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At the Atlanta HIT Summit, a Deep Dive into IT Security Risks

December 14, 2016
by Mark Hagland
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A panel of experts on healthcare IT security probed the tangle of issues facing healthcare IT leaders who are trying to improve their organizations’ security positions

Healthcare IT security was a major focus of discussion on Dec. 14 at the Health IT Summit in Atlanta, sponsored by Healthcare Informatics, and held at the Ritz-Carlton Atlanta. After a session Wednesday morning in which panelists discussed the broad policy, strategic, operational, and technological issues around IT security in the current moment, a panel Wednesday afternoon plunged into the topic of “A Deeper Dive: Understanding the Emerging Hacker Threats.”

The afternoon panel was moderated by Dee Cantrell, R.N., president of the Georgia chapter of HIMSS (the Chicago-based Healthcare Information and Management Systems Society), and president of the HIT Consultancy, LLC. Cantrell, who is best known in the industry as the former CIO at Emory Healthcare, where she served from 2000-2016, was joined by William (Bill) Fleming, director of ITS operations at Gwinnett Medical Center (based in the Atlanta suburb of Lawrenceville); Claude “Chip” Council, Ph.D., senior manager, cyber-security & end-user services, at the Shriners Hospitals for Children (Tampa, Fla.); and Ricardo (Ric) Grave de Peralta, assistant special agent in Charge, in Cyber/Counterintelligence, in the Atlanta Field Division of the Federal Bureau of Investigation (FBI).

As an illustration of how widespread malicious and criminal hacking has become, Grave de Peralta noted that “I just learned this year that one of the orthopedic clinics at which I had been a patient, was hacked. This was not a ransomware attack, it was a malware attack, but the hacker exilftrated the files and then demanded ransom from the clinic to release the patient records to the clinic rather than to the dark web. Mostly,” he continued, “people will get in criminally [into the information systems of patient care organizations in order] to exfiltrate files. There are a lot of vulnerabilities, including because of third-party partners and vendors. And if you haven’t secured your connections to third-party vendors, you’ve got the biggest open front door there is,” he added.

“In fact, what’s happening now is being referred to in some cases as ‘ransomware as a service’—it’s cybercriminals running ransomware as a service, as a business,” Cantrell noted, “and extortion attempts are definitely a key area” within that phenomenon.

“That’s right,” Grave de Peralta said. “We know of cases in which, oftentimes, these ransomware attacks are perpetrated by hackers from outside the United States. And they’ll send you the message to let you know that they’ve encrypted your files and want money from you. But they actually have a full service desk to respond to your complaints over ‘customer service.’ So it’s a whole new paradigm.”


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Panelists (l. to r.) Council, Fleming, Grave de Peralta, and Cantrell discuss IT security Wednesday

What strategies and tactics are being pursued?

Cantrell asked her panelists what strategies and tactics they’ve been pursuing around data security, and how those are working out. Gwinnett Medical Center’s Fleming reported that “We’ve been working on a lot of phishing [education and training] campaigns. And we’ve been fairly happy with the results. This past month, we did a bigger one to the whole organization, and the results were kind of scary,” he said. It turned out that 10 percent of those across the hospital who had been sent an e-mail mimicking a phishing attempt, had opened it. “And 10 percent, across a whole organization, suddenly sounds like a huge number,” he said. “And so our whole theme with this campaign was, ‘protecting your data at home.’ And people seemed to embrace that idea more,” he said, because he and his colleagues were able to convey clearly to their coworkers at the hospital how the same phishing e-mails that could harm the hospital could also harm them in their home lives. “So I think it was successful. We’re going into the next phase where there will be a bit more of a punishment if you repeatedly click on things,” he added. “Our administrative staff wants to start locking down accounts on people who click and open multiple times on phishing e-mails. And the thing is, people are so busy, but we need to make it a little bit more real.”

In addition, Fleming said, “Meanwhile, we’re working on network segmentation; we’ve already created a firewall between our main network and biomed. But we’re also working on backups. We had our normal audit last spring; it was scary reading the report on it. So we’ve bought new storage that’s encrypted, and that’s going well. But we need to work on a whole new security plan.”

Turning to Council, Cantrell asked, “What scares you, Chip?” “I think the other members of the panel would agree, what scares me the most is the things we don’t even know,” Council said. “It used to be, the focus was on securing the perimeter of the network. But more and more, we have to assume, they’re already in the network. And we know that healthcare is behind other industries. We also know that our user base is far more complex than your typical user base in an organization. We have a more transient user base; there is the Internet of Things; and there is a demand for access to a lot of databases. So we need to come up with a plan for assessing risk, mitigating the highest risks, putting together a good disaster recovery plan, and educating, educating, educating.”

Educating the c-suite and the board

“And the fact is that we’re all victims—we may not know it yet,” Cantrell replied. “But it’s a matter of when, not if. Besides some of the mitigation strategies we’ve all talked about already, is there anything else out there that could help us prepare proactively, and preventing intrusions, rather than just reacting?” she then asked.

“Really, you need support from the board down,” Council said. “You need to be very transparent with your board of directors, with your c-suite, and get them engaged in helping to move forward together. And you actually need to engage your medical staff. In most organizations I’ve worked for, the CMIO has always been a big ally. And if you spend time with your CMIO, they’re going to help you, they’re going to be your friend. You also have to make sure that everyone knows that this is out there, it’s real, and it’s affecting all organizations in healthcare.” “And risk management and compliance are departments that can be good allies, too,” Cantrell added.

Grave de Peralta warned that internal threats remain significant. “From my side,” he said, “we see a lot of activity on the part of disgruntled employees. We work quite a bit with defense contractors, and there are quite a lot of disgruntled employees with access” in that industry. “Nobody wants to think that someone we work with every day could do this, but they are a threat, and that has to be considered, along with the training piece.”

Fleming testified to the fact that “OCR audits [from the Office of Civil Rights within the Department of Health and Human Services] and other processes have helped us to get organized and start tracking who’s accessing data. Patty [Lavely, Gwinnett Medical Center’s CIO] spoke a bit about this earlier today,” he said, referring to Lavely’s participation on the morning’s IT security panel. “But we have so many different applications, and they’re everywhere. So doing a broad audit helps us, because we’ve got all these old systems out there. So undergoing the whole BIA [business impact analysis] process has really helped us figure this out; and we’re trying to get rid of old hardware that we can’t do anything about. But it requires a lot of hard work.”

“Yes, it’s ‘shades of XP,’ isn’t it?” Cantrell replied. “We had old systems on XP at Emory, and had to weed those out. Now, let’s talk about all those smart devices connected to the IoT, the Internet of Things. What are you seeing in your organizations, around smart devices? Are you doing anything in particular to try to protect them more? A lot of times, it’s a device like an insulin pump, a pacemaker, a lab device, right? All of these are computerized. And it’s hard to keep up with all of that. Thoughts?”

“We recently had an application that came in, not through the normal process, but through the pharmacy,” Fleming reported. “So no risk assessment was done at the time. We found out about it later, and had to go through a separate risk assessment on that application later on. That’s the kind of thing that Patty argues for all the time, to approach these things in advance. And this was an application that couldn’t be encrypted, and we push for encryption whenever possible. And we want to show people who are reviewing new applications what the risks are.”

“Whatever the newest ‘bright, shiny object is’ that has a lot or great potential for use,” Cantrell said, “whenever that system bypasses the normal process for security review, it really presents challenges. And then the credibility suffers. Chip, did you have thoughts?”

“I agree with everything here,” Council said. “There needs to be governance in place, and there needs to be minimum guidelines before these devices are brought onto campus. And it’s political, and sometimes you don’t get your way. And we can fix things, but sometimes, it involves upgrading to the next level for that technology. Also, I don’t have anybody on my team who’s a certified biomedical engineer. That process needs to be centralized. And so we need for the biomedical engineers to take ownership of their systems.” “And biomedical devices are seen as devices; but they’re actually information systems, with biomedical capabilities attached,” Cantrell added. “We’re bringing the biomedical devices more and more into the process. And we’ve isolated them from the network, but they’re still there. And it might be an MRI or a CT scan or a bedside device, but they’re still there and at risk,” Fleming said.

Getting help from federal law enforcement

“It’s ‘funny-weird,’ how our lives have changed in the last few years, in terms of how all those devices have come onto the market,” Cantrell said. “And there was a Sans Institute Report that came out that found that 72 percent of cyber attacks were targeted towards healthcare providers, and smaller percentages towards health plans and other organizations. So I’m going to ask you, Ric, when is a good time to engage federal agencies and local law enforcement? How can you help be a partner?”

“Getting engaged allows all of you to collaborate, and it can help you look at new ways to approach these issues,” Grave de Peralta stated. “We at the FBI go out and actively try to build relationships with the private sector—healthcare, financial services, retail, the energy sector, etc. And so then, when something happens, you already know us. You might already know us directly. And you should already have a plan, and should execute on it. And we’re glad to come out and help you. So when something happens, you already have a plan in place, your mitigation strategy in place; and now you’re calling us in to try to figure out who’s done this to you. Because you have to understand that we, the FBI, view you as the victim. You’re no different from a bank on the corner that just got held up in a bank robbery.”

Indeed, Grave de Peralta continued, “Too often, we’ve found that private companies don’t want the exposure in the media that they’ve been hacked. And they don’t want their reputation to be besmirched, and we get that. But we do advocate that you get your legal counsel involved. Currently, we’ve developed a great relationship with the folks in the office of the U.S. Attorney for Northern Georgia, and we’re going around and giving providers these briefings, so your internal counsel and the U.S. Attorney can ‘talk lawyer’ to each other. That’s important.” “Yes, it’s very important to establish these resources in advance so that when you need them, the relationships already exist,” Cantrell said.



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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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