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In an Evolving Threat Landscape, Healthcare IT Security Leaders Face the Growing Challenge of IoT Devices

July 21, 2017
by Heather Landi
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During a recent webinar hosted by the Center for Connected Medicine, healthcare IT security thought leaders examined the proliferation of internet-connected devices in healthcare and parsed the challenges of cybersecurity and the Internet of Medical Things (IoMT) in an evolving threat environment.

The Center for Connected Medicine is a Pittsburgh-based collaborative health care executive briefing center comprised of five founding partners—GE, IBM, UPMC, Nokia and Lenovo Health. The organization hosted the webinar in an effort to help health system executive leaders better understand the risks and solutions of cybersecurity and IoMT. During the webinar, industry thought leaders explored the threats and how the industry is responding.

“It seems like I read new headlines every day about the latest cyber attack targeting health institutions, many of which have involved IoMT devices,” Rasu Shrestha, M.D., chief innovation officer at UPMC and executive vice president at UPMC Enterprises, who moderated the webinar, said during the presentation.

To get a sense of the current healthcare data security landscape, cyber attacks targeting patient data organizations increased 300 percent from 2014 to 2016, according to a report from TrapX Security. The U.S. healthcare industry is currently spending an estimated $6.2 billion a year in fines and other costs related to health data breaches, reports the Ponemon Institute.

As cyber attacks against the healthcare industry continue to evolve, IoMT devices are becoming a bigger target. Data security leaders at patient care organizations now see the vulnerability of IoMT as a top concern in large part because connected medical devices are proliferating in health care.


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“The trend is not slowing down,” Shrestha said, noting that in the first quarter of this year, healthcare faced more cyber attacks than any other industry vertical, citing data from Vectra Networks. “As you can see, we’re in the midst of an unprecedented barrage of cybersecurity attacks. The time to take action is now. The industry has recognized the challenge and is responding.”

At UPMC, Shrestha said, cybersecurity is a recurring board-room agenda item. “Across the country, healthcare leaders are placing a greater emphasis on protecting their networks and intrusion. There is more attention and spending allocated to cybersecurity, but there is more that needs to be done.”

Garrett Hall, research director, cybersecurity and implementation services at Orem, Utah-based KLAS Research, recently co-authored a report on the healthcare security landscape, which entailed speaking to almost 200 healthcare professionals about their cybersecurity program. Only about 16 percent said their security program was fully functional, he said. During the webinar, Hall delved into the report’s findings and his take on the current security landscape.

“As a healthcare industry, we’re behind the times. There are a number of different reasons. One is that with all the technology advancements, there have been a lot of other priorities that have taken the forefront, with EMRs [electronic medical records], population health, and some other really valuable aspects of healthcare technology, and that has pushed cybersecurity to the back burner a little bit. In addition, there is some trouble that providers report to us about finding good cybersecurity resources in healthcare to fill the gaps and to help organizations prepare and respond to attacks.”

Hall noted that, according to KLAS’s research, about 41 percent of providers reported their organizations have dedicated less than 3 percent of the IT budget to cybersecurity.

“It just hasn’t been a top priority for the board. The good news is, we’re starting to see more of an emphasis on cybersecurity, and, I think, the IoMT has really helped to push some things to the forefront because of the potential for real harm to be done through these attacks. We see more organizations trying to get out in front of attacks and be proactive. The bad news, we are behind. The good news, I think we are catching up,” Hall said.

When asked how healthcare provider organizations can prepare for evolving cybersecurity attacks, Hall responded, “We are seeing that one of the most important ways to prepare and stay ahead of evolving attacks is to do an annual risk assessment to identify gaps and weaknesses, and once you understand those gaps, take that and build a security program or security plan that will allow you to take proactive steps to prepare for attacks and detect and respond to attacks, rather than just wait for something to happen and then react to it. With the evolution of attacks, and with the valuable nature of healthcare information, these attacks are not going to go away. These attacks will continue to change, so staying on top of it with risk assessments and a proactive security program and plan, those are the foundations of what providers should be doing to prepare for whatever may be coming.”

In addition, advanced organizations are leveraging detection strategies, such as security information and event management (SIEM), to monitor activity on their networks for proactive detection, and then build incident response plans and policies, Hall said.

Shrestha noted that UPMC, one of the nation’s largest integrated health systems, has 1,400 applications to manage and support and during annual system reviews, IT leaders identify vulnerabilities associated with each application. “In a typical year, we find more than 1 million vulnerabilities across our environment, which are prioritized by risk and resolved. In fact, UPMC identified and remediated over 3,000 instances of ransomware this last year alone. We recognize the challenge of keeping up with the hackers,” he said.

Shrestha continued, “We also partner with a third-party information security provider that moves 1 billion log files through its systems each day to identify anomalies and potential threats in real time. Our security operations center team investigates all high-risk anomalies that are identified through this process.”

What’s more, providers are becoming increasingly dependent on Internet-based resources to facilitate patient care, Shrestha said, noting that UPMC has 105,000 connected devices to manage and support. These connected devices, which are connected to networks and the cloud, have the potential to act as a gateway to break into a hospital’s main networks, he said.

Drilling down specifically into the vulnerabilities and security risks of IoMT devices, Beth Musumeci, vice president, cybersecurity at GE Healthcare, said the threat is significant, as connected health devices, by definition, “increase the attack surface.”

By 2020, 78.5 million number of people worldwide will be using home health technologies by 2020. By 2019, 87 percent of healthcare facilities will implement IoMT, up 60 percent from this year. The rise in breaches coupled with the rate that we’re implementing IoMT, it’s easy for us to see the challenge we have before us from cybersecurity perspective,” Musumeci said.

She outlined a number of key steps that IT security leaders at patient care organizations should take to strengthen their organization’s security posture to be able to withstand, detect and respond to constantly emerging threats.  First, she said, it’s important for IT leaders to recognize that compliance does not equal protection, she said, and, further to that point, IT security leaders need to know what vulnerabilities exist in their environment and then manage those vulnerabilities regularly and diligently.

“Understand that criminals will take the trouble to know your network, anything you accidentally connect to can accidentally get you attacked. You must know your network. A common oversight is a short-sighted definition of your network; you need to expand beyond you enterprise employees and include third-parties, suppliers, vendors and accountants connecting to your environment. Make sure they are following your security policy, and that includes their suppliers too,” she said.

It’s also critical to have an emergency response plan and policy, and then, practice recovery. “Having an effective and tested recovery plan can prove to be a vital defense, and plan for events like ransomware,” she said.

Applying Advanced Capabilities to Cybersecurity

Rob Marson, head of strategy and business development, Nokia, who also participated in the webinar, outlined cutting-edge techniques that healthcare organizations are deploying to protect against evolving threats. “To stay ahead of some of these threats, we’re starting to see organizations trying to strike the right balance between reactive and proactive security best practices. Security teams are working hard to identify and limit threat vectors, detect faster and respond faster. When I use the words ‘active security’ that means the right blend and balance between proactive and reactive.”

Active security involves constantly measuring the organization’s security posture and risk level, Marson noted. “As Beth [Musumeci] said, it’s more than just auditing for compliance, it’s an ongoing, near-time assessment of network security posture. To do this effectively, you need to rely on security software solutions that can help you automate and measure holistically your security risk and security posture.”

Rapid response is the key to minimize the impact of cyber attacks, Marson said. “Expect to be attacked, so the art is how quickly can you detect and respond appropriately. What needs to happen is we need to eliminate the time between detection and mitigation.”

Marson continued, “By now, it’s well acknowledged that as an industry, there is simply a cyber skillset shortage, and the traditional incident response strategies, which rely on manual processes, now need to turn to automation. Software plays a key role helping you automate your response strategy so you can respond faster and deal with more of those threats.”

Active security is about transforming security operations to become more predictive and more automated, he noted, “so we’re seeing techniques leveraging analytics, machine learning, leveraging threat intelligence to drive rapid and automated responses.”

Shrestha with UPMC noted that predictive analytics applied to data could enable IT security leaders to anticipate vulnerabilities before they occur and remediate faster, and then asked the panelists, “How distant are these capabilities?”

“From a network perspective, I don’t think they are as far off,” Marson said. “Already we’re seeing the application of data science to solve different problems and the application of data science and the evolution of machine learning and big data analytics in the realm of cybersecurity is upon us.”

KLAS’s Hall concluded that technology is critical, yet “training and culture is really the key. He added, “Making sure employees understand the policies, making sure everybody is on the same page about what is appropriate within the security program. We build the right culture to make it a more secure place for healthcare providers.”











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Targeting Third Party Risk: Leading CISOs Detail Efforts to Secure the Healthcare Supply Chain

December 18, 2018
by Heather Landi, Associate Editor
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Healthcare information security leaders are faced with the dauting challenge of securing information systems and data at a time when the cyber threat landscape is evolving rapidly and becomingly increasingly complex.

Most patient care organizations’ supply chains are filled with third parties who support the care delivery process and require access to patient information. Properly vetting and monitoring these third parties is a major challenge, and in some cases, insurmountable for many organizations who simply don’t have the expertise or resources, according to healthcare IT security leaders.

Many healthcare chief information security officers (CISOs) have found that effectively assessing the security posture up and down the supply chain is expensive given the complexity of the risks posed by privacy and security concerns, as well as an everchanging regulatory landscape. Currently, the process of managing third-party risk is often inefficient and time-consuming, for both vendors and providers, while still leaving organizations vulnerable to security threats.

During a recent webinar, sponsored by HITRUST, focused on healthcare cybersecurity and managing third party risk, John Houston, vice president, privacy and information security at the 40-hospital UPMC health system in Pittsburgh, outlined a number of factors that have made third-party risk management increasingly challenging and complex.

“There has been a fundamental change in IT, and a rapid move to the cloud. At the same time, we all see an increasingly complex cyber threat landscape where the threats are more sophisticated, and the technology solutions are more sophisticated as our business requirements are changing. It’s an increasingly complex landscape,” Houston said.


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He further noted, “As a result, there is a lot of confusion about how we best ensure our information is secure and available, and what is reasonable in terms of trying to achieve that. And finally, we are all worried about risk, and the biggest risk is patient safety. We worry about the cost of litigation and penalties, but first and foremost, we need to think about ensuring that we are able to deliver the best care to our patients.”

The stakes are changing, Houston noted, as federal regulators are investigating and penalizing organizations for failure to monitor third parties’ security practices, and hackers are increasingly targeting medical devices, he said.

“From a CISO perspective, we need to ensure that we are applying proper oversight over all of this. We can’t assume third parties are doing the right thing,” he said.

What’s more, healthcare organizations are increasingly reliant on cloud technology. A year ago, Nuance Communications, a provider of voice and language tools, was knocked offline when the company was hit with the Petya ransomware virus.

“I was around during Y2K, and about 95 percent of all our applications at UPMC, we ran within the data center, on premise. About 95 percent of newly acquired applications were run on on-premise, there was little on the cloud. In that environment, it falls upon the entity to secure data within its possession,” he said.

Contrast that with today’s environment, as Houston noted that “very little of what we acquire today runs on-premise. In some way, shape or form, at least one copy of the data is in the cloud.”

Studies have estimated that by 2023 no more than 25 percent of applications will be run on-premise in an organization’s data center, with about 75 percent run in the cloud, Houston said. “Many copies of our data end up in the cloud, and it’s not just one cloud provider. We get services from a lot of different vendors, all of which are in the cloud. That speaks to the fact we, as CISOs, can no longer directly secure our own information. We are dependent upon third parties to secure our data for us. We can’t simply trust that they are going to adequately secure that information.”

From a healthcare CISO’s perspective, a vendor’s IT and data security practices should be at least as effective as the provider’s security posture, Houston said. “I should expect nothing less. As soon as I expect less, that’s a sign of defeat.”

Across the healthcare industry, ineffective security, compliance and assurance methods drive cost and confusion within organizations and across third parties.

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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