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At the CHIME LEAD Forum-Toronto, A Strong Focus on Cybersecurity Challenges

September 20, 2016
by Mark Hagland
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Healthcare IT leaders from both the U.S. and Canada came together Tuesday to discuss cybersecurity challenges

All the sessions at Tuesday’s CHIME LEAD Forum-Toronto, being held at the Omni King Edward Hotel in downtown Toronto, focused strongly on the many dimensions of cybersecurity challenges in patient care organizations—across the U.S. and Canada, and globally. The event, being sponsored by the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), in cooperation with the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group corporate umbrella), began with a keynote address by Russell P. Branzell, CHIME’s president and CEO.

Branzell began the day by offering attendees a stark view of the current international cybersecurity landscape. Placing the current healthcare data and IT security situation into a global, pan-industry context, Branzell shared with LEAD Forum attendees his perspectives on why the healthcare industry, in the United States and Canada and internationally, is particularly vulnerable.

Early on in his presentation, Branzell asked the question, “How are we truly going to secure a world that’s uncontrollable, in terms of data?” He shared a story about a healthcare IT vendor’s client conference in which about 40 hospital and health system CEOs had been gathered together. Branzell said that some of what was said at that meeting astonished him. For example, he told his audience, “I asked those CEOs, how many of you outsource data to a third party? They all did. And the reality, when people talk about the cloud, is that there isn’t really some amorphous ‘cloud’—in fact, your data is in a data center—or in multiple data centers. And I also asked the CEOs, how many of you know where your data actually is? And no one could say that they did. People don’t know where their data is, because we’ve gone to a virtualized world.”

What makes the healthcare industry particularly vulnerable, Branzell told the CHIME LEAD Forum audience, derives from two different factors. First is that the value of a medical record on the open market is ten times greater than the value of a credit card number; second is that healthcare data is so fragmented and exists in so many places.

Branzell shared with his audience several key facts, including the following:


Components of Strong Cybersecurity Program - A Closer Look at Endpoint Security Best Practices

Endpoint protection remains a core security challenge for many healthcare organizations and it is more important than ever for healthcare organizations to actively manage their full range of...

>  In 2015, 110 million medical records were breached in the top ten breach incidents in the United States, while at least half of the medical records in the U.S. were breached last year.

> Globally speaking, there has been a 60-percent increase in data breach incidents, year over year, among healthcare payers and providers.

>  Also internationally, the largest single data breach in healthcare, in a patient care organization in 2015, was a breach in South Korea that exposed 17 million patient records at once.

>  The largest number of data breaches that occurred in any country in 2014 occurred in the United Kingdom.

>  Also worldwide, 35 percent of breaches took place in the healthcare.

>  The average cost of a data breach, globally, was $3.79 million. And that is a bankruptcy even for a small hospital.

The challenge for healthcare providers in all countries, Branzell noted, is that more than 98 percent of all processes in healthcare are automated now, more than 98 percent of all devices are networkable, more than 95 percent of patient information is digitized, and that accountable care and patient engagement rely on it. Thus, any outage, corruption of data, loss of information, risks patient safety and care.

Looking at the top data security risks in healthcare, Branzell noted that they include the following:

>  Theft, fraud, and loss: nearly half of all healthcare data breaches involve the theft or loss of a device that was not properly protected.

>  Insider abuse: nearly 15 percent of breaches in healthcare are carried out by knowledgeable insiders for identity theft or some form of fraud.

>  Unintentional action: nearly 12 percent of data breaches are caused by mistakes or unintentional actions such as improper mailings, errant emails, or facsimiles.

>  Cyber-attacks: There was almost a doubling of these types of attacks in 2014.

>  Meanwhile, there was a 138-percent increase in medical records exposed worldwide in 2013.

Among the challenges facing healthcare executives, Branzell noted, are the following:

>  Patient care organizations’ cybersecurity defenses are not keeping pace with the emerging threats.

>  The three most common types of cyber-attacks now are spear phishing, Trojan horse attacks, and malvertising.

>  Most patient care organizations still can’t effectively detect or address these emerging types of attacks.

>  Most hospital boards of directors still lack actual oversight over cybersecurity issues.

>  Most patient care organizations are still not proactively preparing themselves for ransomware attacks.

>  And 17 percent of hospital organizations in the United States have yet to conduct a cybersecurity risk assessment.

In addition, Branzell cited “questionable supply chains,” in which patient care organization leaders cannot confidently name all the entities that are involved in their data, including patient data.

Meanwhile, Branzell also shared with his audience some facts about malware and related threats, including:

>  There are more than 3.4 million Botnets active in United States healthcare markets.

>  Currently, 20-40 percent of recipients in phishing exercises fall for phishing scams.

>  What’s more, 26 percent of malware is being delivered via HTML, with one in every 300 emails infected.

>  Malware analyzed was found undetectable by nearly 50 percent of all anti-virus engines tested.

The threats are only going to become more intense over time, Branzell said, partly because of clinician and staff mobility—and the mobility of all workers. “We are living in a world of mobility,” he noted. “And medical staff are turning to mobile devices to communicate, because doing so is easier, faster, and more efficient. And yet,” the noted, “In that room with 40 CEOs in it, not a single CEO raised their hand when asked whether they had required doctors and others who bring their personal mobile devices into their patient care organization, to have their devices securitized.” That, he said, shows how frightening the situation really is on the ground these days.

Meanwhile, Branzell told his audience, cybersecurity insurance policies are being written, but there are a number of challenges in that emerging area. What those policies are called differs from one insurance company to the next. Common nomenclature includes “identity theft,” “privacy,” and “data security” policies. Those police are being underwritten as sub-policies or endorsements to errors and omissions policies. However, because they are being written under errors and omissions policies, non-insured contracting parties cannot be named as “additional insureds.”

Finally, Branzell noted, the average percentage of overall hospital organization operating budgets being spent on IT right now is 3.5 percent among U.S. hospital-based organizations. And within that, about 3.5 percent of hospitals’ IT budgets are being spent on data security. That, he noted, contrasts strongly with the 8-10 percent of overall operating budgets being spent on IT by big banks, and with the 27 percent of their IT budgets that they are spending on data security. And, he added, “When I talk to people at the big banks, they are saying that that 27 percent of IT budget being spent on data security is not enough.”

Panel reflects on challenges

In the afternoon, the cybersecurity focus continued, as CHIME executive vice president and chief strategy officer Keith Fraidenburg moderated a panel entitled “Essential Factors for Cybersecurity Preparedness.” The three healthcare IT leaders on the panel were all CIOs, one Canadian, and two American. They were: Lydia Lee, senior vice president and CIO of University Health Network, Toronto; Patty Lavely, senior vice president and CIO of Gwinnett Health System, in Lawrenceville, Georgia.; and Jeff Wilson, director of information services, assurance and IT security, Albany (New York) Medical Center.

Asked to summarize some of the current challenges and advances on their organizations’ journeys around cybersecurity, Gwinett’s Lavely said, “Currently, we are in the process of relaunching our cybersecurity program. We started last year. We engaged a consulting firm partner to help us develop our program and to supplement our staff. Staffing is a real issue for us,” Lavely said. Despite the cybersecurity staff deficit, she reported that “We have expanded our risk assessments,” and that, rather than being focused primarily on complying with regulatory requirements, the risk assessment process in her organization is now more strategic, thorough, and comprehensive.

“I think that our senior leadership does realize how important this is,” Lavely continued. “But when it comes down to our labor committee, do we end up hiring more nurses, or cybersecurity people? We continue to hire nurses,” she conceded. “And cybersecurity vulnerability continues to be an issue for us,” with regard to an awareness on her team of the challenges getting end-users to do better at phishing tests. That said, she noted that “We do a daily leadership huddle, and cybersecurity issues and data breaches are reported in that daily huddle.” What’s more, she said, “Our recent phishing awareness campaign did succeed in raising awareness.” Meanwhile, she noted, “We recently did a system-wide password reset. And if you want to get people’s attention, do a system-wide password reset.” Among other areas she and her team are working on are that she and her colleagues have redone their incident response protocols. Further, she noted, “Probably the biggest win for us is that our board of directors really takes an involved approach to cybersecurity and are very concerned, and ask questions,” particularly with regard to the monthly cybersecurity report that she prepares for them.


Albany Medical Center’s Wilson noted that, “Up until 2014, our security group was dedicated to provisioning systems—setting up accounts and turning them off. But with all the data breaches,” he said, “we started reassessing what we were doing and where the gaps were. We did that in 2014 and 2015. By December of 2015, we had completed an incident response assessment. And we have something like 18 projects in play this year,” he noted.

The three keys to success in the cybersecurity arena, Wilson posited, are “prevention, detection, and response. You prevent what you can, you detect what’s going on, and you respond to what is happening. Unless you can effectively respond, your response plans are inadequate.”

University Health Network’s Lee noted that, given that UHN is a four-hospital, 1,304-bed system with 18,000 users, her IT staff of 200 is relatively small. What’s more, she said, noting the academic and research nature of her organization, “We are operating in a highly, highly complex clinical IT environment.”

In addition, Lee said, “The thing that’s a little bit different in this region is that we’re also very active in leading our regional HIE [health information network], which runs across the entire greater Toronto metro area, with 7 million people. Our team led that,” she noted. And the HIE encompasses a diagnostic imaging repository, and “All of our information feeds that repository. And, as much as we’re concerned about what’s going on inside our organization, we’re also concerned about what goes on outside it. So we have to be very concerned about how all of our systems are architected, because your best security is only as good as your weakest link.”

Lee noted that recently, “When we took a step back and took a look at our information security landscape, we looked at our privacy process. We had gone through a whole maturity assessment and program review, and we followed the guidelines developed in our privacy program review, which was ratified across Ontario. There are seven principles about design development in privacy, and we took those and adapted them to security.” Among them, she said, was to make privacy—and now security—a default setting; to embed privacy—and now security—into system design; to achieve proactive functionality; and to provide enterprise-wide, end-to-end security.

Lee noted that a lot of reporting now takes place around data security deficits within the organization, so that the challenge is how to strategically and tactically address those deficits. Interestingly, she said, “Most threats that are uncovered appear ostensibly to come from Canadian sources. We’re thinking that what that means is that international people are using Canadian sources as a doorway. So it’s very tricky to actually see what’s going on.”

When, during the audience-participation portion of their session, the panelists were asked what they would do if they could have an ideal situation, Gwinett’s Lavely said, “Right now, 3 percent of our IT spend is on security; it probably should be above 10 percent. And we should triple our IT staff. Now, we’re in the middle of a merger with another organization, so that will influence the outcome of this; but that’s what we’re looking towards.”

“I would say increasing the overall level of maturity in the system would be my wish,” Albany’s Wilson said. And UHN’s Lee echoed Lavely when she said, “I would definitely like to increase staffing. We have only three people on our IT security team—one CISO, and two who do systematic control and audit. So that keeps me up at night. Staffing is definitely a major issue for us. So rather than buying more stuff, I would invest heavily in more in staffing. So that, instead of us having to remediate after the fact, after someone clicks on something they shouldn’t have, we want to get ahead of that. Just as ten years ago, we said quality was everybody’s business, now we’re saying that about security.”

Some of these broad discussions will continue on Tuesday and Wednesday, as the Health IT Summit-Toronto gets underway, also at the Omni King Edward Hotel in Toronto.


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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.


Components of Strong Cybersecurity Program - A Closer Look at Endpoint Security Best Practices

Endpoint protection remains a core security challenge for many healthcare organizations and it is more important than ever for healthcare organizations to actively manage their full range of...

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.

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, And, 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,” he 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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