This blog answers common questions about HITRUST Assessments and why a HITRUST assessment might be a good choice for your organization.
The agenda for this presentation is first we'll give you a quick introduction to HITRUST. We'll talk about why you should get HITRUST Certified and how to get HITRUST Certified.
HITRUST emerged in 2007 with a primary focus on bolstering information risk management and compliance, especially within the healthcare sector. As per the HITRUST Alliance, an impressive 81% of hospitals and health systems, along with 83% of health plans, rely on HITRUST's Certification Standard Framework (CSF).
HITRUST was created to streamline information risk management for healthcare organizations, employing third-party assessments to consolidate efforts and eliminate the need for multiple reports. This approach, emphasized as "assess once and report many," pairs with HITRUST Certification to provide vendors and covered entities a standardized framework for showcasing their steps to compliance with not just Health Insurance Portability and Accountability Act (HIPAA) but a variety of standards, including PCI and state-specific privacy requirements.
The overarching aim of HITRUST Certification is to equip businesses with the tools to efficiently oversee data, information risk, and compliance across multiple standards.
Recent developments have seen HITRUST extend its scope from healthcare data security to encompass data security in a broader sense. This framework can now be leveraged to protect various forms of sensitive data, from cardholder information and proprietary corporate data to patient records.
By integrating elements from risk management frameworks such as HIPAA, the Payment Card Industry Data Security Standard (PCI DSS), NIST 800-53, NIST CSF, ISO 27001, as well as others like FISMA, Fedramp, and GDPR, HITRUST unifies these diverse standards into a single assessment for comprehensive evaluation.
The "e1" assessment represents fundamental cybersecurity hygiene and serves as an introductory step into the world of HITRUST. Compared to the more rigorous HITRUST i1 and r2 Assessments, the e1 requires less effort to complete while still providing a valuable level of assurance.
The HITRUST i1 Validated Assessment is built on a set of curated controls that guarantee an organization is adopting leading security practices to establish a robust and comprehensive cybersecurity program. Positioned between the foundational HITRUST e1 Essentials and the advanced r2 Expanded Practices Risk-based Assessments, the i1 Assessment provides a balanced level of assurance. Additionally, the i1 Rapid Recertification streamlines the recertification process for greater efficiency.
The HITRUST r2 Validated Assessment is widely regarded as the gold standard for information protection assurances due to its comprehensive control requirements, thorough review process, and consistent oversight. It offers flexible and risk-based control selection, allowing organizations to meet the most stringent risk and compliance factors while tailoring measures to their specific needs. The r2 Assessment's proactive Expanded Practices approach to cybersecurity, along with its extensive requirement statements, ensures the highest level of assurance, making it ideal for organizations facing significant risk exposure.
The difference between the assessments comes down to risk exposure of organizations as well as their cybersecurity practices. e1 assessment is basic and suited for lower-risk organizations, the i1 offers a moderate level of assurance, and the r2 provides the most comprehensive and rigorous validation for organizations with the greatest risk exposure. Organizations can choose the appropriate assessment based on their cybersecurity maturity and risk profile.
Participating in HITRUST Certification showcases your commitment to adhering to rigorous security and compliance standards, particularly for HIPAA compliance. Often, organizations attend this certification because they've faced inquiries from internal stakeholders or customers regarding their HITRUST Certification status.
For many healthcare entities, requiring their business associates to obtain HITRUST certification has become common practice. Given that direct HIPAA certification isn't attainable, achieving HITRUST Certification demonstrates a sincere dedication to data security.
HITRUST offers substantial benefits in terms of time and cost savings, especially in audits. Many HITRUST controls align with numerous regulatory compliance requirements, making it a strategic choice to streamline efforts and reduce redundant reporting. The mantra here is "assess once, report many."
When customers seek assurance about your cybersecurity and compliance measures, a HITRUST Assessment consolidates various requirements into a single report. This report provides a comprehensive overview of your standing in relation to these demands, facilitating a third-party risk assessment.
While you can't substitute a HITRUST Certification for PCI compliance with your acquiring bank, it helps you gauge your readiness and pinpoint gaps before embarking on a PCI assessment.
HITRUST is progressively becoming an adaptable and widely adopted regulatory standard. Its inclusive approach encompasses diverse security and compliance regulations. HITRUST is designed to safeguard all forms of sensitive data, not only PHI or PII. For organizations aspiring to evaluate their performance against these different standards in protecting sensitive data, HITRUST certification delivers substantial value.
Furthermore, HITRUST has adjusted its terminology to emphasize the safeguarding of all sensitive data, moving beyond a sole focus on the security of personal or private information.
The HITRUST approach offers organizations a comprehensive program for managing information risk and achieving compliance. This integrated approach aligns security and compliance mandates, ensuring consistent support for an organization's information risk management and compliance objectives.
HITRUST Certification involves an independent assessment, the duration of which depends on your organization's size, complexity, scope, and the extent of consulting required to attain readiness. Following the assessment, HITRUST's certification process may take up to six weeks to complete.
To prepare for the HITRUST Assessment, the first step is to define your scope, including understanding how sensitive data enters, flows through, and exits your network. This involves creating network and data flow diagrams to visualize data movement, system interactions, and data exposure points.
After scoping, you'll need to decide which HITRUST Assessment level is appropriate for your organization, whether it's a self-assessment, validated certification, or something in between. Subsequently, you should obtain access to the My CSF Portal managed by HITRUST, which offers a range of tools, including a scoping tool.
Within the portal, you can use the scoping tool to generate an assessment specific to your environment. The tool tailors requirements based on your organization's size, systems, records, and transactions, resulting in a unique set of criteria to address.
It's crucial to understand that HITRUST offers multiple levels of validation, differing in whether an assessor validates the assessment. The self-assessment is designed to perform a gap assessment, allowing you to evaluate your environment against HITRUST requirements and identify areas for improvement.
We highly recommend initiating the process with a self-assessment or a third-party gap assessment to comprehend the applicable requirements and grading criteria. Keep in mind that addressing identified risks may require significant time and resources - anywhere from four to ten weeks, depending on the scope and complexity. During this process, you'll need to collect data and evidence, assign scores to required statements, and submit them for assessor review.
It's essential to get the assessment right the first time because you won't have the opportunity to correct issues that the assessor rejects.
Therefore, thorough preparation, including a gap assessment, is critical.
Given the large number of required statements, expect to dedicate considerable time to the assessment, answering numerous questions and providing ample evidence.
HITRUST CSF Certification reports are valid for two years, but an interim assessment is mandatory at the one-year mark to ensure continued compliance.
The HITRUST CSF Certification is a comprehensive framework for organizations that create, access, or exchange sensitive information. Designed to provide a roadmap for data security and compliance, it takes a risk-based approach, focusing on the effectiveness of security measures rather than a mere checklist of compliance items. When undergoing a CSF Assessment, you're not just confirming the presence of security measures but evaluating how well you implement and interpret these requirements.
Within the CSF, there are 19 reporting domains comprising 149 control specifications in an R2 assessment, each categorized into one of three implementation levels. This structured approach goes beyond a simple pass or fail assessment, offering a nuanced evaluation that considers various levels of compliance.
HITRUST initially centered on healthcare information, so it's important to differentiate between HIPAA and HITRUST because it can get confusing. HIPAA is a legislative act shaped by legal professionals and lawmakers, mandating privacy and health information protection. In contrast, HITRUST is a framework devised by security experts, encompassing HIPAA and a range of other data security standards and frameworks. While HIPAA sets forth legal mandates, HITRUST compiles these requirements and enhances them within a comprehensive security and risk-based framework.
The HITRUST Common Security Framework (CSF) offers organizations a method to demonstrate compliance with not just HIPAA's mandated security controls but also additional security controls. HITRUST builds on HIPAA prerequisites and incorporates them into a risk-focused framework. The HIPAA Privacy Rule, as outlined by the HHS, “requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without an individual’s authorization." HITRUST assists in establishing quantifiable criteria and objectives for implementing these safeguards.
However, it's essential to emphasize that HITRUST doesn't replace HIPAA compliance or serve as proof of HIPAA compliance. But is widely recognized for evaluating risk and compliance.
Being HITRUST certified doesn't equate to HIPAA compliance. HITRUST is an effective risk assessment approach but doesn't validate HIPAA compliance. HITRUST also encompasses standards from PCI DSS, among others. However, HITRUST certification doesn't guarantee PCI DSS compliance. Instead, it offers a valuable gap assessment before undergoing a PCI assessment.
HITRUST's foundations include the ISO IEC 27001 2005 and the 27002 2005, along with the NIST SP800-53R2 controls. Yet, achieving HITRUST certification doesn't guarantee full alignment with these security frameworks but serves as a promising indication of progress and aids in gauging the extent of compliance with these standards.
Assess once, report to many: HITRUST aims to streamline assessments across multiple security frameworks and standards. It provides a consolidated approach to security and compliance, offering assurance to customers who rely on various standards. It's essential to communicate with stakeholders and verify whether HITRUST Certification aligns with their requirements.
Determine your scope: Defining your scope is a pivotal step in the HITRUST Assessment process. It shapes the applicable requirements and the level of preparation needed. We recommend conducting a gap assessment using the HITRUST self-assessment tool in the My CSF Portal or collaborating with a third-party assessor to guide you through this critical phase.
Allocate time for remediation: Gap assessments, whether self-conducted or with a third party, are likely to reveal areas requiring remediation. These gaps must be addressed before commencing the official assessment. Planning and allowing ample time for remediation is crucial for achieving a successful outcome.
SecurityMetrics help you get started on your path towards HITRUST certification. Our team takes time to understand your situation, timeline, and specific needs. Request a quote here.
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