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Are Healthcare IT Security Leaders Still Underestimating Cybersecurity Risks?

July 27, 2017
by Heather Landi
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A recent survey of healthcare IT security leaders indicates that the healthcare industry’s level of readiness to defend against concerted cyber attacks has improved in the past two years, which shows progress toward strengthening healthcare organizations’ security postures. However, the bad news is, despite the rising threats, the number of healthcare organizations making investments in information security has actually declined since 2015.

KPMG, an audit, tax and advisory services firm, surveyed 100 CIOS, chief technology officers (CTOs), chief security officers (CSOs) and chief information security officers (CISOs) from both healthcare provider organizations and payers with over $500 million in annual revenue. The firm’s 2017 Cyber Healthcare and Life Sciences Survey found a dramatic rise in computer system breaches and data compromises, which include patient records, over the past two years. And, yet, more C-level IT security executives say they are better prepared than two years ago to protect their organizations against cyber attacks.

Almost half (47 percent) of organizations, including both providers and health plans, said their organizations had instances of security-related HIPAA (Health Insurance Portability and Accountability Act) violations or cyber attacks that resulted in data loss or system compromise in the past two years. That compares to 37 percent of respondents in KPMG’s 2015 survey, an increase of 10 percentage points.

When asked about “readiness to defend against a concerted cyber attack,” 35 percent of CIOs, CISOs, CTOs and CSOs at provider and payer organizations said they are “completely ready” versus 16 percent in 2015. In the survey, respondents were asked to rate their “readiness” at a level of 1 (not at all ready) to 5 (completely ready). Thirteen percent of respondents rated their organization at level 3 and 52 percent rated their organization at level 4. None of the organizations rated themselves as level 1 or 2.

Despite the rising threats, KPMG’s survey found that cyber security as a board agenda item has declined over the past two years (79 percent versus 87 percent in 2015). In addition, KPMG found a disconnect regarding cyber investment in this volatile environment. A smaller majority of healthcare companies made investments in information protection in the prior 12 months (66 percent versus 88 percent in the 2015 survey).


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“Healthcare payers and providers are on treacherous ground here and some organizations are underestimating cyber-security risks,” KPMG’s healthcare advisory leader Dion Sheidy said in a statement. “There needs to be a higher degree of vigilance among boards and executive suites as attacks become much more sophisticated, especially as doctors need to share information to improve quality and as connected medical devices and wearables proliferate. The WannaCry ransomware hack in May was a warning shot against our collective ability to protect patient safety and privacy.”

In an interview about the survey findings, Michael Ebert, leader of KPMG’s cyber security group in healthcare and life sciences, says he is concerned that there is a level of complacency in the healthcare industry regarding cyber risks. “I think the industry has become a bit numb to the fact, that, well, we’re going to have cyber instances and we see it in the news all the time when there is another breach. And, you always see that company in business the next day, so there is complacency building. It’s fallen off the board agenda a little, which is a shame, because we continue to see high rates of infection. There are organizations in the healthcare industry taking this issue very seriously, but to have that broad response reflected in the survey, it’s concerning.”

Regarding recent ransomware and malware cyber attacks, such as WannaCry and Petya, he adds, ‘The last major attack, the hackers did certain modifications and, more importantly, they made it so that it would spready much more rapidly. They are testing our cyber defense capabilities. And, we’ve seen it rip right through institutions. Once it gets in, it just rapidly goes through, and to slow that down or stop it, you’ve got to pull plugs. We’re at war, it’s just a different type of war that’s going to cost the capital economy billions of dollars a year.”

According to the survey, data sharing with third parties is seen as one of the biggest vulnerabilities among healthcare providers and insurers with 63 percent of respondents mentioning it, topping Internet-enabled devices not fully controlled by IT and the lack of resources/budget. Yet sharing data is an important element of coordinating care and succeeding in a healthcare reimbursement environment that is moving away from paying for activity (fee-for-service) and toward outcomes.

Drilling down into the survey findings regarding information security investments, for those organizations that have made investments in the past 12 months, the majority of respondents (76 percent) reported making greater investments in technology, such as software, firewalls and encryption, and 83 percent have invested in stronger policy and controls around data access and processes. Only 41 percent have made investments in staff, such as hiring and training, and 44 percent have invested in governance.

Looking ahead, when asked where their organizations plan to make investments in IT security, the survey findings indicate both payers and providers plan to focus on investing in technology rather than process and staffing. Seventy-nine percent cited security technology will continue to get the bulk of financial investments, and 82 percent cited stronger policy and controls around data access and processes as an area of investment. Staff (hiring, training) ranked last at 24 percent in areas where organizations planned to make investments, trailing planned investments in consulting (41 percent), managed services (47 percent) and hardware (28 percent).

Only 15 percent of respondents said that increased or higher quality staffing are needed to make their organizations more effective in cyber security, while an “overarching strategy” was seen as the biggest need by 24 percent. “Stronger processes” at 21 percent, and “increased funding” and “better technology” at 20 percent were also cited as big needs.

“A solid cyber security program needs people, processes and technology and short-changing staff and the process structure needed to adequately govern, manage and monitor the technology is a faulty approach,” Ebert says. “Software can only protect you so far and staff is important when it comes time to respond to a data breach. The respondents that are not emphasizing staff and processes are underestimating the threats or creating a false sense of security among their management and board.”

Ebert continues, “If you don’t put the proper people and processes in place, then you can implement any technology and it’s not going to appropriately address the risk. Healthcare organizations are not looking at the threat vectors that are impacting them, they are not looking at the risks behind those threat vectors, and then they are not addressing how the technology they are buying integrates. Healthcare organizations are buying technology tools, but they are not fully implementing or fully integrating it, or understanding the full benefits that they can gain from that technology. They are not applying resources to accomplish those tasks and they are underinvesting in this area.”

Cyber Threats and Vulnerabilities

The KPMG survey also examined the attack vectors healthcare organizations are most commonly facing. The respondents were asked, of the known cyber attacks their organizations have faced in the past year, which attack vectors compromised their environments. Sixty-nine percent of respondents cited an external hacking of a vulnerability, 60 percent cited a single system-based malware introduced through human error, such as from a USB drive, and 39 percent cited a phishing email that resulted in a compromise. What’s more, 37 percent cited a third-party device, product or service and 19 percent cited an internal bad actor.

Of the respondents who reported that their organizations had been the victims of cyber attacks in the past year, 32 percent said their organizations were infected with ransomware. Sixty-six percent reported they had not been hit with ransomware and 2 percent said “I don’t know/not sure.”

Also, C-suite level IT security executives were asked how their organizations initially responded to the ransomware infection, and 41 percent reported that they paid the ransom. Only 25 percent reported using a forensic cyber team to fix the problem, 16 percent said they worked around the problem with redundant systems and 19 percent said they worked with authorities to pursue criminal action.

Despite cautions from the FBI and cybersecurity consulting firms that organizations should not pay the ransom, the survey findings indicate that many are choosing to pay to get their data and systems back up. “It’s because they don’t’ have proper back up procedures, or their back ups got corrupted because of way they linked their systems together,” Ebert says. “We’ve gone to real-time recovery capabilities and what happens is the primary system gets infected and so does the back up at the same time. Many organizations haven’t thought about how they interconnect and link those together, so the only way they can operate is to pay.”

What’s more, Ebert says some healthcare organization executive leaders have said they want to pre-buy bitcoins, as a reserve, in case they get hit with ransomware. “That’s not where you want to make your investment; you need to make your investment in protecting your assets, as opposed to making an investment in buying your way out.”

Identify Priorities and Reduce Risks

On a positive note, based on the survey findings and his own experience with the healthcare industry, Ebert says the industry has improved. “We’re not where we need to be, but we’ve done things to improve. We’re doing things that are reducing risk, maybe not increasing our maturity on cybersecurity, but certainly reducing risk. We’re looking at cybersecurity from a much more holistic standpoint; we’re training a lot more of our employees on a continuous basis and increasing awareness.”  He notes that 90 percent of breaches occur because of a single human error, such as an employee clicking on a phishing email. He adds, “We still commonly see with internal phishing training that we still get 22 percent click rates. That’s way too high.”

And, he notes there are lessons to be learned from the financial world. “In the financial industry, they have been dealing with security since the beginning of the concepts of banks and currency, so security is in their DNA. They wake up every day and think about it—What am I doing and how is it going to affect my environment? What new products am I offering and how am I interacting with the consumer, and is it a secure way to do it? The healthcare industry has never woke up and thought about it every day, but it’s getting there and becoming a part of their DNA; it takes time to change that.”

For CIOs and CISOs, the biggest takeaway from the survey findings, Ebert says, is that healthcare organizations are operating in a new threat environment, and risks need to be prioritized and effectively managed.

“The first thing to look at is the critical patient safety issues that occur when these systems go down. You have to think about your resource allocation and your priorities differently,” he says, adding there are obvious financial implications as well. “We’ve seen several organizations out of service for a month or longer, and if you lose one-twelfth of your revenue, you’re going to have critical financial issues. In the healthcare delivery industry, margins are usually three to four percent, if you take away a month of revenue, a lot of healthcare institutions will struggle to be alive the next day.”

Healthcare IT security leaders need to focus on better management and control of privileged access to systems and networks. “The better you control your administrator level access, the better you are going to reduce the risk to your environment. You’re not going to increase the cybersecurity maturity greatly, but you’re going to reduce the risk of something spreading. Having a mature incident response plan can enable you to handle the risk effectively.”


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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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Report: 30 Percent of Healthcare Databases Exposed Online

December 10, 2018
by Heather Landi, Associate Editor
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Hackers are using the Dark Web to buy and sell personally identifiable information (PII) stolen from healthcare organizations, and exposed databases are a vulnerable attack surface for healthcare organizations, according to a new cybersecurity research report.

A research report from IntSights, “Chronic [Cyber] Pain: Exposed & Misconfigured Databases in the Healthcare Industry,” gives an account of how hackers are tracking down healthcare personally identifiable information (PII) data on the Dark Web and where in the attack surface healthcare organizations are most vulnerable.

The report explores a key area of the healthcare attack surface, which is often the easiest to avoid—exposed databases. It’s not only old or outdated databases that get breached, but also newly established platforms that are vulnerable due to misconfiguration and/or open access, the report authors note.

Healthcare organizations have been increasingly targeted by threat actors over the past few years and their most sought-after asset is their data. As healthcare organizations attempt to move data online and increase accessibility for authorized users, they’ve dramatically increased their attack surface, providing cybercriminals with new vectors to steal personally identifiable information (PII), according to the report. Yet, these organizations have not prioritized investments in cybersecurity tools or procedures.

Healthcare budgets are tight, the report authors note, and if there’s an opportunity to purchase a new MRI machine versus make a new IT or cybersecurity hire, the new MRI machine often wins out. Healthcare organizations need to carefully balance accessibility and protection.

In this report, cyber researchers set out to show that the healthcare industry as a whole is vulnerable, not due to a specific product or system, but due to lack of process, training and cybersecurity best practices. “While many other industries suffer from similar deficiencies, healthcare organizations are particularly at risk because of the sensitivity of PII and medical data,” the report states.

The researchers chose a couple of popular technologies for handling medical records, including known and widely used commercial databases, legacy services still in use today, and new sites or protocols that try to mitigate some of the vulnerabilities of past methods. The purpose of the research was to demonstrate that hackers can easily find access to sensitive data in each state: at rest, in transit or in use.

The researchers note that the tactics used were pretty simple: Google searches, reading technical documentation of the aforementioned technologies, subdomain enumeration, and some educated guessing about the combination of sites, systems and data. “All of the examples presented here were freely accessible, and required no intrusive methods to obtain. Simply knowing where to look (like the IP address, name or protocol of the service used) was often enough to access the data,” the report authors wrote.

The researchers spent 90 hours researching and evaluated 50 database. Among the findings outlined in the report, 15 databases were found exposed, so the researchers estimate about 30 percent of databases are exposed. The researchers found 1.5 million patient records exposed, at a rate of about 16,687 medical records discovered per hour.

The estimated black-market price per medical record is $1 per record. The researchers concluded that hackers can find a large number of records in just a few hours of work, and this data can be used to make money in a variety of ways. If a hacker can find records at a rate of 16,687 per hour and works 40 hours a week, that hacker can make an annual salary of $33 million, according to the researchers.

“It’s also important to note that PII and medical data is harder to make money with compared to other data, like credit card info. Cybercriminals tend to be lazy, and it’s much quicker to try using a stolen credit card to make a fraudulent purchase than to buy PII data and run a phishing or extortion campaign. This may lessen the value of PII data in the eyes of some cybercriminals; however, PII data has a longer shelf-life and can be used for more sophisticated and more successful campaigns,” IntSights security researcher and report author Ariel Ainhoren wrote.

The researchers used an example of hospital using a FTP server. “FTP is a very old and known way to share files across the Internet. It is also a scarcely protected protocol that has no encryption built in, and only asks you for a username and password combination, which can be brute forced or sniffed

by network scanners very easily,” Ainhoren wrote. “Here we found a hospital in the U.S. that has its FTP server exposed. FTP’s usually hold records and backup data, and are kept open to enable backup to a remote site. It could be a neglected backup procedure left open by IT that the hospital doesn’t even know exists.”

According to the report, hackers have three main motivations for targeting healthcare organizations and medical data:

  • State-Sponsored APTs Targeting Critical Infrastructure: APTs are more sophisticated and are usually more difficult to stop. They will attempt to infiltrate a network to test tools and techniques to set the stage for a larger, future attack, or to obtain information on a specific individual’s medical condition.
  • Attackers Seeking Personal Data: Attackers seeking personal data can use it in multiple ways. They can create and sell PII lists, they can blackmail individuals or organizations in exchange for the data, or they can use it as a basis for further fraud, like phishing, Smishing, or scam calls.
  • Attackers Taking Control of Medical Devices for Ransom: Attackers targeting vulnerable infrastructure won’t usually target healthcare databases, but will target medical IT equipment and infrastructure to spread malware that exploits specific vulnerabilities and demands a ransom to release the infected devices. Since medical devices tend to be updated infrequently (or not at all), this provides a relatively easy target for hackers to take control.

The report also offers a few general best practices for evaluating if a healthcare organization’s data is exposed and/or at risk:

  • Use Multi-Factor Authentication for Web Applications: If you’re using a system that only needs a username and password to login, you’re making it significantly easier to access. Make sure you have MFA setup to reduce unauthorized access.
  • Tighter Access Control to Resources: Limit the number of credentials to each party accessing the database. Additionally, limit specific parties’ access to only the information they need. This will minimize your chance of being exploited through a 3rd party, and if you are, will limit the damage of that breach.
  • Monitor for Big or Unusual Database Reads: These may be an indication that a hacker or unauthorized party is stealing information. It’s a good idea to setup limits on database reads and make sure requests for big database reads involve some sort of manual review or confirmation.
  • Limit Database Access to Specific IP Ranges: Mapping out the organizations that need access to your data is not an easy task. But it will give you tighter control on who’s accessing your data and enable you to track and identify anomalous activity. You can even tie specific credentials to specific IP ranges to further limit access and track strange behavior more closely.


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