If your organization must comply with several regulatory standards, it can be challenging to keep up with all of the requirements and remain compliant year-round. With the help of a compliance management system, you can implement the essential controls required by these standards across your organization. Read on to learn how.
Steps to Building a Compliance Management System
A compliance management system is crucial to helping your organization comply with the requirements stipulated across multiple regulatory frameworks.
The most important aspects of building a compliance management system include:
- Defining sensitive data categories
- Developing a data security policy
- Standardizing risk management controls
- Managing compliance across several standards
When developed with guidance from a cybersecurity compliance services advisor, your organization will be well-positioned to implement a robust compliance management system.
What is a Compliance Management System?
A compliance management system is a set of processes that enables organizations to streamline their approach to regulatory compliance. It could be a framework, policy, software tool, or any combination of these elements.
Regardless of industry, every organization that handles sensitive data using IT assets is prone to cybersecurity risks. Although these risks may vary from one organization to another, each organization is responsible for managing them and ensuring sensitive data remains safe.
Compliance with regulatory frameworks enables organizations to implement widely-recognized, industry-standard security controls that effectively minimize the impact of data privacy and security risks.
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Why Implement a Regulatory Compliance Management System?
Although regulatory compliance is crucial to mitigating cybersecurity risks from impacting data privacy, availability, and integrity, some organizations may struggle to achieve it.
A regulatory compliance management system provides a framework for any organization can identify risks, categorize them, and implement controls that effectively prevent these risks from becoming full-blown threats.
Whereas some organizations may only be required to comply with a single regulatory framework, others might handle data subject to several frameworks. For instance, a healthcare organization that collects and transmits sensitive patient data or receives card payments from these patients must comply with frameworks like HIPAA and the PCI DSS.
On the other hand, compliance with frameworks like the Service and Organization Controls (SOC) is not strictly required but is recommended for service organizations looking to provide security assurance to their stakeholders. Although SOC 1, 2, or 3 compliance is not legally required, companies that handle sensitive data can benefit from its data privacy safeguards.
Remaining compliant with one or more of these frameworks requires a robust regulatory compliance management system to identify and map the appropriate controls across relevant frameworks when implementing them across your assets.
Taking the example of various privacy and security standards, let’s explore how the components of a compliance management system fit together and streamline regulatory compliance.
HIPAA and Sensitive Healthcare Data Categories
To protect sensitive data, you must identify which categories of data are considered sensitive according to the regulatory frameworks in your industry. Upon identifying these data categories, your organization can develop a unique and tailored compliance management system to safeguard sensitive data from cybersecurity threats.
In the healthcare industry, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) stipulates the standards for protecting sensitive patient data, also called protected health information (PHI).
HIPAA safeguards PHI based on four primary Rules:
- The Privacy Rule – HIPAA’s Privacy Rule establishes PHI as a type of sensitive data and defines which organizations must comply with HIPAA based on the categories of healthcare data they handle.
- The Security Rule – Organizations defined as covered entities by the Privacy Rule must implement the Security Rule safeguards if they handle electronic PHI (ePHI) across their digital assets.
- The Breach Notification Rule – Should a data breach occur impacting the privacy of PHI, covered entities are required to report it to designated authorities, per the Breach Notification Rule’s standards.
- The Enforcement Rule – Covered entities suspected of violating the requirements of the HIPAA Rules may be subject to investigations and potential fines and penalties if there is evidence to prove these violations occurred.
Organizations within and adjacent to healthcare will likely rely on the standards stipulated in all the primary HIPAA Rules to identify the most appropriate safeguards for PHI.
However, the Privacy Rule directly addresses which categories of data qualify for HIPAA’s data privacy and security safeguards.
Categories of PHI Under the HIPAA Privacy Rule
The HIPAA Privacy Rule categorizes organizations within and adjacent to healthcare as covered entities based on the data involved in the transactions they conduct with one another.
Covered entities include:
- Health plans – Organizations that cover the costs of medical care are considered covered entities because they use PHI to decide which services they can pay for on behalf of patients. Health plans include:
- Health, dental, and vision insurers
- Health maintenance organizations (HMOs)
- Long-term care insurers
- Most employer-sponsored health plans
- Healthcare providers – Every organization that provides healthcare services to patients and electronically submits PHI internally or externally is subject to the HIPAA Privacy Rule and must safeguard PHI during transactions such as:
- Filing insurance claims for services rendered to patients
- Inquiring about patients’ benefits eligibility
- Requesting authorizations for referrals
- Healthcare clearinghouses – Any organization that converts data from a non-standard to a standard form or vice versa is also subject to the HIPAA Privacy Rule requirements and must safeguard PHI while conducting these transactions.
Business associates of covered entities must also comply with the HIPAA Privacy Rule’s guidelines for safeguarding PHI. By definition, an organization is a business associate of a covered entity if it uses or discloses PHI on behalf of that entity.
A healthcare compliance management system will be more effective if your organization can identify which data categories are subject to HIPAA.
PCI DSS Compliance and a Data Security Policy
Organizations that handle cardholder data (CHD) via card payment transactions are required to comply with the Payment Card Industry (PCI) Data Security Standards (DSS).
Retail, financial services, or healthcare companies are prone to cyberattacks and data breaches because they process large amounts of CHD. The best way for organizations in these industries to safeguard the sensitive data they handle from cybersecurity risks is to comply with the PCI DSS safeguards.
The PCI DSS comprises 12 Requirements:
- Requirement 1 – Implement network security controls
- Requirement 2 – Secure system components
- Requirement 3 – Safeguard account data storage
- Requirement 4 – Secure CHD transmission using strong cryptography
- Requirement 5 – Safeguard systems and networks from malware
- Requirement 6 – Secure systems and software
- Requirement 7 – Limit access to system components and CHD by business need
- Requirement 8 – Implement user access and authentication controls
- Requirement 9 – Restrict access to physical CHD locations
- Requirement 10 – Track access to system components and CHD
- Requirement 11 – Conduct regular system and network testing
- Requirement 12 – Establish an information security policy
Effective PCI DSS compliance starts with understanding which assets in your infrastructure handle CHD, where it is located, and how best to secure any transactions that involve it. This process can be streamlined with the help of a compliance management system.
Benefits of a PCI Compliance Management System Policy
Notably, the PCI compliance management system must align with your information security policy, ensuring the necessary oversight of the PCI DSS controls implemented across your organization. However, the PCI data security policy must be specific to your organization’s current security, operational, and risk management needs to remain relevant.
For instance, organizations that only collect or transmit CHD internally will likely have different security concerns than those which do so when working with third-party partners. Likewise, companies with cloud-based digital assets may require different levels of access controls than those operating primarily on-premise or within a hybrid environment.
With numerous controls listed within each PCI DSS Requirement, your organization must identify those that apply to your unique scenario and effectively manage security risks.
The guidance and oversight provided by a PCI compliance management system policy will help identify current or anticipated risks and optimize your safeguards accordingly.
Cybersecurity Risk Management with the NIST CSF
A risk-based compliance management system guided by a widely-applicable framework like the National Institute of Standards and Technology (NIST) Cybersecurity Framework (CSF) helps reduce risk across your digital assets.
NIST CSF compliance is essential because cybersecurity risks come in various forms, with some being more complex than others.
Whereas organizations within the same industry may face similar security risks, the potential for these risks to impact individual organizations varies based on intrinsic and extrinsic factors.
Your organization can manage intrinsic risk factors like employees’ security awareness or exploitable vulnerabilities internally or by outsourcing risk management to a cybersecurity partner. However, extrinsic factors like complex attack vectors are best managed by implementing and optimizing cyberdefenses based on recommended regulatory standards.
Unlike frameworks like HIPAA or the PCI DSS, the NIST CSF is standardized, meaning its controls can be mapped to any security framework—regardless of industry.
Per the NIST CSF, a risk-based approach to compliance management typically involves:
- Identifying assets at risk for cybersecurity threats (e.g., networks, applications, systems)
- Safeguarding at-risk assets by implementing security controls (e.g., firewalls, identity and access management (IAM) systems)
- Monitoring assets for potential security gaps and vulnerabilities (e.g., via penetration testing)
- Developing incident response and management plans to promptly manage threat risks swiftly
- Implementing recovery plans to restore system normalcy if cyberattacks occur
A robust risk management plan, such as that recommended by the NIST CSF, will help your organization manage risk irrespective of, or in addition to, the regulatory requirements that pertain to your specific industry or the sensitive data you handle.
Cross-Framework Compliance Management with HITRUST
Compared to other regulatory standards, HITRUST is unique in that it is comprehensive and risk-based. These two features make it a robust and attractive tool for organizations with different risk profiles to manage compliance across several security frameworks.
Implementing a HITRUST-based compliance management system enables your organization to comply with frameworks such as:
Compliance with HITRUST streamlines the application of privacy and security controls listed across these frameworks, helping you to remain compliant with multiple frameworks throughout the year.
Choosing the Right HITRUST Assessment
HITRUST is an adaptive compliance management system, meaning organizations can choose an assessment rigor that best matches their current needs. Some organizations choose to start from the lowest rigor assessments and work their way up to those requiring more involved and rigorous preparation.
There are currently three levels of HITRUST assessments for organizations to choose from:
- 1-year (e1) assessments – Organizations looking to conduct basic entry-level evaluations of their most critical security controls can use the e1 assessments to demonstrate a basic level of cybersecurity hygiene.
- 1-year (i1) assessments – Entities whose cybersecurity controls are somewhat more advanced and effective against a broader range of threats can demonstrate moderate security hygiene with the i1 assessments.
- 2-year (r2) assessments – For organizations that implement specific, high-level security controls with robust risk management, r2 assessments provide a high level of assurance to stakeholders.
Among the notable benefits of HITRUST compliance is that organizations can leverage the HITRUST Alliance’s SaaS platform, the MyCSF Tool, to track risk and compliance management. This tool enables any organization to conduct accurate risk assessments, identify gaps in compliance, and report on compliance.
The MyCSF Tool can also be integrated into existing governance, risk management, and compliance (GRC) platforms to streamline the management of evolving risks and help organizations keep up with regulatory trends.
Compliance management systems will look different from one organization to another, depending on each organization’s unique needs.
But, with the help of a trusted compliance advisor, you will design, build, or find the right compliance management system that effectively secures your data throughout the year—even as your organization grows.
Professional, Reliable Compliance Management
With the help of a compliance management system, your organization will stay on top of critical regulatory requirements—safeguarding data at all times. Partnering with a cybersecurity compliance services specialist like RSI Security will enable you to remain compliant and get certified across applicable frameworks.
To learn more and get started, contact RSI Security today!
