Purpose:

The purpose of the Commitment to Security Statement is to provide ConsensioHealth’s clients and prospective clients with an objective description of the system’s boundaries and security commitments.

Policy:
Commitment to Security

Health information is an important asset to the company. ConsensioHealth along with its employees, are committed to protecting the integrity, privacy and security of confidential health information as required by law, professional ethics, and accreditation requirements.

ConsensioHealth acknowledges the duty and responsibility to protect the privacy and security of Individually Identifiable Health Information (“IIHI”) generally, and Protected/ Personal Health Information (“PHI”) specifically, as defined in:

The Privacy and Information Security Regulations of each region,
Other applicable laws protecting the confidentiality of personal information,
Under principles of general and professional ethics.

ConsensioHealth also acknowledges the duty and responsibility to support and facilitate the timely and unimpeded flow of health information for lawful and appropriate purposes. All ConsensioHealth employees and contractors must comply with the requirements of regulations with respect to privacy principles of minimum necessary use, security safeguards and controls, and accountability and oversight; and make reasonable efforts to limit use of and access to PHI within its systems.

ConsensioHealth has implemented appropriate privacy and security policies and procedures to meet, and in many instances, exceed, the relevant privacy and security standards for five (5) key areas outlined below:

1. ADMINISTRATIVE SAFEGUARDS
ConsensioHealth has implemented policies, practices and procedures to safeguard protected health information as defined in the Information Security Standards and relevant Regulations including, but not limited to the following policies:

Security Management Process
– ConsensioHealth has implemented policies and procedures including Risk Analysis to identify potential risk and vulnerabilities to the confidentiality, integrity and availability of PHI and remediate those risks as needed.
– ConsensioHealth has a comprehensive Risk Management Policy including routine internal and external security audits, use of third-party security experts and annual review of all security policies and procedures.

Sanction Policy
– ConsensioHealth maintains Human Resource Policies regarding employees and contractor’s conduct relative to a number of areas that impact PHI. The Human Resource Policies highlights the potential range of penalties when employees and contractors violate any of the policies.

Information System Activity Review
– ConsensioHealth has implemented automated and continuous system monitoring that provides alerts and notifications to service staff. This includes procedures to follow when a system alert occurs.

Assigned Security Responsibility
– ConsensioHealth has identified an Information Security Officer and Privacy Officer. The Information Security Officer is responsible for the overall security policies.
– The Privacy Officer is responsible for all privacy policies and related matters. The Information Security Officer works is responsible for the development, maintenance, workforce training and implementation of company privacy and security policies and procedures.

Workforce Security
– ConsensioHealth employees and contractors may have access to PHI as this may be related to their job function. Where access is required, this is minimized to an as needed basis. Employment at ConsensioHealth is subject to completion of a successful background check.
– ConsensioHealth has a termination policy and procedure in place to ensure that access to all systems and information is locked upon termination.

Information and Access Management
– Access to all resources is controlled by Access Control Policy. The level of access is based on the employee or contractor’s job description within the organization.

Security Awareness and Training
– All ConsensioHealth employees and contractors are required to have Information Security training upon hire and at least annually thereafter.
– ConsensioHealth utilizes malware software on all production, development and test servers and on all user workstations. This includes real time scanning and nightly and weekly scans for all files and folders contained on each computer. Anti-malware databases are configured to be updated every hour for new signatures that are being made.
– ConsensioHealth requires the use of complex passwords.
– ConsensioHealth monitors all log-on attempts. Logs are reviewed monthly for unauthorized access where this is not automatically alerted.

Security Incident Protection and Response
– ConsensioHealth maintains an Incident Management process in order to facilitate the reporting of potential security incidents and/or breaches. ConsensioHealth takes all suspected incidents seriously and investigates all suspected incidents immediately.

Contingency Plan
– ConsensioHealth maintains a Data Back-up Plan which creates and maintains retrievable copies of data within application level clustering and replication, disk and tape backups, snapshots on storage devices and storage device replication. Where data is hosted by a third party, this process is managed by ConsensioHealth with the third party.
– ConsensioHealth maintains a disaster recovery plan for recovery in the event of failure or disaster including all critical elements of the applications, snapshot technology in the event of major data corruption, backup databases for production data and an alternate site in the event the primary site goes down.
– ConsensioHealth periodically tests contingency plans to verify procedural steps are valid and to provide updates to the procedures.
– All ConsensioHealth applications, including its elements such as the network, servers, storage and databases are equipped and operated at high-availability.

2. PHYSICAL SAFEGUARDS

Workstation Security
– ConsensioHealth has implemented policies and procedures that govern the use and security of employee and contractor’s workstations, including laptops and portable devices.

Device and Media Controls
– ConsensioHealth has implemented policies and procedures that govern the movement of all devices and media. This includes disposal, re-use, data back-up, and data storage.

3. TECHNICAL SAFEGUARDS
ConsensioHealth has implemented policies and procedures in order to meet all the required and addressable specifications as defined in the relevant regional Information Security Regulations. These policies and procedures include:

Access Control
– Unique user IDs and secure passwords for access to systems
– Automatic Log off procedures
– Emergency Access procedures
– Data that is moving is encrypted, with data at rest is either encrypted or de-identified.

Audit Control
– All remote access to servers, network and storage equipment is logged. Database access and activities are also logged locally and centrally. Where able, all web accesses to the applications from users are logged in a platform and/or application specific database down to the activity level.

Integrity Control
– Digital Signatures are employed to protect data from improper alteration or destruction during transit.

Monitoring and Alerting
ConsensioHealth uses several systems and tools that complement each other to provide the best protection and coverage for its hosted application environments. These include monitoring and alerting for the following:
– System and Services Health and Availability
– Resource Capacity and Utilization Monitors
– Application Performance Monitors
– Synthetic and Real User Monitors

4. ORGANIZATIONAL REQUIREMENTS
ConsensioHealth maintains Agreements with all applicable customers and vendors relevant to the regional legislation and regulations. Agreements are reviewed annually to ensure compliance with the latest requirements.

5. DOCUMENTATION REQUIREMENTS
Annual Assessments
– ConsensioHealth has a comprehensive Compliance Audit Plan which includes a review of policies and practices.

Vendor Management Program
– ConsensioHealth has a Vendor Management Program in place to evaluate, select and monitor vendors in order to minimize the risks associated with vendors working with Sensitive or Personal Information. This program includes vendor screening, Agreements, Service Level Agreements, and monitoring.

Applies To:
This policy applies to all employees and contractors of ConsensioHealth. Violation of this policy could result in disciplinary action leading up to and including termination of employment and/or legal action.

Policy Owner:
Chief Information Officer
Date of Last Update: 08/22/2023