintain the safeguards required of HIPAA once the data is transmitted out of RxRevu Systems. RxRevu will provide the customer with the ability to export data in commonly used format, currently CSV, for 30 days from the time of termination.

15. IDS Policy

In order to preserve the integrity of data that RxRevu stores, processes, or transmits for Customers, RxRevu implements strong intrusion detection tools and policies to proactively track and retroactively investigate unauthorized access. RxRevu currently utilizes Falco to track file system integrity and detect rootkit access.

15.1 Applicable Standards

15.1.1 Applicable Standards from the HITRUST Common Security Framework

15.1.2 Applicable Standards from the HIPAA Security Rule

15.2 Intrusion Detection Policy

  1. Reports and logs generated by Falco are reviewed by the Security Officer on a weekly basis.
  2. Falco generates alerts to analyze and investigate suspicious activity or suspected violations.
  3. Falco monitors file system integrity and sends real time alerts when suspicious changes are made to the file system.
  4. Automatic monitoring is done to identify patterns that might signify the lack of availability of certain services and systems (DoS attacks).
  5. RxRevu firewalls monitor all incoming traffic to detect potential denial of service attacks. Suspected attack sources are blocked automatically. Additionally, our hosting provider actively monitors its network to detect denial of services attacks.
  6. New firewall rules and configuration changes are tested before being pushed into production.
  7. RxRevu utilizes redundant firewall on network perimeters.
  8. Local network firewalls, configurations and connections are reviewed quarterly.

16. Vulnerability Scanning Policy

RxRevu is proactive about information security and understands that vulnerabilities need to be monitored on an ongoing basis. RxRevu utilizes OpenVAS to consistently scan, identify, and address vulnerabilities on our systems. We also utilize Falco on all managed systems, for file integrity checking and intrusion detection.

16.1 Applicable Standards

16.1.1 Applicable Standards from the HITRUST Common Security Framework

16.1.2 Applicable Standards from the HIPAA Security Rule

16.2 Vulnerability Scanning Policy

  1. OpenVAS management is performed by the RxRevu Security Officer, or an authorized delegate of the Security Officer.
  2. OpenVAS is used to monitor all internal IP addresses (servers, VMs, etc) on RxRevu networks.
  3. Frequency of scanning is as follows:
    1. on a weekly basis;
    2. after every production deployment.
  4. Reviewing OpenVAS reports and findings, as well as any further investigation into discovered vulnerabilities, is the responsibility of the RxRevu Security Officer. The process for reviewing OpenVAS reports is outlined below:
    1. The Security Officer initiates the review of a OpenVAS Report by initiating a Vulnerability Scanning Process in Asana.
    2. The Security Officer, or a RxRevu Security Engineer assigned by the Security Officer, is assigned to review the OpenVAS Report.
    3. If new vulnerabilities are found during review, the process outlined below is used to test those vulnerabilities. Once those steps are completed, the Issue is then reviewed again.
    4. Once the review is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review.
    5. If the review is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
  5. In the case of new vulnerabilities, the following steps are taken:
    • All new vulnerabilities are verified manually to assure they are repeatable. Those not found to be repeatable are manually tested after the next vulnerability scan, regardless of if the specific vulnerability is discovered again.
    • Vulnerabilities that are repeatable manually are documented and reviewed by the Security Officer and Privacy Officer to see if they are part of the current risk assessment performed by RxRevu.
    • Those that are a part of the current risk assessment are checked for mitigations.
    • Those that are not part of the current risk assessment trigger a new risk assessment, and this process is outlined in detail in the RxRevu Risk Assessment Policy.
  6. All vulnerability scanning reports are retained for 6 years by RxRevu. Vulnerability report review is monitored on a quarterly basis using Asana reporting to assess compliance with above policy.
  7. Penetration testing is performed regularly as part of the RxRevu vulnerability management policy.
    • External penetration testing is performed annually by a third party.
    • Internal vulnerability scanning is performed quarterly. Below is the process used to conduct internal vulnerability scans.
      1. The Security Officer initiates the Vulnerability Scanning Process in Asana.
      2. The Security Officer, or a RxRevu Security Engineer assigned by the Security Officer, is assigned to conduct the vulnerability scan.
      3. Gaps and vulnerabilities identified during vulnerability scans are reviewed, with plans for correction and/or mitigation, by the RxRevu Security Officer before the Issue can move to be approved.
      4. Once the testing is completed, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further testing and review.
      5. If the Issue is approved, the Security Officer then marks the Issue as Done, adding any pertinent notes required.
    • Penetration tests results are retained for 6 years by RxRevu.
    • Following receipt of penetration tests results, the findings are reported to management and corrective action is taken, as necessary.
    • Internal vulnerability scanning is monitored on an quarterly basis using Asana reporting to assess compliance with above policy.
  8. This vulnerability policy is reviewed on a quarterly basis by the Security Officer and Privacy Officer.

17. Data Integrity Policy

RxRevu takes data integrity very seriously. As stewards and partners of RxRevu Customers, we strive to assure data is protected from unauthorized access and that it is available when needed. The following policies drive many of our procedures and technical settings in support of the RxRevu mission of data protection.

Production systems that create, receive, store, or transmit Customer data (hereafter “Production Systems”) must follow the guidelines described in this section.

17.1 Applicable Standards

17.1.1 Applicable Standards from the HITRUST Common Security Framework

17.1.2 Applicable Standards from the HIPAA Security Rule

17.2 Disabling Non-Essential Services

  1. All Production Systems must disable services that are not required to achieve the business purpose or function of the system.

17.3 Monitoring Log-in Attempts

  1. All access to Production Systems must be logged. This is done following the RxRevu Auditing Policy.

17.4 Prevention of Malware on Production Systems

  1. All managed servers in the production system must have Falco running, and set to scan system every 2 hours and at reboot to assure not malware is present. Detected malware is evaluated and removed.
  2. Virus scanning software is run on all Production Systems for anti-virus protection.
    • Hosts are scanned daily for malicious binaries in critical system paths.
    • The malware signature database is checked daily and automatically updated if new signatures are available.
    • Logs of virus scans are maintained according to the requirements outlined in §8.6.
  3. All Production Systems are to only be used for RxRevu business needs.

17.5 Patch Management

  1. Software patches and updates will be applied to all systems in a timely manner. In the case of routine updates, they will be applied after thorough testing. In the case of updates to correct known vulnerabilities, priority will be given to testing to speed the time to production. Critical security patches are applied within 30 days from testing and all security patches are applied within 90 days after testing.
  2. Administrators subscribe to mailing lists to ensure that they are using current versions of all RxRevu-managed software on Production Systems.

17.6 Intrusion Detection and Vulnerability Scanning

  1. Production systems are monitored using IDS systems. Suspicious activity is logged and alerts are generated.
  2. Vulnerability scanning of Production Systems must occur on a predetermined, regular basis, no less than annually. Currently it is quarterly. Scans are reviewed by Security Officer, with defined steps for risk mitigation, and retained for future reference.

17.7 Production System Security

  1. System, network, and server security is managed and maintained by the Security Officer in conjunction with the Systems Engineering Team.
  2. Up to date system lists and architecture diagrams are kept for all production environments, and reviewed quarterly.
  3. Access to Production Systems is controlled using centralized tools and two-factor authentication.

17.8 Production Data Security

  1. Reduce the risk of compromise of Production Data.
  2. Implement and/or review controls designed to protect Production Data from improper alteration or destruction.
  3. Ensure that confidential data is stored in a manner that supports user access logs and automated monitoring for potential security incidents.
  4. Ensure RxRevu Customer Production Data is segmented and only accessible to Customers authorized to access data.
  5. All Production Data at rest is stored on encrypted volumes using encryption keys managed by RxRevu. Encryption at rest is ensured through the use of automated deployment scripts referenced in the Configuration Management Policy.
  6. Volume encryption keys and machines that generate volume encryption keys are protected from unauthorized access. Volume encryption key material is protected with access controls such that the key material is only accessible by privileged accounts.
  7. Encrypted volumes use AES encryption with a minimum of 256-bit keys, or keys and ciphers of equivalent or higher cryptographic strength.

17.9 Transmission Security

  1. All data transmission is encrypted end to end using encryption keys managed by RxRevu. Encryption is not terminated at the network end point, and is carried through to the application.
  2. Transmission encryption keys and machines that generate keys are protected from unauthorized access. Transmission encryption key material is protected with access controls such that the key material is only accessible by privileged accounts.
  3. Transmission encryption keys use a minimum of 4096-bit RSA keys, or keys and ciphers of equivalent or higher cryptographic strength (e.g., 256-bit AES session keys in the case of IPsec encryption).
  4. Transmission encryption keys are limited to use for one year and then must be regenerated.
  5. In the case of RxRevu provided APIs, provide mechanisms to assure person sending or receiving data is authorized to send and save data.
  6. System logs of all transmissions of Production Data access. These logs must be available for audit.

18. Data Retention Policy

Despite not being a requirement within HIPAA, RxRevu understands and appreciates the importance of health data retention. Acting as a business associate, RxRevu is not directly responsible for health and medical records retention as set forth by each state. Despite this, RxRevu has created and implemented the following policy to make it easier for RxRevu Customers to support data retention laws.

18.1 State Medical Record Laws

18.2 Data Retention Policy

19. Employees Policy

RxRevu is committed to ensuring all workforce members actively address security and compliance in their roles at RxRevu. As such, training is imperative to assuring an understanding of current best practices, the different types and sensitivities of data, and the sanctions associated with non-compliance.

19.1 Applicable Standards

19.1.1 Applicable Standards from the HITRUST Common Security Framework

19.1.2 Applicable Standards from the HIPAA Security Rule

19.2 Employment Policies

  1. All new workforce members, including contractors, are given training on security policies and procedures, including operations security, within 30 days of employment.
    • Records of training are kept for all workforce members.
    • Upon completion of training, workforce members must complete the Information Systems Authorization Form and the Security Training Attestation Form.
    • Employees must complete this training before accessing production systems containing ePHI.
  2. All workforce members are granted access to formal organizational policies, which include the sanction policy for security violations.
  3. The RxRevu Employee Handbook clearly states the responsibilities and acceptable behavior regarding information system usage, including rules for email, Internet, mobile devices, social media, and facility usage.
    • Workforce members, whether employees or contractors with access to ePHI, are required to sign an agreement stating that they understand their access rights and will abide by the conditions of use. Signed electronic records contain human-readable information associated with the signing and are kept in Dropbox to ensure all signatures, both electronic and handwritten, are available for auditing and periodic review.
    • A Human Resources representative will provide the agreement to new employees during their onboarding process.
  4. RxRevu does not allow mobile devices to store sensitive information, or connect to any of its production networks, including wireless networks.

  5. All workforce members are educated about the approved set of tools to be installed on workstations.

  6. All new workforce members are given HIPAA training within 30 days of beginning employment. Training includes HIPAA reporting requirements, including the ability to anonymously report security incidents, and the levels of compliance and obligations for RxRevu and its Customers and Partners.

  7. All remote (teleworking) workforce members are trained on the risks, the controls implemented, their responsibilities, and sanctions associated with violation of policies. Additionally, remote security is maintained through production access being limited to the RxRevu office, unless an exception is authorized by the management and security controls have been evaluated through the Exception Request Process.

  8. All RxRevu-purchased and -owned computers are to display this message at login and when the computer is unlocked: This computer is owned by RxRevu Health, Inc. By logging in, unlocking, and/or using this computer you acknowledge you have seen, and follow, these policies (https://policies.rxrevu.com) and have completed the security training. Please contact us if you have problems with this - security@rxrevu.com.

  9. Employees may only use company-purchased and company-owned workstations for accessing production systems with access to ePHI data.

    • Any workstations used to access production systems must be configured as prescribed in §7.13.
    • Any workstations used to access production systems must have virus protection software installed, configured, and enabled.
    • RxRevu may monitor access and activities of all users on workstations and production systems in order to meet auditing policy requirements (§8).
    • Company-owned laptops should always be in the possession of the employee and, if not, the laptop needs to be protected from theft.
  10. Access to internal RxRevu systems can be requested using the procedures outlined in §7.2. All requests for access must be granted by the RxRevu Security Officer.

  11. Request for modifications of access for any RxRevu employee can be made using the procedures outlined in §7.2.

  12. RxRevu employees are strictly forbidden from downloading any ePHI to their workstations.

    • Restricting transfers of ePHI is enforced through technical controls as described in §7.13.
    • Employees found to be in violation of this policy will be subject to sanctions as described in §5.3.3.
  13. Employees are required to cooperate with federal and state investigations.

    • Employees must not interfere with investigations through willful misrepresentation, omission of facts, or by the use of threats against any person.
    • Employees found to be in violation of this policy will be subject to sanctions as described in §5.3.3.
  14. All employees, and contractors, who are involved in software development must sign a technology transfer agreement.

19.3 Workforce Improvement

RxRevu supports an information security workforce development program to define the knowledge and skill levels needed to perform information security duties and tasks, and to encourage advancement in security-related fields.

  1. Role-based training programs are made available for individuals assigned information security roles and responsibilities.
  2. Professional development opportunities, such as conferences and certifications, are reviewed quarterly, and attendance is encouraged.

19.4 Issue Escalation

RxRevu workforce members are to escalate issues using the procedures outlined in the Employee Handbook. Issues that are brought to the Escalation Team are assigned an owner. The membership of the Escalation Team is maintained by the Chief Executive Officer.

Security incidents, particularly those involving ePHI, are handled using the process described in §11.2. If the incident involves a breach of ePHI, the Security Officer will manage the incident using the process described in §12.2. Refer to §11.2 for a list of sample items that can trigger RxRevu’s incident response procedures; if you are unsure whether the issue is a security incident, contact the Security Officer immediately.

It is the duty of that owner to follow the process outlined below:

  1. Create a task in the General project within the Asana Security team and assign the new task to the Security Officer.
  2. The Issue is investigated, documented, and, when a conclusion or remediation is reached, it is moved to Review.
  3. The Issue is reviewed by another member of the Escalation Team. If the Issue is rejected, it goes back for further evaluation and review.
  4. If the Issue is approved, it is marked as Done, adding any pertinent notes required.
  5. The workforce member that initiated the process is notified of the outcome via email.

20. Approved Tools Policy

RxRevu utilizes a suite of approved software tools for internal use by workforce members. These software tools are either self-hosted, with security managed by RxRevu, or they are hosted by a Subcontractor with appropriate business associate agreements in place to preserve data integrity. Use of other tools requires approval from RxRevu leadership and is documented in the company wiki.

21. 3rd Party Policy

RxRevu makes every effort to assure all 3rd party organizations are compliant and do not compromise the integrity, security, and privacy of RxRevu or RxRevu Customer data. 3rd Parties include Customers, Partners, Subcontractors, and Contracted Developers.

21.1 Applicable Standards

21.1.1 Applicable Standards from the HITRUST Common Security Framework

21.1.2 Applicable Standards from the HIPAA Security Rule

21.2 Policies to Assure 3rd Parties Support RxRevu Compliance

  1. Aside from AWS, RxRevu does not allow 3rd party access to production systems containing ePHI.
  2. All connections and data in transit between the RxRevu Platform and 3rd parties are encrypted end to end.
  3. A Business Associate Agreement (BAA) with Customers and Partners is defined and includes the required security controls in accordance with the organization’s security policies and screening procedures. Additionally, responsibility is assigned in these agreements.
  4. RxRevu requires an agreed upon service arrangement, or sufficient EULA, addressing liability, service definitions, security controls, business continuity, disaster recovery and aspects of services management.
    • Subcontractors must coordinate, manage, and communicate any changes to services provided to RxRevu.
    • Changes to 3rd party services are classified as configuration management changes and thus are subject to the policies and procedures described in §9; substantial changes to services provided by 3rd parties will invoke a Risk Assessment as described in §4.2.
    • RxRevu utilizes monitoring tools to regularly evaluate Subcontractors against relevant SLAs.
  5. No RxRevu Customers or Partners have access outside of their own environment, meaning they cannot access, modify, or delete anything related to other 3rd parties.
  6. RxRevu does not outsource software development.
  7. RxRevu maintains and annually reviews a list all current Partners and Subcontractors.
    • The list of current Partners and Subcontractors is maintained by the RxRevu Privacy Officer, includes details on all provided services (along with contact information), and is recorded in §1.4.
    • The annual review of Partners and Subcontractors is conducted as a part of the security, compliance, and SLA review referenced below.
  8. RxRevu assesses security, compliance, and SLA requirements and considerations with all Partners and Subcontractors. This includes annual assessment of SOC2 Reports for all RxRevu infrastructure partners.
    • RxRevu leverages recurring calendar invites to assure reviews of all 3rd party services are performed annually. These reviews are performed by the RxRevu Security Officer and Privacy Officer. The process for reviewing 3rd party services is outlined below:
      1. The Security Officer initiates the review by initiating an 3rd Party Review Process in Asana.
      2. The Security Officer, or Privacy Officer, is assigned to review the agreements and performance of 3rd parties. The list of current 3rd parties, including contact information, is also reviewed to assure it is up to date and complete.
      3. As appropriate, SLA, security, and compliance performance is documented in the Issue.
      4. Once the review is completed and documented, the Security Officer approves or rejects the Issue. If the Issue is rejected, it goes back for further review and documentation.
  9. Regular review is conducted as required to assure security and compliance. These reviews include network configurations, reports, audit trails, security events, operational issues, failures and disruptions, and identified issues are investigated and resolved in a reasonable and timely manner.
  10. Any changes to Partner and Subcontractor services and systems are reviewed before implementation.
  11. For all partners, RxRevu reviews activity annually to assure partners are in compliance with RxRevu contracts and agreements.
  12. 3rd party review is monitored on a annual basis using Asana reporting to assess compliance with above policy.

22. Key Definitions

  1. Any unintentional acquisition, access or use of PHI by a workforce member or person acting under the authority of a Covered Entity (CE) or Business Associate (BA) if such acquisition, access, or use was made in good faith and within the scope of authority and does not result in further use or disclosure in a manner not permitted under the Privacy Rule.
  2. Any inadvertent disclosure by a person who is authorized to access PHI at a CE or BA to another person authorized to access PHI at the same CE or BA, or organized health care arrangement in which the CE participates, and the information received as a result of such disclosure is not further used or disclosed in a manner not permitted under the Privacy Rule.
  3. A disclosure of PHI where a CE or BA has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain such information.

23. RxRevu HIPAA Business Associate Agreement (“BAA”)

TBD

24. HIPAA Mappings to RxRevu Controls

Below is a list of HIPAA Safeguards and Requirements and the RxRevu controls in place to meet those.

Administrative Controls HIPAA Rule RxRevu Control
Security Management Process - 164.308(a)(1)(i) Risk Management Policy
Assigned Security Responsibility - 164.308(a)(2) Roles Policy
Workforce Security - 164.308(a)(3)(i) Employee Policies
Information Access Management - 164.308(a)(4)(i) System Access Policy
Security Awareness and Training - 164.308(a)(5)(i) Employee Policy
Security Incident Procedures - 164.308(a)(6)(i) IDS Policy
Contingency Plan - 164.308(a)(7)(i) Disaster Recovery Policy
Evaluation - 164.308(a)(8) Auditing Policy
Physical Safeguards HIPAA Rule RxRevu Control
Facility Access Controls - 164.310(a)(1) Facility and Disaster Recovery Policies
Workstation Use - 164.310(b) System Access, Approved Tools, and Employee Policies
Workstation Security - 164.310(‘c’) System Access, Approved Tools, and Employee Policies
Device and Media Controls - 164.310(d)(1) Disposable Media and Data Management Policies
Technical Safeguards HIPAA Rule RxRevu Control
Access Control - 164.312(a)(1) System Access Policy
Audit Controls - 164.312(b) Auditing Policy
Integrity - 164.312(‘c’)(1) System Access, Auditing, and IDS Policies
Person or Entity Authentication - 164.312(d) System Access Policy
Transmission Security - 164.312(e)(1) System Access and Data Management Policy
Organizational Requirements HIPAA Rule RxRevu Control
Business Associate Contracts or Other Arrangements - 164.314(a)(1)(i) Business Associate Agreements and 3rd Parties Policies
Policies and Procedures and Documentation Requirements HIPAA Rule RxRevu Control
Policies and Procedures - 164.316(a) Policy Management Policy
Documentation - 164.316(b)(1)(i) Policy Management Policy
HITECH Act - Security Provisions HIPAA Rule RxRevu Control
Notification in the Case of Breach - 13402(a) and (b) Breach Policy
Timelines of Notification - 13402(d)(1) Breach Policy
Content of Notification - 13402(f)(1) Breach Policy