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CISO Describes 10-Point Plan for Data Privacy Improvements

April 12, 2018
by David Raths
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After 2012 breach, Memorial Healthcare System rebounded by addressing access policies, procedures
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In 2017, South Florida-based Memorial Healthcare System (MHS) paid the U.S. Department of Health and Human Services $5.5 million to settle potential violations of the HIPAA privacy and security rules and agreed to implement a robust corrective action plan. During a recent webinar, CISO Rich Leon outlined 10 areas MHS has addressed to beef up its privacy protections.

In its description of the settlement, HHS noted that the protected health information of 115,143 individuals had been impermissibly accessed by MHS’ employees and impermissibly disclosed to affiliated physician office staff. The log-in credentials of a former employee of an affiliated physician’s office had been used to access the ePHI maintained by MHS on a daily basis without detection from April 2011 to April 2012, affecting 80,000 individuals. Although it had workforce access policies and procedures in place, six-hospital MHS failed to implement procedures with respect to reviewing, modifying and/or terminating users’ right of access, as required by the HIPAA rules, according to HHS.

This example highlighted the need for organizations to implement audit controls and review audit logs regularly, HHS noted.

Leon said that MHS has worked to raise awareness about privacy requirements through extensive training and video campaigns and has implemented privacy monitoring systems and managed privacy services. He also said MHS changed its privacy motto to “Privacy is Everyone’s Responsibility” to remind people that they wanted to obligate other entities that are accessing PHI at MHS.

During the webinar he spoke of 10 potential weaknesses and what MHS has done to address them.

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1. No Automated Periodic Access Review Process. MHS has implemented a quarterly automated periodic access review process for employees, physicians, students and vendors, Leon said. It also has created a monthly, automated periodic access review process for non-employed physicians office staff, ACOs and population health organizations. This process wasn't automated or well-documented before the breach, he noted. “We are dialing in deeper trying to get this as close to perfect as possible,” he said.

2. Limited or Inaccurate User Identity Data. MHS now has comprehensive identity data available to the privacy program. Extensive metadata has been added for non-employees.

3. No Dedicated Privacy Department. MHS has hired Pascale Prepetit as corporate director of privacy, and he has created a team to work on privacy issues.

4. Flood of Access Requests for Physicians and Their Staff. MHS now has a strict and binding Enterprise Systems Access Policy with defined sanctions for policy violations. Every new organization it works with must identify the leaders in their organization who will be responsible for monthly verifications. “Those entities are bound to a monthly access verification process and a yearly re-certification process,” he said.

5.  Lack of Documentation of Vendor Access and Business Associate Agreement Tracking. All vendors are now comprehensibly vetted, including a privacy checklist review before they obtain access. “We say, ‘no BAA, no access'" to PHI, Leon said.

6. Limited IT Resources for Provisioning and De-provisioning Users. MHS now has a dedicated System Access Team that manages all automated and manual provisioning processes. The team also manages the periodic access review process.

7. Lack of Adequate Sanctions of Policy Violations. MHS adopted a zero tolerance policy for privacy violations. The privacy program investigates all violations. Employment terminations have occurred. “That was a challenge,” Leon said. We had to have discussions around impacting the rights of employees.”

8. No Dedicated IT Security Team. Leon said he has worn many hats in IT at MHS over the years, but now he is laser-focused on privacy and security as CISO. He also has a manager of IT security.

9. Lack of Tools to Support a World Class Privacy Program. MHS put out a request for proposal for a privacy monitoring solution partner, and chose FairWarning in 2017. A plan of action is in place for eight monitored sources and eight enforced policies.

10. Solely Reactive Privacy Monitoring Program. MHS has contracted with FairWarning Managed Privacy Services and seen a reduction of false positive investigations, he said.

Looking Ahead

MHS is working with accountable care organizations, population health programs, and providers in its Epic Community Connect program.  It is obligating those entities to do their own privacy review of access outside of their patient roster/list. Leon said MHS has identified a need to continue to obtain and document identity data for rapidly moving organizations with high turnover. They must document their workflows and defined access rules to maintain the “Minimum Necessary Standard.”

Leon said he keeps his eyes on technology enhancements that might help with the privacy program. For instance, he is interested in building location awareness into privacy monitoring, as well as developing risk scoring for roles, salary ranges, shifts and locations.

 

 

 


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4.4M Patient Records Breached in Q3 2018, Protenus Finds

November 7, 2018
by Rajiv Leventhal, Managing Editor
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There were 117 disclosed health data breaches in the third quarter of 2018, leading to 4.4 million patient records breached, according to the Q3 Protenus Breach Barometer report.

Published by Protenus, a cybersecurity software company that issues a Breach Barometer report each month, the most recent data shows that although the number of incidents disclosed in Q3 decreased somewhat from Q2, the number of breached records increased from Q2 to Q3. Also, the number of affected patient records has continued to climb each quarter in 2018—from 1.13 million in Q1 to 3.14 million in Q2 to 4.4 million in Q3.

In Q3, the report noted that the single largest breach was a hacking incident affecting 1.4 million patient records that involved UnityPoint Health, an Iowa-based health system. Hackers used phishing techniques, “official-looking emails”, to gain access to the organization’s email system and capture employees’ passwords. This new incident follows one that took place at the same organization in April when 16,400 patient records were breached as a result of another phishing attack.

For incidents disclosed to HHS (the Department of Health & Human Services) or the media, insiders were responsible for 23 percent of the total number of breaches in Q3 2018 (27 incidents). Details were disclosed for 21 of those incidents, affecting 680,117 patient records (15 percent of total breached patient records). For this analysis, insider incidents are characterized as either insider-error or insider-wrongdoing. The former includes accidents and other incidents without malicious intent that could be considered “human error.” 

There were 19 publicly disclosed incidents that involved insider-error between July and September 2018. Details were disclosed for 16 of these incidents, affecting 389,428 patient records. In contrast, eight incidents involved insider-wrongdoing, with data disclosed for five of these incidents.

Notably, when comparing each quarter in 2018, there has been a drastic increase in the number of breached patient records as a result of insider-wrongdoing. In Q1 2018, there were about 4,600 affected patient records, in Q2 2018 there were just over 70,000 affected patient records, and in Q3 there were more than 290,000 affected patient records tied to insider-wrongdoing.

What’s more, the report found that hacking continues to threaten healthcare organizations, with another increase in incidents and affected patient records in the third quarter of 2018. Between July and September, there were 60 hacking incidents—51 percent of all Q3 2018 publicly disclosed incidents. Details were disclosed for 52 of those incidents, which affected almost 3.7 million patient records. Eight of those reported incidents specifically mentioned ransomware or malware, ten incidents mentioned a phishing attack, and two incidents mentioned another form of ransomware or extortion. However, it’s important to note that the number of hacking incidents and affected patient records have dropped considerably when comparing each month between July and September 2018.

Meanwhile, of the 117 health data breaches for which data was disclosed, it took an average of 402 days to discover a breach from when the breach occurred. The median discovery time was 51 days, and the longest incident to be discovered in Q3 2018 was due to insider-wrongdoing at a Virginia-based healthcare organization. This specific incident occurred when an employee accessed thousands of medical records over the course of their 15-year employment.

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Survey Reveals Disconnect Between Perception and Reality of Medical Device Security

November 6, 2018
by Heather Landi, Associate Editor
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A recent survey of healthcare IT professionals found a troubling disconnect between IT leaders’ confidence in the visibility and security of their connected medical devices and the effectiveness of legacy solutions to secure connected medical devices.

The vast majority of healthcare IT professionals (87 percent) feel confident that the connected medical devices in their hospitals are protected in case of a cyberattack. However, the survey also revealed a contradiction between the confidence that healthcare professionals have in the visibility of connected medical devices and security of their networks, and the inefficient and ineffective legacy processes many still rely on to keep them secure.

The survey from Zingbox, a provider of Internet of Things (IoT) security solutions, is based on responses from 400 U.S.-based healthcare IT decision-makers and clinical and biomedical engineers and indicates that there continues to be a widespread misconception that traditional IT security solutions can also adequately secure connected medical devices.

Seventy-nine percent of respondents say their organization has real-time information about which connected medical devices are vulnerable to cyber attacks. And, 69 percent feel traditional security solutions for laptops and PCs are adequate to secure connected medical devices.

“Most organizations are thinking about antivirus, endpoint protection and firewalls, but there are many devices — like medical monitoring equipment — and no one is thinking about securing them,” Jon Booth, Bear Valley Community Hospital District IT director and Zingbox customer, said in a statement. Additionally, as noted in a Gartner report, Market Trends: Five Healthcare Provider Trends for 2018 published in November 2017 notes: “Generally, medical devices are not replaced for at least 10 years, with many running old software that has not been updated or patched.”

And there are other challenges: the Zingbox survey revealed 41 percent of healthcare IT professionals do not have a separate or sufficient budget for securing connected devices.

When asked about inventory of connected medical devices, majority of clinical and biomedical engineers (85 percent) were confident that they have an accurate inventory of all connected medical devices even though many rely on manual audits, which are prone to human error and quickly become outdated.

What’s more, close to two-thirds (64 percent) of responses from clinical and biomedical engineers indicate reliance on some form of manual room-to-room audit or use of static database to inventory the connected devices in their organization. Just 21 percent of responses say their devices receive preventative maintenance based on device usage as opposed to some kind of fixed schedule.

The survey also shows that more than half (55 percent) of responses indicate clinical/biomedical engineers must walk over to the device or call others to check on their behalf whether a device is in-use before scheduling repairs. Many make the trip only to find out that the device is in-use by patients and must try again in the future hoping for better luck, according to the survey.

“Despite the recent progress of the healthcare industry, the survey exemplifies the continued disconnect between perception of security and the actual device protection available from legacy solutions and processes. Unfortunately, much of the current perception stems from the use of traditional solutions, processes and general confusion in the market,” Xu Zou, CEO and co-founder of Zingbox, said in a statement. “Only by adopting the latest IoT technology and revisiting decade-old processes, can healthcare providers be well prepared when the next WannaCry hits.”

 

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HHS Opens Rebranded Healthcare Cyber Center

November 2, 2018
by Heather Landi, Associate Editor
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The U.S. Department and Health and Human Services (HHS) this week officially opened the Health Sector Cybersecurity Coordination Center (HC3), designed to strengthen coordination and cybersecurity information sharing within the healthcare sector and promote cybersecurity resilience.

According to HHS officials, HC3 is an operational cybersecurity center designed to support and improve the cyber defense of the healthcare and public health sector. The center will work to cultivate cybersecurity resilience by providing timely and actionable cybersecurity intelligence to health organizations and developing strategic partnerships between these organizations.

The Administration, under President Donald Trump, has designated the Department of Homeland Security (DHS) as the lead organization to combat cyber threats and develop preventive strategies across the entire economy, with HHS given the role to focus cybersecurity support on information sharing within the healthcare and public health (HPH) sector.

“HHS is proud to work with the health community to better protect Americans’ health data and confidential information,” HHS Deputy Secretary Eric Hargan said in a statement, adding that the announcement “is a recognition of the importance we place on stakeholder engagement as part of our cybersecurity work.”

Jeanette Manfra, assistant secretary for cybersecurity and communications in DHS, said in a statement that HC3 is a “vital capability for the early detection and coordination of information between the private sector and the federal government, and with cyber professionals across the federal government.”

“We believe that when a risk is shared across sectors, the only way to manage that risk successfully is to manage it collectively. We know that the majority of the cybersecurity attacks that occurred over the past year could have been prevented with quality and timely information - and the heightened importance of sharing information cannot be stressed enough,” Manfra said.

The opening of HC3 respresents the second healthcare-focused cybersecurity center in two years. In June 2017, the Healthcare Cybersecurity and Communications Integration Center (HCCIC) launched and was designed to focus its efforts on analyzing and disseminating cyberthreats across the healthcare industry in real time. However, the fledgling HCCIC was almost immediately mired in controversy due to abrupt changes in leadership. In just six months after HCCIC began operations, the HCCIC’s top leaders were reassigned.

In November 2017, there were reports that HCCIC's work was stalled as it was at the center of an investigation into contracting irregularities and possible fraud allegations. The cyber operations center was “paralyzed” by the removal of its top two officials, according to reports. Leo Scanlon, deputy chief information security officer at HHS, who ran the HCCIC, was put on administrative leave in September 2017  and his deputy, Maggie Amato, left the government. The HHS Office of the Inspector General then confirmed, at the time, an ongoing investigation into the reassignment of HCCIC leadership.

About a week letter, the House Committee on Energy and Commerce issued a letter saying it was examining whether HHS retaliated against two key HHS cybersecurity officials and whether those actions weakened the federal agency’s role in responding to healthcare cybersecurity incidents.

During the summer of 2017, HHS officials had touted the center’s success in light of the WannaCry ransomware attack back in March 2017, in which the U.S. healthcare system saw minimal impact. In an interview with Healthcare Informatics this past March, former HHS Deputy CISO Scanlon said the HCCIC, which played such a promising role during the WannaCry incident, had been "derailed" by the leadership reassignments.

There also were rumors back in March that the HCCIC would be rebranded and housed within Homeland Security in order to align with DHS’s information-sharing efforts. Scanlon said at the time that the effort to create a healthcare-specific cybersecurity information-sharing center was now "back to square one.”

It seems those rumors bore out as the new cyber center, HC3, is housed within DHS, whereas HCCIC, which is now gone, was intended to be a standalone entity partnering with NH-ISAC.

In the past year and a half, Congressional leaders have voiced concerns about the lack of clarity on the direction of HCCIC and HHS’ overall cybersecurity capabilities. Back in June, members of the House Energy and Commerce Committee and the Senate Committee on Health, Education, Labor and Pensions wrote a letter to HHS leaders citing concerns about the leadership changes, specifically the reassignment of senior officials responsible for the day-to-day operation of the HCCIC. “HHS’s removal of senior HCCIC personnel has had undeniable impacts on HCCIC and HHS’s cybersecurity capabilities.”

According to HHS and DHS officials, the mission of the new cybersecurity center, HC3, is now more important than ever with the healthcare sector reporting over 400 major breaches from 2017 to 2018. “Within the HPH sector, the threats are significant and hackers covet having the potential to access sensitive medical data, damage medical equipment, secure intellectual property for financial gain, or even conduct terrorist attacks.  The HC3 provides a service to healthcare organizations that enables them to protect their assets and patients,” Administration officials said in a press release.

To address these threats to the sector, HHS has developed a “coordination center” in the HC3 to coordinate the activities across the sector and report to DHS threats, profiles, and preventive strategies. The HC3’s role is to work with the sector, including practitioners, organizations, and cybersecurity information sharing organizations to understand the threats it faces, learn the bad guys’ patterns and trends, and provide information and approaches on how the sector can better defend itself, officials said.

 

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