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At the CHIME16 Fall Forum, a Conversation around Avoiding CIO Minefields

November 2, 2016
by Rajiv Leventhal
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A group of industry leaders discuss what CIOs should do to avoid danger

Healthcare leaders at the CHIME16 CIO Fall Forum took to discussing the biggest trouble areas for CIOs today, what actions should be taken to avoid these minefields, and how to survive if they do occur.

The panel discussion took place on Nov 2. at the JW Marriott Phoenix Desert Ridge Resort in Phoenix, Ariz., the setting for the 25th CIO Forum from the College of Healthcare Information Management Executives (CHIME). The panel consisted of two CIOs, a CIO recruiter and a consulting firm CEO. They were, respectively: Keith Perry, senior vice president and CIO, St. Jude Children’s Research Hospital (Memphis, Tenn.); Chris Belmont, vice president and CIO, University of Texas MD Anderson Cancer Center in Houston; Chris Wierz, R.N., principal Witt/Kieffer; and Dana Sellers, CEO, Encore, A Quintiles Organization.

Sellers, who moderated the discussion, began by telling personal anecdotes of how her CIO friends have gotten “trapped” in these minefields, ranging from: a CIO getting a call from her hospital about a security breach that occurred on New Year’s Eve, meaning limited resources were available to remedy the situation; to another CIO friend who had a Microsoft audit done on her organization, only to find that the institution was using licenses that weren’t paid for; to another CIO whose organization was dealing with a merger and felt he or she might be on the short end of the stick after the deal’s completion. The lesson learned from all this? “Surround yourself with people who are smarter than you,” Sellers said half facetiously.

Witt/Kieffer’s Wierz has seen plenty of these occurrences in her time as a CIO recruiter. In her role, she also hears the stories firsthand from CIOs coming to her. Wierz attested that while there are not many times when these minefields become fatal for a CIO’s career, there are things that can be done to avoid them. Also, she asks, “How do you handle them and come out on the other side? At the same time, the pace of change and technology is moving so quickly, so these things are on the board's agenda, and minefields are becoming much more public and prevalent,” she said. Wierz noted four of the biggest minefields CIOs ought to watch out for:

Privacy and security: These are the most visible and expensive, she said. Wierz noted a global CIO study that found CIOs feel even less prepared today to handle security year-over-year compared to before. “We have seen people get fired for security incidents. But it depends on the level of failure and response to the incident. Was the reason for the firing that security incident or something on top of it that leadership didn't say anything about?” Wierz asked.


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Disasters and downtime: “No matter how well you do your backups, redundancies, and procedures, you are made the scapegoat,” she said.

Troubled projects: Many of these troubled or failed projects go unreported, in addition to what's in the media and what’s public knowledge, Wierz noted. It’s important how to handle this from an accountability and transparency aspect, she said.

Leadership change: “New leadership is sometimes inevitable. Be transparent as possible, work through it, and understand why change is happening,” Wierz said.

Drilling down on the first of these four areas, MD Anderson’s Belmont said frankly that he doesn’t like to talk about security, for one. “How do you make your information systems easy to use, accessible and also be on ‘lockdown,’ too? That's the situation we're in and it's almost impossible,” he said. “It’s not about the tools but about how you use them.” Belmont reflected on when his organization was changing its storage network and lost a large amount of raw genomic files. “Our researchers depend on that since you have to be able to repeat your research. So not having raw files causes problems. We did fix it quickly, though,” he said, simply urging CIOs in the audience to get out in front of it, work with partners and just “figure it out.”

Further touching on security, St. Jude’s Perry said that in the little more than a year he has been at the patient care organization, he has been working with his CISO in elevating that role. He insisted that it’s not about who's reporting to who, but rather having a conversation with the CISO while walking down the hall about him or her taking a stand to leadership on architecting the network, Perry said, offering an example.

To this end, Wierz said the CISO market is “a very active one.” She noted, “We get requests for CISO searches on a regular basis. So if you don’t have one, I would say hire one quickly. We are seeing these individual salaries go up by $50,000 each month,” she said, drawing a reaction of shock from attendees. As far as who the CISO reports to, Wierz mentioned that it varies: sometimes it’s to the audit committee or the board, and sometimes it’s to the CIO, but overall, changes are occurring within that reporting structure. She also advised CIOs and organizational leaders too look outside of healthcare for hiring a CISO. “Folks say that they would like to do that but when push comes to shove they don't make that commitment. I think it's important to do that now,” she said.

Regarding disasters and downtime, Perry spoke about a storage outage at a company he was working with at the time that resulted in clinical systems being disabled, thus affecting patient care. “After we brought it back up in a few days, I talked to my CISO about being transparent about what happened during the downtime and why, and we brought in a company to do a root cause analysis, which we then took to our executive board. That was a good thing; we instilled trust in the process that we're engaged in the conversation and take these things seriously,” Perry said.

MD Anderson’s Belmont had the most significant disaster experience among panelists, having closely witnessed Hurricane Katrina in New Orleans. “We ran out of disaster planning by page 10, so we kept writing down more as we were going along,” he said. But Belmont also said going through that kind of situation can also lead to an overreaction for the next time. “We ran out of fuel to power the generators so we brought in this [military fuel] and we didn't know what to do with all of it. So it’s important not to look at disasters as predictable events that all run the same way. Find out who those leaders are that you want to be in the trenches with,” he advised. “And how do you recover? With a hurricane, you might spend a week or more [hunkered down], so make sure you have a relief staff to get you through it.” For some disasters, Belmont noted, there simply isn’t a script to follow or a book to look something up.

Meanwhile, on the troubled project front, Belmont said that often it might be the perception of a problem that the CIO has to deal with as much as the actual issue itself. With an EHR (electronic health record) transformation, for example, there are growing pains and perceptions that stem from that, he said. “You might read in the paper about financial problems due to an EHR implementation, and you have to manage the perception and the news that's out there,” he said, likely referring to press reports that MD Anderson’s income took a hit after a recent EHR implementation. “The reality is that you have to lead your way through it, and this isn't a single event; it’s a journey. We had a couple of loud doctor voices in the room and others who were [easier to work with]. So find your champions to work with and don't be defensive,” he said.

When a CIO is going through a troubled project, Perry said there is often a lack of vision. “Ask yourself, where's the value for why I started this effort to begin with? You need to get people back to the value you're trying to create for the organization,” he offered. Belmont, meanwhile, said it’s okay to step back from a troubled project and re-evaluate. “Don't be afraid to hesitate, hit the brakes or stop all together. A reboot can be a good thing. We once took a year off from a project, and came back stronger,” he said.

Leadership change, the fourth minefield that Wierz noted at the top of the discussion, can be a very difficult thing, and Perry said that it’s important to not be beholden to the technology that’s been implemented and leveraged in the past since the new leader might have a different approach in mind. “You want to be that person’s trusted advisor,” he said.

Belmont added, “Ask yourself if you’re a good fit for the organization. You need to reflect on yourself and ask if you're doing best to serve the mission of the institution,” he said. “Be the right person for the job, and make adjustments for yourself and the team. I can't control what happens above me; changes happen without us all the time,” he 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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