client-side server-side security

# 14.5. HIPAA and HITECH Obligations

Certain organizations that interact with protected health information (PHI) have obligations to follow HIPAA/HITECH - the Health Insurance Portability and Accountability Act (1996) and the Health Information Technology for Economic and Clinical Health Act (2009).

The following illustrates a non-exhaustive list of how SFTPPlus can help meet your organization's regulatory obligations under HIPAA/HITECH.

This guide is aimed at those involved in administering file transfer systems in hospitals, clinics, health care and medical practice organizations and practices either in-house or as a third party consultancy.

If you are looking for a secure file transfer software solution in other compliance jurisdictions for the medical and health care industry, you can still read the examples below as a guide. For more information about what we can do for your specific requirements, please contact the Sales team.

## 14.5.1. Introduction

SFTPPlus can help organizations meet their HIPAA/HITECH obligations by providing a centralized secure managed file transfer solution using the main standard file transfer protocols over a wide range of supported platforms, with authentication controls and utilizing a detailed audit trail.

Appropriate processes should be defined by the organization in order that the obligations are met. Such processes will vary according to the specific scenario, organization scale and other factors.

For example, one of the key requirements revolves around the audit trail. Please see the page on the audit trail for more details.

Please note that readership of this page is oriented towards those with existing familiarity to HIPAA/HITECH recommendations.

## 14.5.2. Information System Activity Review

The audit trail allows administrators to conduct a review of records of information system activity in relation to file transfer activities.

Examples of such changes captured in the audit trail include:

1. Changes to file transfer services such as enabling a service or changing the listening port.

2. Changes to different identity and authentication providers of an account.

3. Changes to components that implement custom business logic for file transfer workflows.

4. Changes to component states such as the start / stop / failure states.

5. And more as a multitude of components make up the file transfer process.

Corresponding HIPAA requirements: § 164.308 (a)(ii)(D)

## 14.5.3. Access Control

There are a number of components used to configure access control such as lock_in_home_folder options. Accounts can be application specific, operating system, can authenticate against an LDAP server, or accounts can be supplied by third party identity providers.

SFTPPlus can be configured to utilize existing policies and procedures to allow access only to accounts that have been granted access rights.

Corresponding HIPAA requirements: § 164.312 (a)(1)

## 14.5.4. Unique User Identification

UUIDs are used by the SFTPPlus server to support renaming of accounts, services, servers, and to provide a detailed audit of all activities performed by an entity. In this case, UUIDs can be set to specific users.

Corresponding HIPAA requirements: § 164.312 (a)(2)(i)

## 14.5.5. Automatic Logoff

A timeout can be implemented for a client connection that has been idle for a configurable amount of time.

Corresponding HIPAA requirements: § 164.312 (a)(2)(iii)

## 14.5.6. Audit Control

SFTPPlus logs changes to settings that pertain to the file transfer process.

Changes to components such as listening ports and protocols are tested and logged so that changes to the configuration settings are automatically available (before and after installation).

Since there is a number of components that can be configured when managing file transfers - such as protocols, listening ports, user / group authentication, event handlers, email notifications and more - there is a page on the audit trail available for further reading on what is available.

Corresponding HIPAA requirements: § 164.312 (b)

## 14.5.7. Integrity

SFTPPlus logs user actions such as moving, copying, renaming or deleting files to help organizations implement policies to protect PHI from improper changes.

Corresponding HIPAA requirements: § 164.312 (c)(1)(2)

## 14.5.8. Person or Entity Authentication

Users are authenticated via application-only settings or via the authentication methods provided by the operating system.

Use of secure authentication methods such as password stored using one way encryption method or SSH key-based authentication will also help improve transmission security when authenticating.

Log in attempts are also included in the audit trail for further review.

Corresponding HIPAA requirements: § 164.312 (2)(d), § 164.308 (5)(ii)(C)

## 14.5.9. Transmission Security

Transmission settings are logged, thus validating secure transmission of PHI (protected health information). For example, SFTPPlus will keep a detailed log of any file transferred (push / pulled). This can include details about the initial transfer request and the status of the request finalization (success / failure).

Corresponding HIPAA requirements: § 164.312 (e)(1)

## 14.5.10. Encryption and Decryption

SFTPPlus will work with the current encryption/decryption mechanism that is already available on the operating system in which the software is installed.

Corresponding HIPAA requirements: § 164.312 (a)(2)(iv)

## 14.5.11. Encryption

A number of cryptography method, protocols, and algorithms are supported by SFTPPlus. Please see the page on cryptography for further details.

An example of how SFTPPlus can help organizations with HIPAA/HITECH obligations is the use of transfer method encryption to help maintain the integrity of ePHI. Organizations can opt to use FTPS or SFTP for file transfer rather than FTP.

Corresponding HIPAA requirements: § 164.312 (e)(2)(ii)

## 14.5.12. Breach Notification

HIPAA covered entities and their business associates are required to provide notification following a breach of unsecured protected health information. Similar breach notification provisions implemented and enforced by the Federal Trade Commission (FTC), apply to vendors of personal health records and their third party service providers, pursuant to section 13407 of the HITECH Act.

FIPS 140-2 is required by HHS guidelines to comply with the HITECH breach notification guidelines. Further details about FIPS 140-2 and SFTPPlus is available in this guide.

Further details are available on on HHS.

Corresponding HIPAA requirements: §§ 164.400-414

## 14.5.13. Is SFTPPlus HIPAA/HITECH Compliant?

Customers are reminded that there is no certification for HIPAA/HITECH compliance and that this page does not serve as confirmation of compliance.

SFTPPlus can help organizations with HIPAA/HITECH obligations. SFTPPlus is an on-premise software application focusing on secure file transfer only. Data, including PHI data, is not stored, analyzed, intercepted, or recorded by SFTPPlus. Since SFTPPlus acts as a conduit that transports data, as such it is not an entity considered to be a business associate as there is no need for access to the PHI.

The SFTPPlus software provides an audit trail of events that have taken place during the file transfer process. These logs are stored on-premise. Customers with HIPAA/HITECH obligations that are required to send logs to Pro:Atria Support are encouraged to sanitize logs sent through as an additional measure.

14.4. Notes for ISO27001
14.6. Protective Monitoring Obligations