Information Security Policy (SEC-POL-001)

1. Objective

The objective of this policy is to establish [Company Name]’s comprehensive Information Security Management System (ISMS) and define the overarching framework for protecting the confidentiality, integrity, and availability of all information assets. This policy serves as the foundation for all security controls and demonstrates [Company Name]’s commitment to safeguarding electronic Protected Health Information (ePHI), maintaining compliance with applicable regulations, and supporting business objectives through effective risk management.

2. Scope

This policy applies to all [Company Name] workforce members, including employees, contractors, temporary staff, and interns. It encompasses all information assets owned, operated, or managed by [Company Name], regardless of format (electronic, physical, or verbal), location (on-premises, cloud, or remote), or lifecycle stage (creation, processing, storage, transmission, or disposal). This policy also applies to all third parties, vendors, and business associates who access, process, or store [Company Name] information.

3. Policy

  • [Company Name] is committed to implementing and maintaining a comprehensive information security program that protects information assets and ensures regulatory compliance.

3.1 Information Security Governance

  • [Company Name] shall establish and maintain a formal information security governance structure to oversee the implementation and effectiveness of the ISMS.

  • A designated Security Officer shall be appointed with ultimate responsibility for the information security program. The Security Officer shall report directly to executive leadership and have the authority to implement security controls across the organization.

  • An Information Security Committee shall be established, comprising representatives from key business functions including executive leadership, IT, legal, compliance, human resources, and operations. The committee shall meet at least quarterly to review security performance, approve policy changes, and make strategic security decisions. Meeting minutes shall be documented and retained to provide an audit trail of all decisions.

  • Information security objectives and requirements shall be integrated into all business processes, system development lifecycles, and vendor management activities.

  • Security roles and responsibilities shall be clearly defined, documented, and communicated to all workforce members through formal job descriptions and training programs.

3.2 Risk Management Framework

  • [Company Name] shall implement a systematic approach to identifying, assessing, and managing information security risks.

  • A formal risk assessment shall be conducted annually and whenever significant changes occur to the business environment, technology infrastructure, or regulatory landscape.

  • Risk treatment decisions shall be documented and approved by appropriate management levels based on risk tolerance and business impact.

  • Residual risks shall be monitored continuously, and risk treatment effectiveness shall be reviewed quarterly.

  • A risk register shall be maintained to track all identified risks, treatment actions, and ownership assignments.

3.3 Information Classification and Handling

All information assets shall be classified according to their sensitivity level and handled in accordance with established security controls.

  • Information shall be classified into defined categories (e.g., Public, Internal, Confidential, Restricted) based on the potential impact of unauthorized disclosure, modification, or destruction.

  • Appropriate security controls shall be applied to each classification level, including access restrictions, encryption requirements, storage limitations, and disposal procedures.

  • Data handling procedures shall comply with applicable privacy regulations, including HIPAA for ePHI and other data protection requirements.

  • Information owners shall be designated for all critical information assets and shall be responsible for classification decisions and access approvals.

3.4 Access Control and Authentication

Access to information systems and data shall be controlled through formal processes that implement the principles of least privilege and separation of duties.

  • All users shall be assigned unique identifiers and shall be authenticated before accessing any company systems or data.

  • Multi-factor authentication shall be required for all systems containing sensitive information, including ePHI.

  • Access review cadence is defined in the IAM Policy (AC-POL-001) for standard access and the Privileged Access Management Policy (AC-POL-004) for privileged access. See AC-POL-001 and AC-POL-004 for authoritative requirements.

  • Privileged access shall be subject to additional controls, including time-limited sessions, enhanced monitoring, and separate administrative accounts.

3.5 Security Awareness and Training

All workforce members shall receive comprehensive security awareness training to understand their security responsibilities and recognize potential threats.

  • New workforce members shall complete security awareness training within [Number, e.g., 30] days of hire.

  • Annual refresher training shall be provided to all workforce members, with additional specialized training for roles with elevated security responsibilities.

  • Training effectiveness shall be measured through assessments and security metrics.

  • Targeted awareness campaigns shall be conducted to address emerging threats and security trends.

3.6 Incident Management

  • [Company Name] shall maintain the capability to detect, respond to, and recover from security incidents in a timely and effective manner.

  • A formal incident response plan shall be maintained and tested regularly through tabletop exercises and simulations.

  • All suspected security incidents shall be reported immediately through established channels and investigated according to documented procedures.

  • Incident response activities shall be documented, and lessons learned shall be incorporated into security improvements.

  • Regulatory notification requirements shall be met for incidents involving ePHI or other regulated data.

3.7 Business Continuity and Resilience

Critical business functions and information systems shall be protected through comprehensive business continuity and disaster recovery planning.

  • Business impact assessments shall be conducted to identify critical functions and acceptable recovery timeframes.

  • Backup and recovery procedures shall be implemented and tested at least annually to ensure data and system availability. Test results shall be documented.

  • Alternative processing arrangements shall be established for critical systems to maintain operations during disruptions.

  • Full recovery testing shall be performed annually and after significant infrastructure changes, with results documented and reviewed by the Information Security Committee.

3.8 Vendor and Third-Party Management

Security requirements shall be established and enforced for all vendors and third parties with access to [Company Name] information or systems.

  • Security assessments shall be conducted before engaging vendors who will access, process, or store company information.

  • Contractual agreements shall include specific security requirements, liability provisions, and audit rights.

  • Business Associate Agreements (BAAs) shall be executed with all vendors who will handle ePHI.

  • Vendor security performance shall be monitored through regular assessments and security questionnaires.

3.9 Compliance and Audit

  • [Company Name] shall maintain compliance with all applicable laws, regulations, and contractual obligations related to information security.

  • Regular compliance assessments shall be conducted to verify adherence to HIPAA, SOC 2, and other applicable requirements.

  • Internal audits shall be performed annually to evaluate the effectiveness of security controls and identify improvement opportunities.

  • External audits and assessments shall be facilitated as required by regulatory or contractual obligations.

  • Audit findings and corrective actions shall be tracked to completion and reported to appropriate management levels.

3.10 Continuous Improvement

The information security program shall be subject to continuous monitoring and improvement based on changing threats, business requirements, and industry best practices.

  • Security metrics and key performance indicators (KPIs) shall be established and monitored to measure program effectiveness.

  • Regular reviews of policies, procedures, and controls shall be conducted to ensure they remain current and effective.

  • Industry threat intelligence and security advisories shall be monitored and incorporated into security planning.

  • Employee feedback and suggestions for security improvements shall be encouraged and evaluated.

3.10.1 Threat Intelligence and Security Information Sharing Implementation

  • [Company Name] shall implement comprehensive threat intelligence and security information sharing processes as follows:

  • Healthcare-Specific Threat Intelligence: Subscriptions to healthcare-specific threat intelligence feeds including [Threat Feeds, e.g., HHS HCCIC, FBI IC3, MS-ISAC] shall be maintained to receive current threat information relevant to the healthcare sector.

  • Automated Threat Indicator Ingestion: Automated ingestion of threat indicators including IoCs, TTPs, and vulnerability information shall be configured into [Threat Intelligence Platform] for systematic processing and analysis.

  • Internal Security Data Collection: Internal security data from SIEM, IDS/IPS, endpoint detection, and vulnerability scanners shall be collected and analyzed for threat pattern identification.

  • Daily Threat Analysis: Daily analysis of threat intelligence feeds shall be performed to identify threats relevant to healthcare sector and organizational infrastructure, with correlation to internal security events.

  • Security Monitoring Integration: Threat intelligence indicators shall be integrated into security monitoring tools for automated detection and alerting capabilities.

  • Proactive Threat Hunting: Weekly proactive threat hunting using intelligence-driven hypotheses shall be conducted to identify advanced persistent threats and sophisticated attack activities.

  • Intelligence Briefings: Weekly threat intelligence briefings shall be generated for security teams including emerging threats, attack trends, and recommended countermeasures.

  • External Information Sharing: Sanitized threat indicators shall be shared with [Sharing Partners, e.g., HC3, industry peers] through secure information sharing platforms, subject to approval processes to protect sensitive organizational information.

  • Incident Response Intelligence: Threat intelligence shall be leveraged during incident response to understand attacker tactics, techniques, and procedures (TTPs), with analysis of security incidents to extract new threat intelligence.

  • Vulnerability Prioritization: Vulnerability remediation shall be prioritized based on threat intelligence indicating active exploitation in healthcare sector.

  • Security Control Updates: Security controls and monitoring rules shall be updated based on threat intelligence findings and emerging attack techniques.

  • Documentation and Retention: Threat intelligence records and sharing documentation shall be maintained for minimum [Retention Period, e.g., 2 years] for audit compliance purposes.

4. Standards Compliance

See Annex: Control Mapping

5. Definitions

See Annex: Glossary

6. Responsibilities

Role Responsibility
Executive Leadership Provide strategic direction and resources for the information security program. Approve security policies and ensure accountability.
Security Officer Develop, implement, and maintain the ISMS. Oversee security operations, incident response, and compliance activities.
Information Security Committee Provide governance oversight, approve policy changes, and make strategic security decisions.
IT Department Implement technical security controls, manage system security configurations, and support security operations.
Human Resources Integrate security requirements into hiring processes, conduct background checks, and manage workforce security training.
Legal/Compliance Team Ensure regulatory compliance, review contracts for security requirements, and manage legal aspects of security incidents.
Information Owners Classify information assets, approve access requests, and ensure appropriate handling of sensitive data.
All Workforce Members Comply with security policies, complete required training, and report security incidents or concerns.
Managers/Supervisors Ensure their teams comply with security policies, approve access requests, and conduct regular access reviews.
Threat Intelligence Analyst Collect, analyze, and disseminate threat intelligence. Correlate external threats with internal security events and generate intelligence briefings.
Security Operations Center Integrate threat intelligence into monitoring tools and respond to intelligence-driven alerts and detections.
Threat Hunting Team Conduct proactive threat hunting using intelligence-driven hypotheses to identify advanced threats and attack activities.
Incident Response Team Leverage threat intelligence during incident response and analyze incidents to extract new threat intelligence.
Vulnerability Management Team Prioritize vulnerability remediation based on threat intelligence indicating active exploitation patterns.
Security Architecture Team Update security controls and monitoring rules based on threat intelligence findings and emerging attack techniques.