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At Banner Health, the Focus Turns to the Evolution of Cybersecurity Threats and How to Stop Them

March 22, 2018
by Rajiv Leventhal
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The health system’s CISO discusses the ways in which his organization is looking to stay ahead of the game and keep cyber criminals away

As part of Healthcare Informatics’ Cybersecurity Special Report in its First Quarter 2018 print issue, in one of the report’s four pieces, healthcare IT security experts emphasized a few key strategies that forward-thinking organizations are deploying to improve their data security defense—namely, monitoring users’ behaviors, in which organizations monitor their users at a high level; and leveraging identity and access management (IAM) protocols to avoid unauthorized access or disclosure of information.  

One of those interviewed experts was Bryan Kissinger, Ph.D., vice president and CISO (chief information security officer) at Phoenix, Ariz.-based Banner Health, one of the largest health systems in the U.S. Kissinger, who has been in his role at Banner for less than a year, said in the story that in some ways his organization is ahead of the curve in terms of leveraging these strategies to improve Banner’s cybersecurity defense; but in other ways, there is a lot of work to be done. Below is the full interview with Kissinger, edited for length and formatting purposes.

How are you taking to your new role at Banner Health?

I came here as part of an initiative to enhance the maturity of our information security program. My job was to come in, look at the people, processes and technology that we had, and rapidly mature the program. We’re making a big investment in IAM, and we’re also looking a lot at behavioral monitoring. We have a number of big projects that we are in-flight on. 


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Bryan Kissinger, Ph.D.

What are some of the specific projects you are working on right now?

On the identity side, we’re really looking at it from an efficiency and customer service perspective, so getting to day-one birthright access for all workforce members, and doing that in an automated way. Like most organizations, [Banner] has historically had an in-house developed system [for IAM] or they have done it manually, but now we are using a technology to help us give automated day-one access to all workforce members. And that access is tracked and governed within the platform such that on a quarterly basis we’re re-certifying that access with the workforce member’s manager.

For privileged access we are using a tool to vault privileged passwords and system, and privileged accounts in a safe vaulting technology such that database administrators and other privileged users need to go into the vault and check out an encrypted password to be able to escalade privileges from a normal user to an escalated user.

And lastly on the identity management front, we are getting ready to implement a single sign-on tool that allows clinicians to be able to tap their badges on a badge reader—say in an exam room or the ED, or wherever they need to access health record technology—which then single signs them in to all of the applications they need for their job. It probably saves each clinician five to six hours a week that he or she would normally need to do to manually type in log-ins and passwords to different systems throughout the day. So it’s a security feature but an efficiency one, too.

I am keenly aware of the concept that every click and keystroke that you add for security [to a doctor’s workflow] is not welcomed. I am doing as many things as I can that are either back-office, or doesn’t impact the end user, or if it will have to touch the end user, I am hoping it makes him or her more efficient.

How sophisticated are behavioral monitoring strategies at Banner?

We have one area that we’re mature in and another where we’re at the beginning. On the mature front, we have a technology in place that evaluates a number of inputs such as: the clinician’s job; where he or she physically is doing work; and which patients he or she is looking at, and it makes sure that clinicians are only accessing patient records they should be accessing.

But when it comes to malicious activity traversing the network or systems behaving the way they shouldn’t be, we’re only at the beginning. We are looking at baselining what normal behavior is for most of our systems. We have implemented some database anomaly monitoring technology to be able to look for normal behavior on our most critical databases, and then alert and take action when that behavior is not considered normal. And that all feeds into our SIM [security information management product].

How key is it to deploy these strategies in a proactive way rather than be reactive following an incident?

We would all prefer to be on the proactive and preventative side, so we are trying to do everything we can do to prevent an incident from happening. On the defensive/reactive side, we’re trying to shorten that window of reaction latency. Whereas a bot could be operating in your environment for months, we’re trying to make sure that as we see anomalous behavior happening, we can address it quickly. And we’re putting in drawbridge technology in some cases. If something is looking a little strange, the time to get that resolved could be hours or days. If there is an attempt to extract millions of medical records out through our network, you want that reaction time to be seconds or minutes—not hours or days. So it depends what part of the network you are talking about and what data you are talking about. The more on the preventative side, the faster the reaction time, and the more expensive that is. You can only spend so much money.

Does the “human factor” concern you most when it comes to cybersecurity incidents?

It’s the human factor; machines/computers/technology do not make mistakes. Most ransomware is the result of unpatched systems and most systems can’t patch themselves—they require human intervention. Humans are the ones who click on phishing emails, upload credentials and download malicious software. We and others spend a lot of our IS budget on technologies and staff, but we don’t spend a proportional amount of that money on training, awareness and addressing those human weaknesses. So at Banner, I am spending a significant amount of our budget on training and awareness, and what we can do to make sure the human element is as little of a weak link as possible.

Do you and other CISOs collaborate often on best practices and things you’re seeing? If so, how helpful is that?

Yes, and it’s very helpful. I am part of three or four different CISO forums. There is the informal network where I just know other CISOs, and we might get together once in a while for lunch or connect socially. Then there are formal monthly and quarterly CISO roundtables that people participate in. And in Phoenix, I have a special relationship with another big healthcare provider here, and we connect regularly and we get our leadership teams together on a quarterly basis. So we are sharing information and ideas that way. No one I know of in the healthcare CISO market views information security as intellectual property. We share threats, ideas, projects, technologies, successes and failures. There is tons of value in having an open and collaborative community.

When it comes to both areas—behavioral monitoring and IAM—if organizations invest more energy and effort into these strategies, could the adage we always hear about “cybersecurity getting worse before it gets better” reverse course?

They will make a difference but this is an area in which the threat will continue to evolve over time. There’s no limit to the creativity of organized crime or nation-state actors being able to try and get to sensitive information and resources. The old analogy of the Golden Gate Bridge applies; you start to paint it on one end and by the time you get to the other end you have to start back at the beginning. We are constantly painting this bridge. You always have your foundational technologies in place, and a lot of us in healthcare are still putting foundational security safeguards in place. Once that’s in place, it becomes what we need to do from a refresh perspective or an emerging technology perspective to keep up with how the threats are evolving.


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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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