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Aligning Strategy and Tactics: Dallas CHIME LEAD Forum Experts Tackle the Issues

December 6, 2016
by Mark Hagland
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CHIME LEAD Forum panelists took the long view of the challenges and opportunities in IT security

In a series of lively discussion panels on December 6 in Dallas, healthcare IT and healthcare IT security leaders looked at some of the core challenges facing the leaders of U.S. patient care organizations, at a time of accelerating IT security threats across the healthcare system.

All those leaders were participants in discussions at the Dallas CHIME LEAD Forum, being held at the Joule Hotel in downtown Dallas, and cosponsored by the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) at Healthcare Informatics. The daylong event was focused on cybersecurity, and included several important panels whose discussants included CIOs, CISOs (chief information security officers), and others. All of the day’s panels were moderated by Adrienne Edens, CHIME’s vice president of education.

In the first panel, “Essential Factors for Cybersecurity Preparedness,” Edens led a discussion among John Delano, CISO at Cook Children’s Health System (Ft. Worth); Major Chani Cordero, CIO of the Medical Education Training Campus of the Defense Health Agency (headquartered at Joint Base San Antonio), and Dave Kythe, vice president of security services and strategy at the Carpinteria, Calif.-based Redspin, an Auxilio Company.

First things first, Delano emphasized, near the start of that discussion. “When you’re building a house, you need a structural framework; you can’t just start nailing boards together.” The same is true with regard to healthcare IT security planning, he said. “So you need a security framework to start with. Then you have to prioritize your risk, from the most critical risks, and on. It’s important to create an incident response plan,” he added. “It’s been said that there are two types of networks—one, you have a breach and know it, and the other, you don’t. So develop an incident response plan. Develop security awareness training materials. We do weekly and monthly security tips for our end-users. We train our employees on phishing attempts. You should also invest in cyber insurance,” he urged.

“I saw some numbers recently,” Delano continued. “The average cost of a breach is $7 million to the average organization. So cyber insurance is really a drop in the bucket. And we had a breach where about 3,000 records were compromised. We were able to tap into some resources from the cyber insurance we had bought, and, based on our investigation, we were able to determine that only 11 of those 3,000 records actually had been compromised.” That, he said, demonstrated the value both of cyber insurance, and of strong analytics and processes to investigate potential breaches and other incidents.


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Maj. Cordero noted the size and breadth of scope of the operations at the Defense Health Agency’s Medical Education Training Campus. “We’re the DoD’s [Department of Defense’s] largest integrated training campus,” she noted. “We have about 8,000 students and 2,000 staff members at any given time. What we focus on for the most part is defense in depth. One thing that we probably do a bit differently from you is that we’re really big on policy. We have the ability to cut things off—if we have to remove a system or application, we can do it if necessary. Our job is to support providers in patient care, and we do our best to mitigate any risk. I’m pretty sure the bulk of what we do is also what you do.”

Among the advantages that she and her colleagues have at the Defense Health Agency, Cordero said, is that, “For you to have a network account within the DoD, you have to acquire at least a baseline security certification, to add a computer to the domain or do any administrative tasks. As you go up the line as an information security manager or officer, you have to have your CSSP [Certified SonicWall Security Professional certification], or one of two other certifications. Your information assurance manager is not going to be your network chief; your inspection auditor won’t be a facility person. We try to keep those things separate. And Lord forbid you work on Windows XP or anything—we separate all of those consumer-level applications and systems” from the DoD’s networks. “Also, the medical network is typically separate for the Army from the network that the rest of the DoD is on. We do that not only because of traffic, such as PACS [picture archiving and communications systems], because images are very big items, but also because devices on our medical network could be very vulnerable, and we don’t want them to be on an arms system together.” Most importantly, Cordero said, “What we really focus on is known attacks and vulnerabilities. A lot of the attacks today are known to us; they’re just variants on what’s out there. So we focus on what we know right now.”

Kythe noted that “One of the things I’ve seen in larger corporations, especially in global companies, but which we can also do in the U.S., is to spread out responsibilities across time zones.” In U.S. healthcare, that could occur within a national integrated health system, which in some cases, he noted, could relieve the burden on any one portion of an IT team to manage a security crisis.

“Unlike the Army, with its 50 hospitals and a whole slew of government folks who could be all hands on deck if something happened,” Cordero said. “If you’re a standalone facility, I would absolutely do what it takes to have someone at the ready. The risk, we know, is there. And if your team is not available to handle the incident, I would look at insurance and at outsourcing capability.”

CHIME’s Edens noted that “One of the things that makes this work is to have a very frank dialogue about this. It helps to be able to talk about what we’re doing about a real breach or problem,” among healthcare IT security professionals from across the U.S. healthcare system. “It is hard to get a non-bedside FTE, yes. And one of the challenges we have is to start to change that dialogue.” She cited an example of when she went to a position as CIO of a hospital system in a relatively rural state, and found that her new organization was not even in compliance with basic IT security and privacy standards required by the HIPAA (Health Insurance Portability and Accountability Act of 1995) law. Needing to catch up to basic standards at that hospital organization, Edens told her audience that “I actually did a study and put together some numbers and scenarios for them. So if you need to bring in a consultant, then go out and do it. And I got a CISO, a new budget set aside, all because I could put my facts together and present it to the board. So outsource resources, or try to get together a community-wide consortium,” she emphasized.

Time to take a risk-portfolio approach to IT security?

The second panel of the day, “Winning Cybersecurity Strategies Focused on Prevention, Detection, Response and Recovery,” opened with a forceful opening statement by Ron Mehring, CISO of the integrated, 24-facility Texas Health Resources health system (based in Arlington). “We’re changing the way we look at cybersecurity and the way we integrate services in the organization. First,” Mehring said, “I want to say that cynicism, negativity, and defeatism seem to be a big part of the cybersecurity world. But the reality is that, as a healthcare system, we are getting better. There are amazing efforts and advances taking place. So it’s not inevitable that you will be breached. And the reason we have been breached that we carry dogma and practices forward from the past, including such elements as complex passwords. You have to get rid of the dogma and say, I’m going to approach this from a healthcare delivery perspective and engineer it that way,” he said. “Cybersecurity success is all about integration and about trade-offs. You’re not going to be able to do everything. The trade-off is a conversation with stakeholders in the organization on what the appropriate steps and resources are.”

Mehring said that what is absolutely essential is to “take a risk-portfolio approach: put good risk and bad risk into the same portfolio. Most organizations are still thinking only about bad risk. But here might be a reason why you might not do something particular. There has to be a realism,” he said; “otherwise, trade-off discussions will become too difficult and too fraught with dogma.” One key element in taking that risk-portfolio approach, he said, is that “The way forward, from my vantage point: it’s about putting high-reliability principles into the program. And everything I learned in aviation in the Marine Corps—it’s all about putting high-reliability principles into operations. And the program has to adopt. And finally, integrated service delivery. The security program must be fully integrated, and becomes a robustness element within your operations.” And that means incorporating threat management, incident management, and vulnerability management elements into an integrated whole, in a data-driven operating environment.

Wayne Keatts, director of enterprise security and architecture at Methodist Health System (Dallas), emphasized that “In order to create a winning strategy, you first have to define your goal for what a winning strategy is. Do you just want to stay out of the news? Simply achieve compliance? Does your organization have a culture where care of the data is as important as caring of the patient? If so, you’ll have the ability to develop a much more successful, more in-depth, program, than one solely focused on compliance.” He cited six key strategies essential to success: keeping the organization’s board informed; understanding one’s organization’s organizational culture; understanding that “an ounce of prevention is worth a pound of cure”; understanding the layers of complexity involved; routinely testing one’s prevention detection response and recovery capabilities; and training one’s team and one’s organization’s end-users on the security policy. “It is essential to tie your data security strategy to your organization’s business strategy,” he said. “I spend a lot of time in our organization trying to frame our security goals in alignment with patient experience, patient satisfaction, physician satisfaction, major goals of our organization. If you can frame your security strategy as being aligned with the overall business strategy of your organization, that will help a lot. For example, as was mentioned, a benchmark number that has been shared here is that cost of $221 per record breached—I’ve read similar numbers. I know that I don’t ask for $221 per record to defend the records; we can address it for much less than that,” he said.

Looking at cybersecurity from a truly strategic standpoint

Meanwhile, during the third panel of the day, entitled, “Process Makes Perfect: Strategies for Cybersecurity Success,” Will Long, vice president and CISO at Children’s Health System of Texas (Dallas), noted that “You can’t manage vulnerabilities on things you don’t know you own, which is why asset management is so important. And you can’t manage vulnerabilities on things that you don’t know your organization is purchasing. The first thing is that your risk management program has to be is a threat-centric program,” he asserted. “It has to be designed based on threats to your environment. The sheer number of vulnerabilities, and making sure you design a program that is threat-centric is important. Align your projects and priorities to align with your understanding of your vulnerabilities. Vulnerability scanning and tools and services are very important. Patch management is a big part of the risk management program, and goes way beyond servers and PCs to IoT devices, home health devices. The patch management and vulnerability management has to grow exponentially.”

What’s more, Long said, “The news that some people don’t like to hear is that you can’t patch certain things. We have to have integration strategies in our plans to mitigate risks. That might include network segmentation, intrusion detection, and other strategies, for areas where you can’t patch certain things. And you have to inventory things.” He further added what he said was a tip—the fact that the Department of Homeland Security “offers a whole suite of free programs, taxpayer-funded. They have a cyber hygiene program—they’ll scan your Internet presence and send you a weekly report; they’ll scan your security posture, that is free, too. They will also do a two-week engagement where they’ll do an internal and external penetration test program, for free. This was all protected by a presidential order and a PCII, meaning it cannot be disclosed to any other organization.” In any case, it is very important, he said, to “implement a risk assessment and governance program, one that touches on your asset management.”

And Mac McMillan, co-founder and CEO of the Austin-based CyngerisTek consulting firm, advocated for a long-term, strategic perspective on all of this. “I want to talk about the business level of this,” McMillan said. “One of the things we need to understand in any organization is that managing risk is a business process, not just a security process. And the really successful folks understand that, understand the vulnerabilities, and understand how risks impact the organization’s ability to accomplish its core mission.”

Unfortunately, McMillan said, as a healthcare industry, “We got off on the wrong foot early on in terms of data security, and talked way too much about compliance. And the reason we did that is that there wasn’t yet a security culture in healthcare, so we focused on compliance standards. But today, our environment is completely different from how it was 20 years ago, and compliance will not get us there.”

Indeed, McMillan said, “We need understand that we are in a very tech-savvy threat environment. This now involves very sophisticated technical attacks, and using social media and social engineering approaches. And we really have to up our game. We need smarter technology today as well. The antiquated approaches of the past, including rules-based analysis, won’t cut it. We need heuristic-based analysis, role-based analysis, based on how individuals and systems behave. How do we succeed at this? The formula is simple; the doing is difficult: understand security and vulnerability, which means understanding your tradecraft. If you’re a CISO and aren’t up to date on understanding the threats and the technology, then you’re just not doing your job. We all need to study the enemy and understand how they’re coming at us, how they’re going to attack us. And we need to understand what’s important in our business—what’s really important. At any time of any day, something bad is happening, something’s going awry. But not everything affects our business equally.” In short, he summarized, “You have to be focused on impact. It’s not just about PHI or information anymore; it’s about impact analysis. It’s about analyzing impacts. I would submit to you that losing your systems and losing access to your information where it affects your ability to deliver care, is a far bigger threat than someone simply accessing your organization. So we need to understand that. And while that smaller percentage of hacks is representing almost 98 percent of the data that’s being compromised.”


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Targeting Third Party Risk: Leading CISOs Detail Efforts to Secure the Healthcare Supply Chain

December 18, 2018
by Heather Landi, Associate Editor
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Healthcare information security leaders are faced with the dauting challenge of securing information systems and data at a time when the cyber threat landscape is evolving rapidly and becomingly increasingly complex.

Most patient care organizations’ supply chains are filled with third parties who support the care delivery process and require access to patient information. Properly vetting and monitoring these third parties is a major challenge, and in some cases, insurmountable for many organizations who simply don’t have the expertise or resources, according to healthcare IT security leaders.

Many healthcare chief information security officers (CISOs) have found that effectively assessing the security posture up and down the supply chain is expensive given the complexity of the risks posed by privacy and security concerns, as well as an everchanging regulatory landscape. Currently, the process of managing third-party risk is often inefficient and time-consuming, for both vendors and providers, while still leaving organizations vulnerable to security threats.

During a recent webinar, sponsored by HITRUST, focused on healthcare cybersecurity and managing third party risk, John Houston, vice president, privacy and information security at the 40-hospital UPMC health system in Pittsburgh, outlined a number of factors that have made third-party risk management increasingly challenging and complex.

“There has been a fundamental change in IT, and a rapid move to the cloud. At the same time, we all see an increasingly complex cyber threat landscape where the threats are more sophisticated, and the technology solutions are more sophisticated as our business requirements are changing. It’s an increasingly complex landscape,” Houston said.


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He further noted, “As a result, there is a lot of confusion about how we best ensure our information is secure and available, and what is reasonable in terms of trying to achieve that. And finally, we are all worried about risk, and the biggest risk is patient safety. We worry about the cost of litigation and penalties, but first and foremost, we need to think about ensuring that we are able to deliver the best care to our patients.”

The stakes are changing, Houston noted, as federal regulators are investigating and penalizing organizations for failure to monitor third parties’ security practices, and hackers are increasingly targeting medical devices, he said.

“From a CISO perspective, we need to ensure that we are applying proper oversight over all of this. We can’t assume third parties are doing the right thing,” he said.

What’s more, healthcare organizations are increasingly reliant on cloud technology. A year ago, Nuance Communications, a provider of voice and language tools, was knocked offline when the company was hit with the Petya ransomware virus.

“I was around during Y2K, and about 95 percent of all our applications at UPMC, we ran within the data center, on premise. About 95 percent of newly acquired applications were run on on-premise, there was little on the cloud. In that environment, it falls upon the entity to secure data within its possession,” he said.

Contrast that with today’s environment, as Houston noted that “very little of what we acquire today runs on-premise. In some way, shape or form, at least one copy of the data is in the cloud.”

Studies have estimated that by 2023 no more than 25 percent of applications will be run on-premise in an organization’s data center, with about 75 percent run in the cloud, Houston said. “Many copies of our data end up in the cloud, and it’s not just one cloud provider. We get services from a lot of different vendors, all of which are in the cloud. That speaks to the fact we, as CISOs, can no longer directly secure our own information. We are dependent upon third parties to secure our data for us. We can’t simply trust that they are going to adequately secure that information.”

From a healthcare CISO’s perspective, a vendor’s IT and data security practices should be at least as effective as the provider’s security posture, Houston said. “I should expect nothing less. As soon as I expect less, that’s a sign of defeat.”

Across the healthcare industry, ineffective security, compliance and assurance methods drive cost and confusion within organizations and across third parties, according to IT leaders.

While most healthcare organizations are taking the right steps to monitor and screen vendors and their products and services during the pre-selection and on-boarding phases and are also conducting security risk assessments, it’s still not enough to protect IT systems, data, and, most importantly, patients, said Taylor Lehmann, CISO at Wellforce, the Burlington, Mass.-based health system that includes Tufts Medical Center and Floating Hospital for Children. “We are still seeing breaches, and the breaches are still coming after we do all this screening,” he said.

“We’re not being effective and it’s difficult to be effective with the current paradigm,” Houston added.

From the CISO’s perspective, there are inefficiencies in the third-party supply chain ecosystem. Suppliers are commonly required by their customers to respond to unique questionnaires or other assessment requests relating to their risk management posture. Vendors often must fill out questionnaires with 300-plus questions. What’s more, there’s no assurance or audit of the information the vendor provides, and the process is completely inefficient for suppliers who are audited 100 times annually on the same topics, but just different questions, Lehmann and Houston noted. What's more, the security assessment often occurs too late in the process.

“We’re creating a lot of waste; we’re taking time away from our organizations and we’re taking time away from suppliers,” Lehmann said. “The current way we’re doing supply chain risk management, it doesn’t work, and it doesn’t scale, and there is an opportunity to improve.”

To address these issues, a group of CISOs from a number of healthcare organizations established the Provider Third Party Risk Management (TPRM) Initiative to develop a standardized method to assess the risk management posture of third-party suppliers to healthcare firms. Launched this past August, the founding member organizations for the Provider TPRM Council include Allegheny Health Network, Cleveland Clinic, University of Rochester Medical Center, UPMC, Vanderbilt University Medical Center and Wellforce/Tufts University. Working with HITRUST and PwC, the Council aims to bring uniformity and consistency to the process while also reducing the burden on providers and third parties.

The healthcare industry, as a whole, will benefit from a common set of information security requirements with a standardized assessment and reporting process, Lehmann noted.

In the past four months, the governing members have been expanded to include Nuance, The Mayo Clinic, Multicare, Indiana University Health, Children’s Health Dallas, Phoenix Children’s Hospital, and Banner Health.

The Provider TPRM initiative is increasing membership and gaining momentum as security leaders from both healthcare providers and their suppliers embrace the unified approach, Lehmann said.

One of the goals for the Council is to address the inefficiencies found in the third-party supply chain ecosystem. By reducing the multiple audits and questionnaires, the financial savings will allow business partners to invest in substantive risk reduction efforts and not redundant assessments, the Council leaders say.

“By reducing wasted effort and duplication, suppliers will find their products and services will be acquired more quickly by healthcare providers. This will also reduce the complexity of contracts and provide third parties with better visibility regarding the requirements to do business with providers,” said Omar Khawaja, VP and CISO of Allegheny Health Network and Highmark Health. Khawaja’s organization is a founding participant and governing member of the Provider TPRM initiative.

As part of this initiative, going forward, provider organizations that join the effort will require third-party vendors to become HITRUST CSF Certified within the next two years, by September 2020. The HITRUST CSF Certification will serve as the standard for third parties providing services where they require access to patient or sensitive information and be accepted by all the Council’s organizations. HITRUST CSF is an industry privacy and security framework that is continuously evolving with the changing cyber landscape.

 “After September 1, 2020, third parties without certification cannot do business with participants,” Khawaja said.

Houston added, “We recognize that there are limitations in our current processes, and what we’re putting in place is at least as good or better than what we’re already doing. This will lead to faster onboarding, less waste, better transparency, and simpler compliance.”

By choosing to adopt a single comprehensive assessment and certification program, healthcare organizations represented by the council are prioritizing the safety, care, and privacy of their patients by providing clarity and adopting best practices that their vendors can also adopt, while providing vendors the expectation of what it takes to do business with their organizations.

“It provides transparency,” Houston said “It sends a message to suppliers that we’re an open book about what it takes to do business. That’s powerful.”

Moving forward, the Provider TPRM initiative will focus on adding business associates to the effort to increase membership and impact, Lehmann said. “The simple fact is, many of us are pushing this through our supply chain and there are organizations that may not have a process or low maturity process. But, through the efforts of council members, more suppliers will show up, which is means safer products are possible to purchase.”

Further, the program will likely develop additional requirements on vendors such as breach response and monitoring security threats and alerts observed as third-party vendors.

The Council also plans to focus on certification programs for smaller vendors. “A lot of innovation in healthcare is coming from smaller companies, and we understand there is a gap between what those companies can do with respect to cyber. We’re not lowering our standards, but we want to be thoughtful and create a certification program for those areas. We want to do business and we need a vehicle to bring them in in a safe and secure way,” Lehmann said.

“We want to build a community of health providers working together, business associates working together, to share information,” Lehmann said. “We want to better inform ourselves and align other programs, like cyber insurance, to enable more effective planning throughout the supply chain. The things we learn through these relationships can translate to other aspects of our organizations.”

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Florida Provider Pays $500K to Settle Potential HIPAA Violations

December 12, 2018
by Heather Landi, Associate Editor
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Florida-based Advanced Care Hospitalists PL (ACH) has agreed to pay $500,000 to the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) to settle potential HIPAA compliance failures, including sharing protected health information with an unknown vendor without a business associate agreement.

ACH provides contracted internal medicine physicians to hospitals and nursing homes in west central Florida. ACH provided services to more than 20,000 patients annually and employed between 39 and 46 individuals during the relevant timeframe, according to OCR officials.

Between November 2011 and June 2012, ACH engaged the services of an individual that claimed to be a representative of a company named Doctor’s First Choice Billings, Inc. (First Choice). The individual provided medical billing services to ACH using First Choice’s name and website, but allegedly without the knowledge or permission of First Choice’s owner, according to OCR officials in a press release published last week.

A local hospital contacted ACH on February 11, 2014 and notified the organization that patient information was viewable on the First Choice website, including names, dates of birth and social security numbers. In response, ACH was able to identify at least 400 affected individuals and asked First Choice to remove the protected health information from its website. ACH filed a breach notification report with OCR on April 11, 2014, stating that 400 individuals were affected; however, after further investigation, ACH filed a supplemental breach report stating that an additional 8,855 patients could have been affected.

According to OCR’s investigation, ACH never entered into a business associate agreement with the individual providing medical billing services to ACH, as required by the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, and failed to adopt any policy requiring business associate agreements until April 2014. 

“Although ACH had been in operation since 2005, it had not conducted a risk analysis or implemented security measures or any other written HIPAA policies or procedures before 2014. The HIPAA Rules require entities to perform an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of an entity’s electronic protected health information,” OCR officials stated in a press release.

In a statement, OCR Director Roger Severino said, “This case is especially troubling because the practice allowed the names and social security numbers of thousands of its patients to be exposed on the internet after it failed to follow basic security requirements under HIPAA.”

In addition to the monetary settlement, ACH will undertake a robust corrective action plan that includes the adoption of business associate agreements, a complete enterprise-wide risk analysis, and comprehensive policies and procedures to comply with the HIPAA Rules. 

In a separate case announced this week, a Colorado-based hospital, Pagosa Springs Medical Center, will pay OCR $111,400 to settle potential HIPAA violations after the hospital failed to terminate a former employee’s access to electronic protected health information (PHI).

Pagosa Springs Medical Center (PSMC) is a critical access hospital, that at the time of OCR’s investigation, provided more than 17,000 hospital and clinic visits annually and employs more than 175 individuals.

The settlement resolves a complaint alleging that a former PSMC employee continued to have remote access to PSMC’s web-based scheduling calendar, which contained patients’ electronic protected health information (ePHI), after separation of employment, according to OCR.

OCR’s investigation revealed that PSMC impermissibly disclosed the ePHI of 557 individuals to its former employee and to the web-based scheduling calendar vendor without a HIPAA required business associate agreement in place. 

The hospital also agreed to adopt a substantial corrective action plan as part of the settlement, and, as part of that plan, PSMC has agreed to update its security management and business associate agreement, policies and procedures, and train its workforce members regarding the same.

“It’s common sense that former employees should immediately lose access to protected patient information upon their separation from employment,” Severino said in a statement. “This case underscores the need for covered entities to always be aware of who has access to their ePHI and who doesn’t.”

Covered entities that do not have or follow procedures to terminate information access privileges upon employee separation risk a HIPAA enforcement action. Covered entities must also evaluate relationships with vendors to ensure that business associate agreements are in place with all business associates before disclosing protected health information. 


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Eye Center in California Switches EHR Vendor Following Ransomware Incident

December 11, 2018
by Rajiv Leventhal, Managing Editor
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Redwood Eye Center, an ophthalmology practice in Vallejo, Calif., has notified more than 16,000 patients that its EHR (electronic health record) hosting vendor experienced a ransomware attack in September.

In the notification to the impacted patients, the center’s officials explained that the third-party vendor that hosts and stores Redwood’s electronic patient records, Illinois-based IT Lighthouse, experienced a data security incident which affected records pertaining to Redwood patients. Officials also said that IT Lighthouse hired a computer forensics company to help them after the ransomware attack, and Redwood worked with the vendor to restore access to our patient information.

Redwood’s investigation determined that the incident may have involved patient information, including patient names, addresses, dates of birth, health insurance information, and medical treatment information.

Notably, Redwood will be changing its EMR hosting vendor, according to its officials. Per the notice, “Redwood has taken affirmative steps to prevent a similar situation from arising in the future. These steps include changing medical records hosting vendors and enhancing the security of patient information.”

Ransomware attacks in the healthcare sector continue to be a problem, but at the same time, they have diminished substantially compared to the same time period last year, as cyber attackers move on to more profitable activities, such as cryptojacking, according to a recent report from cybersecurity firm Cryptonite.

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