Information Security Policy

1. Purpose and Scope

1.1 Purpose

This Information Security Policy establishes the administrative, physical, and technical safeguards required to protect the confidentiality, integrity, and availability of Protected Health Information (PHI) in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule (45 CFR Part 164, Subpart C).

1.2 Scope

This policy applies to all workforce members, including employees, contractors, volunteers, and any other persons whose conduct is under the direct control of the organization, who have access to PHI through the MedConsult AI platform or related systems.

2. Definitions

3. Roles and Responsibilities

3.1 Privacy Officer

Responsible for developing and implementing privacy policies, conducting privacy training, investigating complaints, and ensuring compliance with privacy regulations.

3.2 Security Officer

Responsible for implementing and maintaining security safeguards, conducting risk assessments, managing security incidents, and ensuring compliance with security regulations.

3.3 Workforce Members

All workforce members are responsible for complying with this policy, completing required training, reporting security incidents, and protecting PHI in their possession.

4. Access Control Policy

4.1 Unique User Identification

Each user must be assigned a unique identifier (username) for tracking user activity. Sharing of login credentials is strictly prohibited.

4.2 Authentication Requirements

• Multi-factor authentication (MFA) is required for all users
• Passwords must meet complexity requirements (minimum 12 characters)
• Passwords must be changed every 90 days
• Previous 12 passwords cannot be reused

4.3 Automatic Session Termination

User sessions will automatically terminate after 15 minutes of inactivity. Users must re-authenticate to regain access.

4.4 Minimum Necessary Access

Access to PHI is restricted to the minimum necessary to accomplish the intended purpose. Access privileges are reviewed quarterly and adjusted as needed.

5. Workforce Security

5.1 Background Checks

Background checks are performed for all workforce members with access to PHI prior to granting access.

5.2 Access Authorization

Access to PHI must be formally authorized by management. Access requests are documented and approved before access is granted.

5.3 Termination Procedures

Upon termination, access to all systems containing PHI must be revoked immediately. Physical access badges, keys, and equipment must be collected.

6. Information System Activity Review

The organization implements procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.

• Audit logs are reviewed weekly for unusual activity
• Failed login attempts are monitored and investigated
• Access to sensitive records is logged and reviewed
• Audit logs are retained for a minimum of 6 years

7. Security Incident Procedures

7.1 Incident Identification

All workforce members must immediately report suspected or confirmed security incidents to the Security Officer.

7.2 Incident Response

The Security Officer will investigate all reported incidents, document findings, take corrective action, and report to management. See the Breach Response Plan for detailed procedures.

8. Contingency Plan

• Data Backup: PHI is backed up daily with copies stored securely offsite
• Disaster Recovery: Documented procedures for restoring systems within 24 hours
• Emergency Access: Procedures for accessing PHI during emergencies while maintaining security
• Testing: Contingency plans are tested annually

9. Device and Media Controls

• PHI stored on portable devices must be encrypted
• Devices containing PHI must not be left unattended
• Media containing PHI must be securely destroyed before disposal
• All devices must be tracked in an inventory system

10. Audit Controls

The organization implements hardware, software, and procedural mechanisms to record and examine activity in systems that contain or use ePHI.

• All access to PHI is logged with timestamp and user ID
• All modifications to PHI are logged
• Login attempts (successful and failed) are logged
• Administrative actions are logged

11. Transmission Security

• All ePHI transmitted over networks must be encrypted using TLS 1.2 or higher
• Email containing PHI must use secure/encrypted email services
• Wireless networks must use WPA3 or equivalent encryption
• VPN must be used for remote access to PHI

12. Business Associate Management

Business Associate Agreements (BAAs) must be executed with all vendors who create, receive, maintain, or transmit PHI on behalf of the organization. BAAs must include required HIPAA provisions.

• All business associates are documented in a BA inventory
• BAAs are reviewed annually for compliance
• Business associates must report security incidents

13. Policy Enforcement

Violations of this policy may result in disciplinary action, up to and including termination of employment. Serious violations may be reported to law enforcement and regulatory agencies.

14. Policy Review and Updates

This policy will be reviewed annually and updated as necessary to address changes in the organization's operations, technology environment, or regulatory requirements.

Policy Acknowledgment