PHI Leakage (Protected Health Information)

Routine reviews of user accounts and their associated privileges and permissions should be conducted to identify overly-permissive accounts, or accounts that are no longer required to be active.

A Data Loss Prevention (DLP) solution refers to policies, technologies, and controls that prevent the accidental and/or deliberate loss, misuse, or theft of data by members of an organization. Typically, DLP technology would take the form of a software agent installed on organization endpoints (such as laptops and servers).

Typical DLP technology will alert on the potential loss of data, or activity which might indicate the potential for data loss. A DLP technology may also provide automated responses to prevent data loss on a device.

A Data Classification Policy establishes a standard for handling data by setting out criteria for how data should be classified and subsequently managed and secured. A classification can be applied to data in such a way that the classification is recorded in the body of the data (such as a footer in a text document) and/or within the metadata of a file.

An Acceptable Use Policy (AUP) is a set of rules outlining acceptable and unacceptable uses of an organization's computer systems and network resources. It acts as a deterrent to prevent employees from conducting illegitimate activities by clearly defining expectations, reinforcing legal and ethical standards, establishing accountability, specifying consequences for violations, and promoting education and awareness about security risks.

This section cannot be readily mitigated at a system level with preventive controls since it is based on the abuse of fundamental features of the system.

Regulation Awareness Training equips staff with the knowledge and understanding required to comply with legal, regulatory, and policy obligations relevant to their roles. This includes, but is not limited to, export controls, international sanctions, anti-bribery laws, conflict-of-interest rules, antitrust regulations, and data protection requirements.

The training should be customized according to the specific risks of different roles within the organization, ensuring that employees in high-risk areas—such as legal, procurement, sales, finance, engineering, and senior management—receive in-depth education on how to recognize and avoid behaviors that could lead to regulatory violations. Scenarios that could result in inadvertent or intentional breaches should be addressed, alongside practical advice on how to report concerns and escalate issues.

To accommodate varying learning styles and operational needs, Regulation Awareness Training can be delivered through multiple formats:

• eLearning Modules: For general staff, to provide flexible, scalable training on compliance topics, which can be completed at the employee's convenience.
• Instructor-led Sessions: For higher-risk roles or senior management, where more interactive, in-depth training may be necessary to address complex regulatory requirements and nuanced decision-making.
• Scenario-based Workshops: To reinforce learning with real-world examples and role-playing exercises that help employees internalize regulatory concepts.

By fostering a culture of compliance and accountability, Regulation Awareness Training helps minimize the risk of breaches, whether intentional or accidental, and strengthens the organization’s ability to identify, prevent, and respond to regulatory infringements.

An agent capable of Endpoint Detection and Response (EDR) is a software agent installed on organization endpoints (such as laptops and servers) that (at a minimum) records the Operating System, application, and network activity on an endpoint.

Typically EDR operates in an agent/server model, where agents automatically send logs to a server, where the server correlates those logs based on a rule set. This rule set is then used to surface potential security-related events, that can then be analyzed.

An EDR agent typically also has some form of remote shell capability, where a user of the EDR platform can gain a remote shell session on a target endpoint, for incident response purposes. An EDR agent will typically have the ability to remotely isolate an endpoint, where all network activity is blocked on the target endpoint (other than the network activity required for the EDR platform to operate).

An agent capable of User Activity Monitoring (UAM) is a software agent installed on organization endpoints (such as laptops); typically, User Activity Monitoring agents are only deployed on endpoints where a human user Is expected to conduct the activity.

The User Activity Monitoring agent will typically record Operating System, application, and network activity occurring on an endpoint, with a focus on activity that is or can be conducted by a human user. The purpose of this monitoring is to identify undesirable and/or malicious activity being conducted by a human user (in this context, an Insider Threat).

Typical User Activity Monitoring platforms operate in an agent/server model where activity logs are sent to a server for automatic correlation against a rule set. This rule set is used to surface activity that may represent Insider Threat related activity such as capturing screenshots, copying data, compressing files or installing risky software.

Other platforms providing related functionality are frequently referred to as User Behaviour Analytics (UBA) platforms.

An agent capable of User Behaviour Analytics (UBA) is a software agent installed on organizational endpoints (such as laptops). Typically, User Activity Monitoring agents are only deployed on endpoints where a human user is expected to conduct the activity.

The User Behaviour Analytics agent will typically record Operating System, application, and network activity occurring on an endpoint, focusing on activity that is or can be conducted by a human user. Typically, User Behaviour Analytics platforms operate in an agent/server model where activity logs are sent to a server for automatic analysis. In the case of User Behaviour Analytics, this analysis will typically be conducted against a baseline that has previously been established.

A User Behaviour Analytic platform will typically conduct a period of ‘baselining’ when the platform is first installed. This baselining period establishes the normal behavior parameters for an organization’s users, which are used to train a Machine Learning (ML) model. This ML model can then be later used to automatically identify activity that is predicted to be an anomaly, which is hoped to surface user behavior that is undesirable, risky, or malicious.

Other platforms providing related functionality are frequently referred to as User Activity Monitoring (UAM) platforms.

A Data Loss Prevention (DLP) solution refers to policies, technologies, and controls that prevent the accidental and/or deliberate loss, misuse, or theft of data by members of an organization. Typically, DLP technology would take the form of a software agent installed on organization endpoints (such as laptops and servers).

Typical DLP technology will alert on the potential loss of data, or activity which might indicate the potential for data loss. A DLP technology may also provide automated responses to prevent data loss on a device.