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Figure 8-1
Normative control mapping of HIPAA, PCI DSS, and SOX controls
The normative mapping arrangement would assign equivalence to controls by assigning them to new controls within the normalized framework The new framework would represent the unified set of controls that everyone in the company had to meet, and it no longer required the various compliance projects to concentrate on the specifics of HIPAA or of PCI DSS Another advantage of this approach included a greater flexibility in treating more ambiguous controls, such as those required under SOX, in a way that best met the goals of the organization The limitations of the normative mapping strategy included a need for standard, sometimes more generalized language to be used to address the controls of multiple frameworks This raised concerns that in an audit situation the auditors would be looking for very precise terminology specific to the compliance requirements they were assessing This would require careful scrutiny by the hospital s corporate counsel and thorough documentation of the new controls framework so that mapping these controls back to the original framework requirements would be straightforward Transitive Control Mapping The transitive mapping strategy did not involve creating an entirely new controls framework, but instead took the approach of prioritizing one of the existing frameworks into a key compliance requirement against which the others were mapped It was decided that HIPAA was the priority framework and therefore should be the central control set Figure 8-2 shows the same sample set of previously examined controls reconfigured into a transitive control map The risk managers thought this strategy benefited from the need for fewer resources on the front end to map between the
HIPAA (Prioritized Framework) 164308(a)(1)(ii)(A) SOX Section 404 1212 51 164308(a)(5)(ii)(B) PCI DSS 511 52
Figure 8-2
Transitive control mapping of HIPAA, PCI DSS, and SOX controls
8:
Measuring Compliance and Conformance
various controls Since no new framework was needed, the majority of the effort could be focused on identifying specific equivalencies between the HIPAA controls and the other frameworks If controls did not overlap, they would remain as they were and be handled by the specific teams responsible for that area of compliance It was assumed in this scenario that the main goal would be a CCF of only those controls that overlapped, which would then be assigned and coordinated among the various teams The risk managers also identified several limiting factors of the transitive mapping strategy The first limitation involved the assumptions when mapping the frameworks together When a PCI DSS control was mapped to a HIPAA control, an equivalent relationship was established The same thing occurred when a SOX control was mapped to the same HIPAA control By mapping these two controls to the same HIPAA control, however, there was also an implied equivalence between the PCI DSS and the SOX control, although these controls were not explicitly mapped to one another The risk management team saw in these implied relationships the potential for audit risks if controls that had not been mapped were implemented as though they were the same control, even if they met the primary control requirement The second limitation identified was the inverse of the first By choosing to map only through HIPAA, equivalent controls in other frameworks might not be identified, because they had no equivalent in the primary framework This would mean that redundancies and duplicated efforts would continue among the compliance teams The false positive and false negative equivalents that were possible under this system were viewed as the primary limiting factors of the strategy Granular Control Mapping Granular control mapping attempts a one-to-one crossreferencing of every control in every framework against every other control in every framework All equivalencies are identified and documented Figure 8-3 shows the sample of controls mapped under a granular strategy In a granular map, nothing is left to chance, and every relationship between every control is identified and documented
HIPAA 164308(a)(1)(ii)(A)
HIPAA 164308(a)(5)(ii)(B)
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