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Getting Granular on Cybersecurity: Experts Talk Frameworks and Hacks in Philadelphia

August 14, 2017
by Mark Hagland
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IT leaders from across healthcare share their perspectives on cybersecurity challenges—and the way forward

What are some of the most urgent cybersecurity issues facing the IT leaders at patient care organizations and health plans right now, in the wake of some recent, massive attacks on organizations worldwide? And what must healthcare IT leaders do in order to ramp up their cybersecurity strategies and implementations? Those were some of the questions pondered by industry leaders during a session entitled “Practical Tips for Creating a Cybersecurity Framework that Meets Your Privacy Standards,” on Friday, August 11. The session was held on the second day of the Healthcare Informatics Health IT Summit Series-Philadelphia, being held at the Warwick Hotel in center-city Philadelphia.

The panel was moderated by Sriram (Sri) Bharadwaj, chief information security officer and director, information services, at UC Irvine Health (Irvine, Calif.). Bharadwaj was joined by Leo Scanlon, HHS senior advisor for healthcare and public health and deputy chief information security officer in the Department of Health and Human Services; and J. Mark Eggleston, vice president and chief information security officer and privacy officer at Health Partners Plans (Philadelphia).

Early on in the discussion, Bharadwaj asked his fellow discussants, “Why do we need to make use of a framework for data security? What do we need to get done, from a framework perspective, Leo?”

“I was listening to the last panel with a great deal of interest, because the description of what’s being done” in patient care organizations “mirrors what’s been done in the federal government for the past 12 years,” Scanlon told Bharadwaj. “It’s very difficult work; we have a lot of scars. And the hardest thing is persuading people of the risks involved. We have a framework based on NIST [the cybersecurity framework from the National Institute of Standards and Technology], based on FISMA [the Federal Information Security Modernization Act of 2014]. The guideline,” in short, he said, is, “use commercial software and manage the risk. That’s basically what the FISMA statute said. NIST was tasked with developing the framework. Congress asked them to develop what became 800-53 [the Security and Privacy Controls for Federal Information Systems and Organizations, from the Joint Task Force Transformation initiative], the control set. And we wasted probably five to seven years, spending a tremendous amount of money, demonstrating that we were compliant with controls, but showing very little that we had developed the craft of risk management,” Scanlon recalled.” And then there was a revolt among federal CISOs, and at the same time, NIST was busy developing the control set. One could argue that a framework should have been developed first, but they were under pressure to develop a control set,” he said, so that’s what happened.

“The reality,” Scanlon continued, “is that we’re going to use software that is not secure and was never designed to be secure. Andin the outside world, outside segments of the military, the reality is that nothing will ever be fully secure. The key is to suggest approaches.” In the areas of the Department of Health and Human Services (HHS) focused on data security, he reported, “We’ve developed a whole array of tools and self-assessments. We use audits, and we have a staff of people who organize audits and do nothing but respond to audits. And we use those audits as the cross-check against the self-assessments in various areas, to measure maturity. The cybersecurity framework was developed to be directly connected to the NIST framework. It involves a maturity model assessment. So our big lesson,” he said, “was how to get out of a compliance mode and get out of checking boxes and writing reports, but rather, moving towards targets.”


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(l. to r.) Panelists Scanlon,Eggleston, and Bharadwaj discuss cybersecurity issues

In addition, Scanlon said, “The other thing out of the federal government was an executive order, which said that cybersecurity is the responsibility of the individual agency, full stop. The executive order said, stop this, pay attention, and lead it.” Meanwhile, he said, “The third leg of what the federal government has done to support the framework is workforce development. To implement the framework, you need skill sets at every level—people who can understand these things, lead, and translate this into strategies at the upper management level. And need to evaluate tools and technologies, and apply them in the appropriate way. That’s what all of this is about, and what drives the cybersecurity framework in the federal government.”

Bharadwaj turned to Eggleston and asked him, “Mark, how do you use frameworks like this?” “We kind of stay away from the checkbox compliance piece. Studies have shown time and time again that simply checking boxes and being compliant doesn’t make you more secure,” Eggleston responded. “I’ve long been a proponent of HIPAA [the Health Insurance Portability and Accountability Act of 1996]; but HIPAA is the floor; it’s a dated protocol or law. We augment HIAPA by a series of vulnerability audits. We do quarterly tests. And we do a full external audit every two years. In actuality, I do do it every year. And I’m a big advocate of the NIST 800 series. And the CSC20—there are free protocols out there,” he said, referring to the Critical Security Controls for Cyber Defense framework. This is a framework that doesn’t require you to conduct a gap assessment. You hit the ground running with these protocols, and you know automatically that you’ll reduce your risk. And also in healthcare, you’ve got HITRUST”—the HITRUST CSF Framework from the Frisco, Tex.-based, not-for-profit HITRUST Alliance—“which is actually free.”

Moving towards an enterprise-wide risk management framework

“Here is my viewpoint of the concept of frameworks,” Bharadwaj stated. “Everybody understands the management of risk, at the board level. But the minute you talk about managing cybersecurity risk, people kind of run away. So you have a conversation with the board to help them understand that you have to have an enterprise-wide risk management framework, or ERM. The folks at the top need to understand that this is something we abide by and do. The concern we have is that the security industry has used a check-the-box approach for many years—‘I passed HIPAA’—that kind of thing. We put the cart before the horse. We didn’t talk about how we managed risk, but rather, we focused on check boxes and completing tasks.”

Bharadwaj went on to say that “The feds have released the NIST framework, but I still say that it lacks a risk management perspective, though it has marketing and communication elements in it. But in our organization, we’ve developed our own risk management asset” to address cybersecurity issues more broadly. “We went ahead and took the NIST 800 document and started working on it. But we also asked, how easy is it to fix specific problems? It doesn’t take a ton of hours to do this; it does require some management.”

“We’ve done studies of that type,” Scanlon replied. “And the SANS controls—SANS [the Bethesda, Md.-based SANS Institute] took the NIST 853 Controls, and said, look, let’s boil these groups down into one form of control. Do you basically have identity management in place, to make sure that you know what you’re doing in that area? One big part of the federal task force on that was a framework for developing a healthcare version of this. Not everyone can manage use of the NIST 853 controls. And the government is developing a common set of security controls. Fundamentally,” he said, “you need to ask, what are your assets, do you know where they are, and do you know their vulnerabilities? You need to know where to patch. If you don’t know that, you can’t fix it. Mark described upper-level capabilities; most organizations don’t have that. There’s a capability matrix. A small organization can’t consume a highly sophisticated level of automated information. This is where framework comes in, with the ability to communicate to ourselves in terms of where we are and what we need. And there’s a value to getting this sort of assessment in place.”

Further, Scanlon said, “We did an interesting study where we took the whole control set, and looked at the tools we were using. Now, most security tool vendors will give you something that looks like the NIST security list,” he continued. “Most tools can do multiple things. We know that a particular tool can do a particular thing. We were able to map our risk state and our capability state, and we were able to put a plan in place. And we’ve found in that sense, that the framework helps us to mitigate security risk management.”

“Every vendor wants to do everything, and every vendor wants to become your sole service provider,” Bharadwaj noted. “With that scenario in mind, and with vendors trying to do anything all the time, if you use a framework or checklist, how do you do that?”

“In my world, I get three resources to do what I do, people, process and technology,” Eggleston responded. “And the order of this is important. Vendors are great. They’ like to come to you and say, we can make you HIPAA-compliant, and we are HIPAA-compliant. Neither can be true. They can assist you in making yourself more compliant. And for the next two decades, we’ll see a shortage of security staff. How do you get the people? Some organizations are using SOCs [security operations centers], hosted by people you can call on, to alert you to the bad guys when they try to get into your network. And patching work isn’t very sexy, right? But it’s necessary.”

In the wake of WannaCry and Petya/NotPetya

“Well, being fully patched just got sexy after WannaCry!” Bharadwaj exclaimed. “But it’s a very different approach from going to a vendor and thinking they will manage everything. The number of people who want to get into cybersecurity is very large, but the number who can really do it is very small.” Meanwhile, he asked, “How do you really deploy your framework? I come from an academic medical center, and academic medical centers have this other side, the university, where anything goes. So for us, putting in controls in a university-type scenario is even more difficult. I cannot just block GMail; it just can’t happen. So we have to rely on people. People are part of the fabric, and they have to speak security.”

Bharadwaj went on to note that, “If people understand that security is paramount, they’ll do a good job. And helping people understand is very important for us to do. So when WannaCry happened, we sent out a note to everybody. We were not worried about our systems; we were concerned about people [computing] at home. We weren’t concerned about work, but about home. And people will be connecting to your network from home.”

“WannaCry and Petya/NotPetya were very big events for us. And we run the Indian Health Service, so we were vulnerable” as a provider system, Scanlon noted.”We can patch a thousand servers in a day. But an interesting problem in the aftermath of that is—when you try to mobilize, patching out of cycle is very, very  expensive. We have contracts with SLAs [service level agreements] that determine when patches will be employed. And we have contracts that allow for emergency  patching; but it’s very, very expensive. And it took us about 24 hours from the time the WannaCry virus became a well-recognized threat, to figure out where we were. And the Secretary said, just patch or get offline. You can’t just go to CMS that’s running 50,000 data centers, and tell them, shut everything off or get offline. But the key question is, what’s my patch state today? What’s my average time for propagation? Is that time window acceptable to me without invoking the emergency clauses in contracts? And you look at high-value systems. And those systems get the most attention first. It sounds like a simple thing,” he said,  but it’s difficult to do: getting people to think, can I report this? And what would that look like? In many cases, it’s not worth the effort and the cost to jump that last 5 percent without thinking about it. And you’re right: patching isn’t sexy.”

Scanlon continued,” What security is all about is good operating practice. We’re training our network operators to operate efficiently and correctly. And why is it hard to patch? Because sometimes a patch breaks the system. So we’re really thinking through, how do you drive good operational practice on a day-to-day basis?”

“For us, coming from a medical center perspective, if you want to cry, go buy a medical device,” Bharadwaj said. “We’ve got tons of devices that are plugged in across the industry. And by the time that those guys understand that they can’t be running on Windows OS—it’s a pain, it’s tough. If you really want to cry, go talk to the FDA [Food and Drug Administration]. We were able to patch servers and all that, but we were relying on vendors to do the patching. And they are years behind, compared to where the industry is. And these are life-saving devices. So that’s where the challenge becomes more difficult for us. And then comes Petya, right? The next hit. And that took [a number of vendor solutions and] devices down. And we realized, you can’t outsource the responsibility to vendors. It’s your baby. And I heard a few people saying, I’ve given the responsibility to the vendor. But OCR [the Office for Civil Rights in the Department of Health and Human Services] isn’t going to knock on your vendor’s door—it’s going to knock on yours.”

“And,” Eggleston noted, “if you’re counting on regulation to save you and give you a framework, please don’t. Regulations take years to go through their processes. And the bad guys are updating their strategies daily.”


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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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