IT Inventory & Asset Management | Device42 SoftwareLast week, in its Cybersecurity Summer Newsletter, the Office of Civil Rights (OCR) published best practices for creating an IT asset inventory list to assist healthcare providers and business associates in understanding where electronic protected health information (ePHI) is located within their organization, and improve HIPAA Security Rule compliance.  OCR investigations often find that organizations “lack sufficient understanding” of where all of their ePHI is located, and while the creation of an IT asset inventory list is not required under the HIPAA Security Rule, it could be helpful in the development of a risk analysis, and in turn and implementing appropriate safeguards – which are HIPAA Security Rule requirements. Essentially, if an organization doesn’t know what IT assets it has or where its ePHI is, how can it effectively assess the risks associated with those assets and information and protect them?

The lack of an inventory, or an inventory lacking sufficient information, can lead to gaps in an organization’s recognition and mitigation of risks to the organization’s ePHI.  Having a complete understanding of one’s environment is key to minimizing these gaps and may help ensure that a risk analysis is accurate and thorough, as required by the Security Rule.

In general, an organization’s IT asset inventory list consists of “IT assets with corresponding descriptive information, such as data regarding identification of the asset (e.g., vendor, asset type, asset name/number), version of the asset (e.g., application or OS version), and asset assignment (e.g., person accountable for the asset, location of the asset.”

The OCR Newsletter suggests including the follow types of assets in an organization’s IT asset inventory list:

  • Hardware assets that comprise physical elements, including electronic devices and media, which make up an organization’s networks and systems. This can include mobile devices, servers, peripherals, workstations, removable media, firewalls, and routers.
  • Software assets that are programs and applications which run on an organization’s electronic devices. Well-known software assets include anti-malware tools, operating systems, databases, email, administrative and financial records systems, and electronic medical/health record systems. Though lesser known, there are other programs important to IT operations and security such as backup solutions, virtual machine managers/hypervisors, and other administrative tools that should be included in an organization’s inventory.
  • Data assets that include ePHI that an organization creates, receives, maintains, or transmits on its network, electronic devices, and media. How ePHI is used and flows through an organization is important to consider as an organization conducts its risk analysis.

In addition, the OCR Newsletter recommends the inclusion of IT assets that don’t necessarily store or process ePHI, but that still may lead to a security incident, such as Internet of Things (IoT) or other smart devices.  For example, a recent study by Quocirca, a security research firm, found that approximately 60 % of businesses in in the U.S., U.K., France and Germany have suffered a IoT printer related data breach in 2019, with the average breach costing an organization approximately $400,000.

The OCR Newsletter also provides other cybersecurity-related and HIPAA compliance benefits an IT asset inventory list can provide, beyond the risk analysis. For example, HIPAA requires that covered entities and business associates “[i]mplement policies and procedures that govern the receipt and removal of hardware and electronic media that contain [ePHI] into and out of a facility, and the movement of these items within the facility”, which will be more efficient if the organization has IT asset inventory list that has location/owner/assignment information in place.  Moreover, an IT asset inventory list can aid an organization in identifying and tracking devices to ensure timely updates, patches and password changes.

HIPAA compliance is no doubt a significant challenge for large and small covered healthcare providers, and other covered entities and business associates, and data breaches are almost inevitable. Preparation of a comprehensive IT asset inventory, while not required, can go a long way in both ensuring HIPAA compliance, and preventing a security incident.  Below are some additional basic compliance measures:

  • Provide training and improve security awareness for workforce members when they begin working for the organization and periodically thereafter.
  • Maintain written policies and procedures that address required administrative, physical, and technical safeguards required under the Security Rule.
  • Maintain business associate agreements with all business associates.
  • Document compliance efforts.
  • Maintain and practice an incident response plan in the event of a data breach.
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Photo of Joseph J. Lazzarotti Joseph J. Lazzarotti

Joseph J. Lazzarotti is a Principal in the Morristown, New Jersey, office of Jackson Lewis P.C. He founded and currently leads the firm’s Privacy, e-Communication and Data Security Practice, edits the firm’s Privacy Blog, and is a Certified Information Privacy Professional (CIPP) with…

Joseph J. Lazzarotti is a Principal in the Morristown, New Jersey, office of Jackson Lewis P.C. He founded and currently leads the firm’s Privacy, e-Communication and Data Security Practice, edits the firm’s Privacy Blog, and is a Certified Information Privacy Professional (CIPP) with the International Association of Privacy Professionals. Trained as an employee benefits lawyer, focused on compliance, Mr. Lazzarotti also is a member of the firm’s Employee Benefits Practice Group.

In short, his practice focuses on the matrix of laws governing the privacy, security, and management of data, as well as the impact and regulation of social media. He also counsels companies on compliance, fiduciary, taxation, and administrative matters with respect to employee benefit plans.

Privacy and cybersecurity experience – Mr. Lazzarotti counsels multinational, national and regional companies in all industries on the broad array of laws, regulations, best practices, and preventive safeguards. The following are examples of areas of focus in his practice:

  • Advising health care providers, business associates, and group health plan sponsors concerning HIPAA/HITECH compliance, including risk assessments, policies and procedures, incident response plan development, vendor assessment and management programs, and training.
  • Coached hundreds of companies through the investigation, remediation, notification, and overall response to data breaches of all kinds – PHI, PII, payment card, etc.
  • Helping organizations address questions about the application, implementation, and overall compliance with European Union’s General Data Protection Regulation (GDPR) and, in particular, its implications in the U.S., together with preparing for the California Consumer Privacy Act.
  • Working with organizations to develop and implement video, audio, and data-driven monitoring and surveillance programs. For instance, in the transportation and related industries, Joe has worked with numerous clients on fleet management programs involving the use of telematics, dash-cams, event data recorders (EDR), and related technologies. He also has advised many clients in the use of biometrics including with regard to consent, data security, and retention issues under BIPA and other laws.
  • Assisting clients with growing state data security mandates to safeguard personal information, including steering clients through detailed risk assessments and converting those assessments into practical “best practice” risk management solutions, including written information security programs (WISPs). Related work includes compliance advice concerning FTC Act, Regulation S-P, GLBA, and New York Reg. 500.
  • Advising clients about best practices for electronic communications, including in social media, as well as when communicating under a “bring your own device” (BYOD) or “company owned personally enabled device” (COPE) environment.
  • Conducting various levels of privacy and data security training for executives and employees
  • Supports organizations through mergers, acquisitions, and reorganizations with regard to the handling of employee and customer data, and the safeguarding of that data during the transaction.
  • Representing organizations in matters involving inquiries into privacy and data security compliance before federal and state agencies including the HHS Office of Civil Rights, Federal Trade Commission, and various state Attorneys General.

Benefits counseling experience – Mr. Lazzarotti’s work in the benefits counseling area covers many areas of employee benefits law. Below are some examples of that work:

  • As part of the Firm’s Health Care Reform Team, he advises employers and plan sponsors regarding the establishment, administration and operation of fully insured and self-funded health and welfare plans to comply with ERISA, IRC, ACA/PPACA, HIPAA, COBRA, ADA, GINA, and other related laws.
  • Guiding clients through the selection of plan service providers, along with negotiating service agreements with vendors to address plan compliance and operations, while leveraging data security experience to ensure plan data is safeguarded.
  • Counsels plan sponsors on day-to-day compliance and administrative issues affecting plans.
  • Assists in the design and drafting of benefit plan documents, including severance and fringe benefit plans.
  • Advises plan sponsors concerning employee benefit plan operation, administration and correcting errors in operation.

Mr. Lazzarotti speaks and writes regularly on current employee benefits and data privacy and cybersecurity topics and his work has been published in leading business and legal journals and media outlets, such as The Washington Post, Inside Counsel, Bloomberg, The National Law Journal, Financial Times, Business Insurance, HR Magazine and NPR, as well as the ABA Journal, The American Lawyer, Law360, Bender’s Labor and Employment Bulletin, the Australian Privacy Law Bulletin and the Privacy, and Data Security Law Journal.

Mr. Lazzarotti served as a judicial law clerk for the Honorable Laura Denvir Stith on the Missouri Court of Appeals.