Data Breaches and Privacy Concerns: An Overview

undefined
P
RIVACY
Marilyn Prosch, Ph.D., CIPP
Arizona State University
W.P. Carey School of Business
Department of Information Systems
Member AICPA/CICA Privacy Task Force
undefined
IS PRIVACY REALLY ALL
THAT BIG OF A PROBLEM?
 
D
ATA
 B
REACHES
:  W
HERE
 
IS
 
THE
 H
ORSE
?
Some of the reported incidents that have recently occurred.
 
Cleveland Clinic
 
Mercy Medical Center
 
Beaumont Hospital
 
DePaul Medical Center
 
Erlanger Health
System
 
Stevens Hospital
via billing company Med Data
 
Allina Hospitals and Clinics
 
Manhattan Veteran's Affairs Medical Center &
 New York Harbor Health Care System
 
Sisters of St. Francis Health Services
via Advanced Receivables Strategy
 
Jacobs Neurological Institute
 
Swedish Medical Center
 
Akron Children's Hospital
 
McAlester Clinic
& Veteran's Affairs Medical Center
 
Intermountain Health Care
 
Kaiser Permanente Colorado
 
Gundersen Lutheran Medical Center
 
Segal Group of New York
 
via web site of Vermont agency
 
Emory University Hospital, Emory
Crawford Long Hospital, Grady Memorial
Hospital, Geisinger Health System,
Williamson Medical Center 
via Electronic
Registry Systems
 
Deaconess Hospital
 
WellPoint's Anthem
Blue Cross Blue Shield
 
Johns Hopkins Hospital
 
St. Mary's Hospital, MD
 
Kaiser Medical Center
 
Seton Healthcare Network
 
Back and Joint Institute of Texas
 
Gulf Coast Medical Center
 
Westerly Hospital
 
Wellpoint's Empire Blue Cross/
Blue Shield NY
 
Health Resources, Inc.
 
Group Health Cooperative Health Care
System
 
Swedish Urology Group
 
DCH Health Systems
 
Georgia Dept. of Community
Health
 
Univ. of Pittsburgh, Med. Center
 
Healing Hands Chiropractic
 
Univ. Calif. Irvine Medical Center
 
Highland Hospital
 
University of Pittsburgh Medical Center
 
Beacon Medical Services
 
Concord Hospital
 
South County Hospital
 
Prudential Financial Inc.
 
St. Vincent Hospital
 
WorkCare Orem
 
Providence Alaska Medical Center
 
Sky Lakes Medical Center
via Verus Inc
 
Moses Cone Hospital
 
CBIZ Medical Management Professionals
 
Peninsula Orthopaedic Associates
 
Palo Alto Medical Foundation
 
Massachusetts General Hospital
 
St. Rita's Medical Center
 
Northeast Orthopaedics
 
CVS Pharmacies
 
Parkland Memorial Hospital
 
Catskill Regional Medical Center
 
Womancare Inc.
 
Baystate Medical Center
 
St. Anthony Central Hospital
 
Kanawha-Charleston Health Dept.
 
New Hampshire's Lakes Region General Hospital
 
Cedars-Sinai Medical Center
 
New Hampshire Dept. of HS
 
Christus Health Care
 
North Carolina Dept. of HHS
 
Baylor Health Care System Inc.
 
Mary Washington Hospital
 
Bue Cross/Blue Shield
 
Southwest Medical Association
 
Wuesthoff Medical Center
 
Harris County Hospital
 
Grady Memorial Hospital
Some of the causes!
 
A Blackberry containing patient information was stolen from the hospital.
The Blackberry contained an email message that included patient information,
such as Social Security numbers, dates of birth and medical histories. 3,200 people affected
 
Laptop stolen from an employee's car.  14,000 people affected
 
Office broken into and computer stolen.  Unknown people affected
 
Tapes stolen while in transit.  100,000 people affected
 
Office broken into and laptop stolen.  1,000 people affected
 
Paper-based records left on a train by an employee.  56 people affected
 
Child welfare worker’s records ended up with a local TV station. The files, which included names,
Social Security numbers, contact information and details on child abuse investigations, reportedly
were left behind when a DHS worker was evicted from a rent house.
 
Paper based records stolen from an employee's car.  242 people affected
 
Records posted on the Internet. The records appeared on a Web site visvabpo.com, which was a defunct
company in India. 1,000 people affected
 
Documents, such as labels from prescription bottles and old prescriptions, in unsecured dumpsters.
Unknown people affected
 
Laptop stolen from an employee's car.  9,300 people affected
 
A woman was fired for allegedly spying. The employee had access to company files. 431 people affected
 
Medical records were improperly disposed of when left in a dumpster behind the office.
undefined
 
undefined
undefined
W
HAT
 
IS
 P
RIVACY
?
 
9
PRIVACY: AICPA/CICA D
EFINITION
PRIVACY
 encompasses the rights and
obligations of individuals and organizations with
respect to the…
Collection
Use
Disclosure, and
Retention
…of personal information.
10
Rights and Obligations
undefined
W
HAT
 
IS
 
THE
 
RELATIONSHIP
BETWEEN
 
PRIVACY
 
AND
SECURITY
?
 
S
ECURITY
, 
AS
 
IT
 
RELATES
 
TO
 
PRIVACY
Security of
processes and
technologies is a
necessary, but not
sufficient,
condition of
privacy
undefined
W
HY
 
SHOULD
 
SYSTEMS
PROFESSORS
/
PRACTIONERS
 
CARE
ABOUT
 
DATA
 
PROTECTION
 
AND
PRIVACY
?
 
L
AST
 
WEEK
 – V
IRGINIA
 P
RESCRIPTION
M
ONITORING
 P
ROGRAM
 
DRUG
 
DATABASE
HACKED
Data hijackers deleted records on more
than 8 million patients and replaced the
site's homepage with a ransom note
demanding $10 million for the return of
the records.
The database of prescriptions had been
bundled into an encrypted, password-
protected file and payment of the
ransom would result in the password to
decrypt.
Their backups seem to have gone
missing, too.
http://voices.washingtonpost.com/securityfix/2009/05/hackers_break_into_virginia_he.html?wprss=securityfix
R
EASONS
With enterprise systems, personal information
(PI) is commingled with accounting transactions
Much PI is part of accounting transaction data
Data has value and that “value” can be an asset
or a liability
Good internal controls are a mechanism for
protecting all “assets”
undefined
W
HAT
 
IS
 GAPP?
 
17
WHAT IS GAPP?
Generally Accepted Privacy Principles
Developed by the American Institute of Certified
Public Accountants (AICPA) and the Canadian
Institute of Chartered Accountants (CICA) to help
guide organizations in implementing, sustaining, and
auditing privacy programs.
AICPA/CICA G
ENERALLY
 A
CCEPTED
P
RIVACY
 P
RINCIPLES
Available for free download and use
10 Principles of privacy and 66 criteria, (soon to
have an additional 8 criteria with the new
exposure draft is finished with the review
process)
http://infotech.aicpa.org/Resources/Privacy/
 
19
W
HAT
 
ARE
 
THE
 P
RINCIPLES
?
1.
Management
:
 
The entity
defines, documents,
communicates, and assigns
accountability for its privacy
policies and procedures.
2.
Notice
: The entity provides
notice about its privacy policies
and procedures and identifies the
purposes for which personal
information is collected, used,
retained, and disclosed.
3.
Choice and Consent
: The
entity describes the choices
available to the individual and
obtains implicit or explicit
consent with respect to the
collection, use, retention, and
disclosure of personal
information.
4. Collection
: The entity
collects personal
information only for the
purposes identified in the
notice.
5. Use and Retention
:
The entity limits the use
of personal information to
the purposes identified in
the notice and for which
the individual has
provided implicit or
explicit consent. The
entity retains personal
information for only as
long as necessary to fulfill
the stated purposes.
20
W
HAT
 
ARE
 
THE
 P
RINCIPLES
?
6. Access
: The entity provides
individuals with access to their
personal information for review
and update.
7. Disclosure
: The entity
discloses personal information to
third parties only for the purposes
identified in the notice and with
the implicit or explicit consent of
the individual.
8. Security for Privacy
: The
entity protects personal
information against unauthorized
access (both physical and logical).
9. Quality
: The entity
maintains accurate,
complete, and relevant
personal information for
the purposes identified
in the notice.
10. Monitoring and
Enforcement
: The
entity monitors
compliance with its
privacy policies and
procedures and has
procedures to address
privacy-related
complaints and disputes.
21
COMPONENTS OF GAPP
Consistency
 
of
 
Commitments
 
With Privacy Policies
 
and Procedures
Infrastructure
 
and Systems
 Management
undefined
W
HY
 
HAS
 
THE
 AICPA/CICA
ISSUED
 
AN
 
UPDATE
 
TO
 GAPP 
IN
THE
 
FORM
 
OF
 
AN
 
EXPOSURE
DRAFT
?
 
C
ONTINUOUS
 
IMPROVEMENT
 
OF
 GAPP
Major changes
Modification of 2 criteria
8 new criteria
undefined
W
HAT
 
IS
 
THE
 G
LOBAL
 P
RIVACY
S
TANDARD
?
 
G
LOBAL
 P
RIVACY
 S
TANDARD
Final version of the GPS was formally in the
United Kingdom, on November 3, 2006, at the
28th International Data Protection
Commissioners Conference
Championed and developed by Commissioner
Ann Cavoukian, Ontario
10 Principles
undefined
W
HAT
 
ARE
 
THESE
 
NEW
 
RED
 
FLAG
RULES
 
THAT
 
ARE
 
IN
 
THE
 
NEWS
?
 
N
EW
 R
ED
 F
LAG
 R
ULES
EFFECTIVE
 
MAY
1, 2009:  
P
OSTPONED
 
UNTIL
 8/1/2009
Require each financial institution and creditor that holds
any consumer account, or other account for which there is a
reasonably foreseeable risk of identity theft, to develop and
implement an Identity Theft Prevention Program
(Program) for combating identity theft in connection with
new and existing accounts. Originally effective May 1,
2009.
The program can be different, depending on the
organization’s size and complexity.
Thus, a small physician practice might have a much
different program than a large hospital.
Programs should include four basic points/steps, which
could be covered under one or multiple policies.
http://www.hinshawlaw.com/health-care-identity-theft-prevention-programs-and-red-flags-rules-compliance-03-10-2009/
4 R
EQUIRED
 S
TEPS
Identify Common Red Flags
Detect Red Flags
Responses to Red Flags
Program Execution and Updates
http://www.hinshawlaw.com/health-care-identity-theft-prevention-programs-and-red-flags-rules-compliance-03-10-2009/
undefined
W
HAT
 
IS
 
THE
 
RELATIONSHIP
 
OF
PRIVACY
 
AND
 
OTHER
 
MORE
TRADITIONAL
 
AREAS
 
OF
 AIS,
A
UDIT
,
 
AND
 
ASSURANCE
 
T
HE
 
PRIMARY
 
LINK
 
TO
 
THESE
 3 
AREAS
 
IS
effective internal controls!
GAPP provides tangible criteria that can be
audited and about which assurances can be
made.
3 T
RICKS
 
TO
 
GETTING
  
HORSES
 
BACK
 
IN
 
THE
 
BARN
 &
KEEPING
 
THEM
 
THERE
 
Teach your horse that you are in control over
him/her.
Corporate Culture towards the use and management of
personal information will likely have to change.  Who
owns and controls the data?
Make it dang hard for the horse to do the wrong
thing.
Implement privacy enhancing policies, procedures, and
controls.
Ride a lot!
Test the use and management of your data frequently.
undefined
W
HAT
 
ARE
 
SOME
 
RESEARCH
OPPORTUNITIES
?
 
Descriptive research:
What are companies actually doing?
Are they aware of the issues?
If so, how are they handling these issues?
Are they using some kind of data masking during
these processes?
Normative research:  
How can we build privacy
protection into processes?
Data tagging and masking
Data replication (logging)
Security around possession and handling
Data life and destruction techniques (poison pills)
I
MPLICATIONS
 
FOR
 CA/CM R
ESEARCH
F
URTHER
 Q
UESTIONS
?
marilyn.prosch@asu.edu
twitter.com/ProfofPrivacy
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Privacy expert Marilyn Prosch, Ph.D., sheds light on the significant issue of privacy, emphasizing recent data breaches in various institutions and outlining some alarming cases where sensitive information was compromised. The incidents range from stolen laptops and office break-ins to mishandling of paper-based records, highlighting the pervasive nature of privacy violations affecting thousands of individuals.

  • Privacy concerns
  • Data breaches
  • Information security
  • Privacy expert
  • Data protection

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  1. PRIVACY Marilyn Prosch, Ph.D., CIPP Arizona State University W.P. Carey School of Business Department of Information Systems Member AICPA/CICA Privacy Task Force

  2. IS PRIVACY REALLY ALL THAT BIG OF A PROBLEM?

  3. DATA BREACHES: WHERE IS THE HORSE? Some of the reported incidents that have recently occurred.

  4. Manhattan Veteran's Affairs Medical Center & New York Harbor Health Care System Swedish Medical Center Univ. of Pittsburgh, Med. Center St. Rita's Medical Center Beaumont Hospital Univ. Calif. Irvine Medical Center Baystate Medical Center Baylor Health Care System Inc. Sisters of St. Francis Health Services via Advanced Receivables Strategy DCH Health Systems Mercy Medical Center Group Health Cooperative Health Care Cedars-Sinai Medical Center Johns Hopkins Hospital System Southwest Medical Association Allina Hospitals and Clinics CBIZ Medical Management Professionals Prudential Financial Inc. Wuesthoff Medical Center Northeast Orthopaedics DePaul Medical Center Massachusetts General Hospital Christus Health Care Beacon Medical Services Seton Healthcare Network University of Pittsburgh Medical Center Kaiser Medical Center St. Anthony Central Hospital McAlester Clinic & Veteran's Affairs Medical Center Bue Cross/Blue Shield Akron Children's Hospital Highland Hospital Back and Joint Institute of Texas Emory University Hospital, Emory Crawford Long Hospital, Grady Memorial Hospital, Geisinger Health System, Williamson Medical Center via Electronic Registry Systems Palo Alto Medical Foundation Cleveland Clinic Gulf Coast Medical Center Jacobs Neurological Institute Erlanger Health System Parkland Memorial Hospital Westerly Hospital Deaconess Hospital CVS Pharmacies WellPoint's Anthem Blue Cross Blue Shield Health Resources, Inc. Moses Cone Hospital Kanawha-Charleston Health Dept. South County Hospital Kaiser Permanente Colorado Concord Hospital Harris County Hospital Providence Alaska Medical Center Swedish Urology Group Intermountain Health Care Stevens Hospital via billing company Med Data Gundersen Lutheran Medical Center Catskill Regional Medical Center New Hampshire Dept. of HS St. Mary's Hospital, MD Womancare Inc. WorkCare Orem North Carolina Dept. of HHS St. Vincent Hospital Mary Washington Hospital Sky Lakes Medical Center via Verus Inc New Hampshire's Lakes Region General Hospital Wellpoint's Empire Blue Cross/ Blue Shield NY Grady Memorial Hospital Segal Group of New York via web site of Vermont agency Georgia Dept. of Community Health Peninsula Orthopaedic Associates Healing Hands Chiropractic

  5. Some of the causes! A Blackberry containing patient information was stolen from the hospital. The Blackberry contained an email message that included patient information, such as Social Security numbers, dates of birth and medical histories. 3,200 people affected Laptop stolen from an employee's car. 14,000 people affected Laptop stolen from an employee's car. 9,300 people affected Office broken into and computer stolen. Unknown people affected Office broken into and laptop stolen. 1,000 people affected Tapes stolen while in transit. 100,000 people affected Paper-based records left on a train by an employee. 56 people affected Child welfare worker s records ended up with a local TV station. The files, which included names, Social Security numbers, contact information and details on child abuse investigations, reportedly were left behind when a DHS worker was evicted from a rent house. Paper based records stolen from an employee's car. 242 people affected Records posted on the Internet. The records appeared on a Web site visvabpo.com, which was a defunct company in India. 1,000 people affected Documents, such as labels from prescription bottles and old prescriptions, in unsecured dumpsters. Unknown people affected A woman was fired for allegedly spying. The employee had access to company files. 431 people affected Medical records were improperly disposed of when left in a dumpster behind the office.

  6. WHATIS PRIVACY?

  7. PRIVACY: AICPA/CICA DEFINITION PRIVACY encompasses the rights and obligations of individuals and organizations with respect to the Collection Use Disclosure, and Retention of personal information. 9

  8. Individuals Organizations Establish and communicate its privacy policies and commitments to the individual Provide choices or seek consent for the use of the personal information Collect, use, retain, and disclose personal information according to its privacy policies and commitments Allow the individual to update or correct personal information that is used by the organization Protect the personal information from unauthorized use and disclosure Otherwise adhere to its policies, applicable laws and regulations, and other agreements with the individual Be aware of the organization s privacy policies Provide accurate and appropriate information suited to the purpose for which the information is needed Rights and Obligations Notify the organization of inaccuracies in or changes to personal information used by the organization Adhere to applicable laws and regulations, and other agreements with the organization 10

  9. WHATISTHERELATIONSHIP BETWEENPRIVACYAND SECURITY?

  10. SECURITY, ASITRELATESTOPRIVACY Security of processes and technologies is a necessary, but not sufficient, condition of privacy Security Privacy Enhancing Technologies Policies & Procedures Privacy

  11. WHYSHOULDSYSTEMS PROFESSORS/PRACTIONERSCARE ABOUTDATAPROTECTIONAND PRIVACY?

  12. LASTWEEK VIRGINIA PRESCRIPTION MONITORING PROGRAMDRUGDATABASE HACKED Data hijackers deleted records on more than 8 million patients and replaced the site's homepage with a ransom note demanding $10 million for the return of the records. The database of prescriptions had been bundled into an encrypted, password- protected file and payment of the ransom would result in the password to decrypt. Their backups seem to have gone missing, too. http://voices.washingtonpost.com/securityfix/2009/05/hackers_break_into_virginia_he.html?wprss=securityfix

  13. REASONS With enterprise systems, personal information (PI) is commingled with accounting transactions Much PI is part of accounting transaction data Data has value and that value can be an asset or a liability Good internal controls are a mechanism for protecting all assets

  14. WHATIS GAPP?

  15. WHAT IS GAPP? Generally Accepted Privacy Principles Developed by the American Institute of Certified Public Accountants (AICPA) and the Canadian Institute of Chartered Accountants (CICA) to help guide organizations in implementing, sustaining, and auditing privacy programs. 17

  16. AICPA/CICA GENERALLY ACCEPTED PRIVACY PRINCIPLES Available for free download and use 10 Principles of privacy and 66 criteria, (soon to have an additional 8 criteria with the new exposure draft is finished with the review process) http://infotech.aicpa.org/Resources/Privacy/

  17. WHATARETHE PRINCIPLES? Management:The entity defines, documents, communicates, and assigns accountability for its privacy policies and procedures. 1. 4. Collection: The entity collects personal information only for the purposes identified in the notice. 19 5. Use and Retention: The entity limits the use of personal information to the purposes identified in the notice and for which the individual has provided implicit or explicit consent. The entity retains personal information for only as long as necessary to fulfill the stated purposes. Notice: The entity provides notice about its privacy policies and procedures and identifies the purposes for which personal information is collected, used, retained, and disclosed. 2. Choice and Consent: The entity describes the choices available to the individual and obtains implicit or explicit consent with respect to the collection, use, retention, and disclosure of personal information. 3.

  18. WHATARETHE PRINCIPLES? 6. Access: The entity provides individuals with access to their personal information for review and update. 9. Quality: The entity maintains accurate, complete, and relevant personal information for the purposes identified in the notice. 20 7. Disclosure: The entity discloses personal information to third parties only for the purposes identified in the notice and with the implicit or explicit consent of the individual. 10. Monitoring and Enforcement: The entity monitors compliance with its privacy policies and procedures and has procedures to address privacy-related complaints and disputes. 8. Security for Privacy: The entity protects personal information against unauthorized access (both physical and logical).

  19. COMPONENTS OF GAPP Consistency ofCommitments With Privacy Policies and Procedures Infrastructure and Systems Management 21

  20. WHYHASTHE AICPA/CICA ISSUEDANUPDATETO GAPP IN THEFORMOFANEXPOSURE DRAFT?

  21. CONTINUOUSIMPROVEMENTOF GAPP Major changes Modification of 2 criteria 8 new criteria

  22. WHATISTHE GLOBAL PRIVACY STANDARD?

  23. GLOBAL PRIVACY STANDARD Final version of the GPS was formally in the United Kingdom, on November 3, 2006, at the 28th International Data Protection Commissioners Conference Championed and developed by Commissioner Ann Cavoukian, Ontario 10 Principles

  24. WHATARETHESENEWREDFLAG RULESTHATAREINTHENEWS?

  25. NEW RED FLAG RULESEFFECTIVEMAY 1, 2009: POSTPONEDUNTIL 8/1/2009 Require each financial institution and creditor that holds any consumer account, or other account for which there is a reasonably foreseeable risk of identity theft, to develop and implement an Identity Theft Prevention Program (Program) for combating identity theft in connection with new and existing accounts. Originally effective May 1, 2009. The program can be different, depending on the organization s size and complexity. Thus, a small physician practice might have a much different program than a large hospital. Programs should include four basic points/steps, which could be covered under one or multiple policies. http://www.hinshawlaw.com/health-care-identity-theft-prevention-programs-and-red-flags-rules-compliance-03-10-2009/

  26. 4 REQUIRED STEPS Identify Common Red Flags Detect Red Flags Responses to Red Flags Program Execution and Updates http://www.hinshawlaw.com/health-care-identity-theft-prevention-programs-and-red-flags-rules-compliance-03-10-2009/

  27. WHATISTHERELATIONSHIPOF PRIVACYANDOTHERMORE TRADITIONALAREASOF AIS, AUDIT, ANDASSURANCE

  28. THEPRIMARYLINKTOTHESE 3 AREASIS effective internal controls! GAPP provides tangible criteria that can be audited and about which assurances can be made.

  29. 3 TRICKSTOGETTINGHORSESBACKINTHEBARN & KEEPINGTHEMTHERE Teach your horse that you are in control over him/her. Corporate Culture towards the use and management of personal information will likely have to change. Who owns and controls the data? Make it dang hard for the horse to do the wrong thing. Implement privacy enhancing policies, procedures, and controls. Ride a lot! Test the use and management of your data frequently.

  30. WHATARESOMERESEARCH OPPORTUNITIES?

  31. IMPLICATIONS FOR CA/CM RESEARCH Descriptive research: What are companies actually doing? Are they aware of the issues? If so, how are they handling these issues? Are they using some kind of data masking during these processes? Normative research: How can we build privacy protection into processes? Data tagging and masking Data replication (logging) Security around possession and handling Data life and destruction techniques (poison pills)

  32. FURTHER QUESTIONS? marilyn.prosch@asu.edu twitter.com/ProfofPrivacy

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