NY Dept. of Health: Hospital Cybersecurity Readiness
What New York hospitals must do to comply with the state’s new cybersecurity regulations—and practical steps to prepare.
Effective Dates
- Incident Reporting: 72-hour reporting window begins October 2024.
- Regulations Effective: For all general hospitals by October 2, 2025.
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What Hospitals Must Do
- Immediate Incident Reporting: Report any material cybersecurity incident to NYSDOH within 72 hours (ransomware, breaches, material operational impact).
- Written Cybersecurity Program: Implement and maintain a documented program covering risk management, data protection, vulnerability testing, and incident response—with specific protection for all nonpublic information (PII, PHI, business data).
- Annual Risk Assessments & Testing: Conduct thorough risk assessments at least annually; perform vulnerability scanning and penetration testing on a regular schedule.
- CISO Appointment & Annual Report: Designate a qualified CISO to oversee controls and submit a detailed annual report to the hospital board.
- Employee Training: Provide cybersecurity awareness and response training for all staff (clinical and administrative).
- Incident Response & Audit Trails: Maintain an actionable IR plan and keep audit trails for at least six years to support investigations, reporting, and ongoing compliance.
- Third-Party Vendor Security: Ensure all vendors with system/data access meet strict standards and are evaluated regularly for compliance risks.
Preparation Steps for CISOs
- Confirm every third-party vendor can demonstrate compliance and formalize due-diligence processes.
- Ensure board-level visibility and documentation for the annual CISO report.
- Conduct tabletop exercises and staff cyber training.
- Schedule risk assessments, vulnerability scans, and penetration testing ahead of the deadline.
- Review and revise all cyber policies and procedures to reflect the new regulatory language and risk landscape.
FAQ: NYSDOH Hospital Cyber Requirements
The rules are effective for all New York general hospitals by October 2, 2025, with the 72-hour incident reporting requirement beginning in October 2024.
Incidents that materially impact operations, involve ransomware, or result in the compromise of nonpublic information (e.g., PHI/PII) should be treated as reportable within the 72-hour window.
- Risk management and governance
- Data protection for all nonpublic information (PII, PHI, business data)
- Vulnerability management and penetration testing cadence
- Incident response (IR) procedures and audit trail retention
- Third-party/vendor access controls and review
- Staff training and awareness
At minimum, annual risk assessments with ongoing vulnerability scanning; penetration testing should be scheduled on a regular cadence appropriate to your risk profile and system changes.
A qualified CISO must oversee controls and deliver a formal annual report to the board, covering program effectiveness, material risks, incidents, and remediation progress.
Maintain audit trails for at least six years to support investigations, reporting, and ongoing compliance.
Vendors with system or data access must meet strict controls and undergo regular due-diligence and compliance reviews (contractual requirements, evidence of controls, and remediation timelines).
- Readiness assessment mapped to NYSDOH requirements
- Testing plan (risk assessment, scans, penetration testing)
- IR tabletop facilitation and staff training
- Board-ready reporting templates and CISO support
- Vendor due-diligence playbooks and review
Stay Ahead of NYS DOH Requirements
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