At Boston CHIME LEAD Forum, the Cybersecurity Message is Loud and Clear: Good Defense is the Best Offense | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

At Boston CHIME LEAD Forum, the Cybersecurity Message is Loud and Clear: Good Defense is the Best Offense

June 22, 2016
by Rajiv Leventhal
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IT security leaders stress the need for layered defense, neutralizing the human element

At the Boston CHIME LEAD forum, held on Wednesday, June 22 at the Aloft Boston Seaport Hotel, and cosponsored by the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) and the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella), expert health IT security panelists discussed the key components of an effective healthcare cybersecurity strategy.

Throughout the day, program attendees listened to multiple engaging sessions about a myriad of cybersecurity issues, from essential factors on how patient care organizations can be better prepared, to strategies for defense, response, and recovery. A plethora of IT security leaders—many from the healthcare space, but some with years of experience in other sectors—hammered home several core points, including: 1) the healthcare industry has now clearly become an intentional target for hackers; 2) traditional defense strategies such as firewalls and defending the perimeter are outdated and inefficient; 3) some sort of human-related issue contributes to the overwhelming majority of attacks; and 4) establishing a culture in which end users are educated and trained, and IT security is a proactive priority rather than a reactive one, is a must.

So where does the industry stand today in terms of its level of preparedness and sophisticated defense strategies? To start, the security experts in Boston pointed out that despite a recent uptick in making cyber defense a priority, it will be a while before healthcare gets to a place that other industries, such as financial services, have gotten to. Indeed, multiple panelists throughout the day attested that they were either on a solo mission at his/her organization regarding IT security, or had to start a team upon being hired.

Heather Roszkowksi, CISO at University of Vermont Medical Center, for instance, said the organization's security department was essentially non-existent before she arrived four years ago. "The focus has been on building a program, a suite of tools, and changing the culture," she said.  For the first couple years, Roszkowksi was a "solo show" and didn't have an IT security team. "So we started out with an email encryption tool and an endpoint tool. But we have worked our way up from there," she said, noting the incorporation of data analytics and assessment approaches such as testing users with phishing emails, that are present today.

But, the CISO said the biggest thing has been changing the culture. She told an anecdote of a physician at the medical center who called her and said that "time-out" functions that require a user to log back on after a period of inactivity were taking up too much time, and the physician couldn't pay as much attention to patients as a result. "So we went down to the hospital that the physician was in, saw the issue in person, and [fixed] it," Roszkowksi said. Indeed, the system that was requiring log-ins and log-outs was always in site of the physician, making it less necessary to devote contstant attention to it, she said. "Customers see that we're listening to them and helping. And, we're getting what we want too, which is a more secure environment."


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Several panelists also noted how cyber defense strategies from yesterday, such as firewalls and anti-virus programs, are no longer efficient enough once 2015 came and represented the "year of the data breach," in which major data breaches spanning across the year resulted in the exposure of more than 100 million patient records. David Ting, founder and CTO at Lexington, Mass.-based Imprivata, said that the continuum of cybersecurity strategies has gone from defensive measures at the perimeter to technology solutions that monitor how people enter the network. "Some sort of human-related issue contributes to almost all attacks," said Ting, a 10-year healthcare veteran at Imprivata. "For the past 10 years here, it's been about how we neutralize that element of the human factor in which we introduce [a component that makes you] physically steal something rather than just take it from online," he said. Ting mentions two-factor authentication, which employs methods such as smart cards, one-time password tokens and biometric devices to ensure users are who they say they are, as an example of this.

Chris Williams, chief cybersecurity architect at Westfield, Ind.-based Leidos Health, agreed with Ting about monitoring how people enter the network. Williams, who is the security lead on the massive U.S. Department of Defense Healthcare Management Systems Modernization (DHMSM) electronic health record (EHR) contract that Leidos was awarded last year, along with Cerner, Accenture, and others, said that he cares more about knowing an attack took place rather than thwarting an attack. "If you know you are getting hit, you can measure that and adjust responses appropriately," said Williams.

He compared the situation to that of banking: "Knowing how many people were in my bank lobby at 2 a.m. is actionable information; how many people drove by and gave the bank a dirty look is not," he said. “So look at the metrics that measure real-world and actionable activity. The vault isn't the most important room in the bank; the lobby is. If I know someone is in my bank lobby before they should be, I can design my IT environment to get them when in the lobby. The same can be true in healthcare; what's the lobby of your organization? Is it a user's laptop? Figure that out and design your environment around it," Williams advised.

As far as overall axioms for modern cyber defense, Williams said: assume an intelligent attacker will eventually beat all defensive measures; design defenses to detect and delay attacks so defenders have time to respond; layer defenses to contain attacks and provide redundancy in protection; and use an active defense to catch and repel attacks after they start but before they can succeed.

Not to anyone's surprise, the panelists throughout the multiple sessions touched on the ransomware crisis that has plagued the healthcare industry for much of this year. Jon Fredrickson, CISO, MIS Information Security Group, Southcoast Health, a community-based health delivery system with three hospitals in southern Massachusetts, said that his organization has seen a 400 percent ransomware delivery attempt increase over the past three months. As such, Fredrickson and his team looked at who had access to those systems and did targeted education to them. That was successful, he said, and further noted that Southcoast Health was at the industry standard of an 11 to 12 percent click rate prior to targeted education, which went down to a 4 to 5 percent click rate afterwards.

Most ransomware attempts came through attachments, while others came through websites, Fredrickson said. But after the organization implemented sandboxing—a strategy to isolate malicious emails—the ransomware prevention rate went up to 98 percent, from 85 percent, he said. For those ransomware attacks that did sneak through, Fredrickson said they were mostly through HTTPS channels. "That's where user education is huge," he said. What does ransomware look like, what do you do when it presents itself? We unplug the asset immediately, we have a sound backup strategy, and we also work with directory services teams to disable the ID that was running on the machine at the time. Four [ransomware attacks] have made it through in the last 18 months," he said.

Another key strategy that the panelists pointed out was getting third-party help, as the magnitude and complexity of cybersecurity defense in healthcare is simply too much for any one organization to handle. Jeffrey Wilson, director of information services, and assurance and IT security information systems security officer at New York-based Albany Medical Center, said the medical center worked with technology research and advisory company Gartner to figure out where the organization was weak in terms of awareness and response. "That involved a lot of analysis. Some things were obvious off the top as far as technology changes [we needed to make]," said Wilson. Albany Medical Center also conducted a response readiness assessment with an outside organization. Wilson said after that valuation, the medical center realized "it was terrible there too."

Another point brought up during the day was the idea that healthcare, more so, than many other industries, has an environment of trust and openness. Typically, healthcare professionals are more worried about patient safety than they are about security of their IT systems. "Security is often diametrically opposed to the operational mission," Williams said. "So asking people to honor both missions can be an unrealistic request. That being said, you need to train folks so mistakes people make don't prove fatal."

To this end, Christopher Greico, HIT implementation specialist and CISO at Fort Drum Regional Health Planning Organization in northern New York, an agency that is responsible for a consortium of providers and entities, said that patient care organizations must take a "zero trust" approach. "Your partners could be a threat factor, and you have to assume that everyone you are interacting with is a potential threat," he said. You don't want to be called out on the HHS Wall of Shame and be all over the news. You don't want to be CIO who's leading the organization that it happened to. Healthcare has to realize that its in the crosshairs now, so we have to make this a priority, or we'll continue to be in the headlines," Greico said.

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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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