Information Exchange Policies and Procedures

To meet the HITRUST information exchange policies and procedures requirement, you need formal, documented rules and operating procedures that protect information shared through any communication facility (email, chat, portals, APIs, file transfer, removable media). Your policy set must define acceptable use, encryption requirements, and clear responsibilities for anyone sending, receiving, or handling exchanged information. ¹

Key takeaways:

• Cover every exchange channel, not just email and SFTP; include SaaS collaboration, APIs, and support tooling.
• Make encryption and “who is responsible for what” explicit, then enforce it with technical controls and monitoring.
• Keep durable evidence: policies, procedures, configurations, exceptions, and proof that people follow the process.

“Information exchange” is where most organizations quietly lose control of sensitive data: files emailed to third parties, screenshots posted in tickets, exports sent to analysts, API payloads pushed to partners, or messages shared in collaboration tools. HITRUST CSF v11 09.s requires you to treat those exchanges as a governed process. The requirement is straightforward, but audits go sideways when teams have a generic “acceptable use” policy that never names exchange channels, never defines encryption rules, and never assigns accountability across business, IT, security, and third parties.

This page translates HITRUST CSF v11 09.s into an operator-ready implementation. You’ll get a practical blueprint: what must be in your policies, what procedures auditors expect to see, which teams own which pieces, and what evidence to retain. The goal is speed and clarity: you should be able to stand up a defensible program quickly, then mature it into consistent enforcement across tools, teams, and third parties. ¹

Regulatory text

Requirement (HITRUST CSF v11 09.s): “Formal exchange policies, procedures, and controls shall be in place to protect the exchange of information through the use of all types of communication facilities. Policies shall cover the acceptable use of communication facilities, encryption requirements, and responsibilities for protecting exchanged information.” ¹

Operator interpretation (what you must do):

• Write and approve a formal policy that governs information exchange across all communication facilities your organization uses.
• Back the policy with procedures people can follow (and that IT can enforce) for common exchange scenarios.
• Implement controls (technical and administrative) that match the policy, including encryption rules.
• Assign responsibilities: who classifies data, who approves sharing, who configures tools, who monitors, who responds to incidents, and what third parties must do when receiving your data. ¹

Plain-English interpretation of the requirement

HITRUST is asking for a managed “data sharing” system, not ad hoc behavior. If your workforce can send information by email, chat, ticketing tools, file-sharing links, APIs, or removable media, you must define:

1. What is allowed,
2. How it must be protected (especially encryption), and
3. Who is accountable at each step of the exchange lifecycle (prepare, transmit, receive, store, dispose). ¹

Who it applies to (entity and operational context)

Entity scope: All organizations assessed against HITRUST CSF v11. ¹

Operational scope (where auditors will look):

• Internal communications: email, chat, intranet, internal file shares, internal ticketing.
• External communications with third parties: customer support, implementation teams, data feeds, claims exchanges, payment processors, clinical partners, consultants, attorneys, auditors.
• Systems and integration paths: APIs, ETL pipelines, SFTP/managed file transfer, portal uploads, shared cloud drives, EDI-style exchanges.
• Edge cases that still count: printing/scanning, removable media, copying data into tickets, screen recordings, and “temporary” exports shared for troubleshooting.

If a channel can move sensitive information, it is “a communication facility” for purposes of this requirement. ¹

What you actually need to do (step-by-step)

Step 1: Inventory and categorize exchange pathways

Build a simple register of how information leaves or enters your control.

• Channels: email, MFT/SFTP, shared drives, collaboration tools, portals, APIs, ticketing attachments, mobile messaging, removable media, fax/scan (if relevant).
• Typical senders/receivers: workforce roles and third parties.
• Data types: map to your internal data classification scheme (or create a minimum viable one for “public / internal / sensitive / regulated”).
  Output: “Information Exchange Register” with owner per channel.

Step 2: Write the Information Exchange Policy (what’s allowed)

Your policy should be short but specific. Include:

• Acceptable use by channel: what data types can be sent over each channel; what is prohibited (for example, regulated data in unmanaged personal email).
• Approval rules: when security/privacy/Legal review is required; when a data sharing agreement is required; who can authorize exceptions.
• Minimum security requirements: encryption in transit, encryption at rest where applicable, access controls, link-sharing rules, MFA requirements for portals, retention limits for exchanged files.
• Third-party responsibilities: receiving party handling requirements, onward transfer prohibitions, incident notification expectations (tie to contract language).
  Output: approved policy with versioning, owner, review cadence, and exception process. ¹

Step 3: Create procedures people can follow (how to do it)

Auditors expect procedures that match real workflows. Draft playbooks such as:

• “Send sensitive files to a third party” procedure: choose an approved channel, verify recipient identity, apply encryption, set expiry, record transfer reference, confirm receipt.
• “Receive files from a third party” procedure: malware scanning, quarantine, verify sender, store only in approved locations, apply retention tag.
• “Share data through APIs” procedure: approved integration pattern, authentication requirements, payload minimization, logging expectations, key management.
• “Customer support exchange” procedure: rules for screenshots/logs, redaction standards, secure upload links, ticket attachment controls. Each procedure should specify who performs the step and what system records evidence. ¹

Step 4: Implement controls that enforce the policy

Match controls to the channels you allow. Examples:

• Email controls: TLS enforcement where possible, DLP rules for sensitive data patterns, external recipient warnings, approved encryption add-ons where needed.
• File transfer controls: managed file transfer with encryption, access expiry, download auditing, malware scanning.
• Collaboration tools: restrict external sharing, require MFA, configure retention, control guest access, disable public links.
• APIs/integrations: TLS, strong authentication, scoped tokens, logging, rate limiting where appropriate, secrets management.
• Endpoint controls: block or control removable media; prevent copying sensitive data into unapproved apps. If you allow exceptions, enforce them through a time-bound approval workflow, not informal Slack approvals. ¹

Step 5: Assign responsibilities (make accountability testable)

Document a RACI that covers:

• Data owner: classifies data; approves sharing purpose and recipients.
• Security/IT: configures tools; defines encryption standards; monitors and responds.
• Privacy/Compliance: confirms regulatory/contract constraints; oversees training and audits.
• Procurement/Vendor management: ensures third-party contract terms support secure exchange.
• Workforce users: follow procedures; report mis-sends; use only approved channels. ¹

Step 6: Train, monitor, and correct

• Train roles with exchange-heavy duties (support, finance, engineering, implementation).
• Monitor with DLP alerts, MFT logs, portal audit logs, and ticket attachment reviews.
• Run corrective actions: tighten policies, update procedures, fix misconfigurations, and document exceptions.

Where Daydream fits: Many teams fail on evidence and consistency across third parties. Daydream can centralize third-party exchange requirements, track exceptions, and attach proof (configs, logs, contract clauses) to the same record used for due diligence and ongoing monitoring, so audits don’t turn into a spreadsheet chase.

Required evidence and artifacts to retain

Keep evidence that shows: policy exists, procedures exist, controls are configured, and people follow them.

Minimum artifact set (practical):

• Approved Information Exchange Policy with version history and owner.
• Procedures/playbooks for common exchange scenarios (external file sharing, support exchanges, API sharing).
• Information Exchange Register (channels, owners, allowed data types).
• Encryption standard (what encryption is required by channel; key management ownership).
• Tool configurations (screenshots/exports): DLP rules, sharing restrictions, MFT settings, portal access controls, API gateway/TLS settings (as applicable).
• Logs/audit trails: file transfer logs, access logs, sharing audit logs, ticket attachment logs.
• Training records for roles in scope.
• Exception records: risk acceptance, compensating controls, time bounds, approvals.
• Third-party contract artifacts: clauses that require appropriate protection for exchanged information and define responsibilities.

Common exam/audit questions and hangups

Auditors tend to probe the “all types of communication facilities” clause. Be ready for:

• “Show me your inventory of ways data is exchanged externally.”
• “Which channels are approved for sensitive data, and where is that documented?”
• “How do you enforce encryption for email/file sharing/APIs?”
• “How do you prevent staff from using unapproved channels?”
• “How do third parties receive and protect your data, and how do you verify that?”
• “Show examples of completed transfers and the audit trail.”

Common hangup: a policy that says “encrypt sensitive data” but never defines where encryption is mandatory, how it is applied, and who verifies it. ¹

Frequent implementation mistakes and how to avoid them

1. Policy-only compliance.
   Fix: publish procedures and show system controls and logs that match the policy.

2. Ignoring support and operations tools.
   Fix: explicitly address ticketing attachments, log sharing, screen captures, and customer-provided uploads.

3. No channel-by-channel rules.
   Fix: a simple matrix works: channel vs data class vs required protection vs approvals.

4. “Encryption required” with no operational standard.
   Fix: define accepted methods (for example, managed file transfer, encrypted portal upload, enterprise email encryption) and ban ambiguous workarounds.

5. Unmanaged third-party exchanges.
   Fix: require approved exchange methods in onboarding, document responsibilities in contracts, and track exceptions with compensating controls.

Enforcement context and risk implications

No public enforcement cases were provided in the source catalog for this requirement, so this guidance avoids case-based claims.

Risk-wise, weak information exchange governance creates predictable failure modes: misdirected emails, overshared links, unauthorized onward sharing by third parties, and sensitive data persistence in tools not designed for regulated retention. HITRUST’s emphasis on “formal” policies and “all types” of facilities signals an audit focus on completeness and consistency, not isolated controls. ¹

Practical 30/60/90-day execution plan

Days 0–30: Establish the minimum defensible program

• Create the Information Exchange Register and confirm tool owners.
• Draft and approve the Information Exchange Policy with a clear channel-by-channel baseline.
• Publish two high-use procedures: external file sharing and support data exchange.
• Stand up an exception process with approvals and time bounds.
• Capture initial evidence: policy approval, procedure publication, baseline tool configurations.

Days 31–60: Enforce and generate audit-grade evidence

• Implement or tighten technical controls for the top channels (email, file sharing, ticketing, portals, APIs as applicable).
• Add logging and review routines; define who reviews which logs and what triggers escalation.
• Update third-party onboarding to require approved exchange methods and responsibilities.
• Train high-risk teams; document attendance and role-based materials.

Days 61–90: Expand coverage and operational resilience

• Extend procedures to remaining channels (integrations, removable media, scanning/printing if used).
• Perform a tabletop for an exchange incident (mis-send or overshare); document corrective actions.
• Run an internal audit: sample transfers, validate encryption, validate approvals, validate retention/disposal.
• Consolidate evidence in a single system of record (policy repository + GRC/TPRM tooling). Daydream can help here by tying third-party exchange requirements, exceptions, and proof to each third party record.

Frequently Asked Questions

Do we need a separate policy, or can this live inside an acceptable use policy?

It can be part of a broader policy set, but it must clearly cover information exchange across communication facilities, including acceptable use, encryption requirements, and responsibilities. If your acceptable use policy is generic, add an information exchange standard and procedures that auditors can map directly to HITRUST CSF v11 09.s. ¹

What counts as a “communication facility” in practice?

Treat any mechanism that transmits or shares information as in scope: email, messaging, portals, file transfer, APIs, collaboration suites, ticketing systems, and removable media. If sensitive data can pass through it, define rules and controls for it. ¹

Do we have to encrypt everything we send externally?

The requirement says policies must cover encryption requirements, so you must define which data types and channels require encryption and how encryption is implemented. Most teams set stricter rules for sensitive and regulated data and document approved encrypted channels. ¹

How do we handle exceptions, like a customer insisting on email?

Use a documented exception with risk acceptance, compensating controls (for example, enterprise email encryption, recipient verification, expiry controls), and a time bound. Keep the approval and the technical evidence that the compensating controls were used.

What evidence is most persuasive in an audit?

Auditors respond well to traceability: a policy plus procedures, a channel inventory, and proof the tools enforce your rules (config exports/screenshots, logs, and samples of real exchanges). Exception records also matter because they show controlled deviation rather than informal workarounds. ¹

How does this connect to third-party risk management?

Exchanged information often goes to third parties, so responsibilities must be clear and enforceable. Align your exchange policy with contract requirements and onboarding checks, then track third-party exceptions and evidence in the same workflow you use for due diligence.

Footnotes

1. HITRUST CSF v11 Control Reference