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Guest Blog: Mac McMillan on Why Improving Cyber Readiness is a Business Imperative

May 12, 2018
by Mac McMillan
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The AMA’s recent recommendation to HHS to eliminate its data security risk assessment requirement was a major misstep
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Most people and most organizations overestimate their cybersecurity readiness.  It’s natural to do.  No one wants to admit that they are not ready, right?  While not admitting that you don’t truly know how ready you are or aren’t ready may seem acceptable publicly, internally it is not.  No matter who your stakeholders are, be they customers, patients, staff, partners, shareholders, the bank, the community, etc., you can bet they expect that you not only know how ready you are to deal with cyber incidents, but they expect you to continuously review your readiness posture.  Why?  It’s real simple. Because they are relying on you to be there when they need you.  There is no rocket science here.  It's a simple matter of trust.  We all assume, no actually we expect that our healthcare provider is “there” when we need them.  So it is important that each and every provider and the service organizations supporting those providers take a look in the mirror and assess how they are doing from a cybersecurity perspective.  This is true for providers and third parties of all sizes as cyber criminals do not discriminate based on size or whether an organization has the resources to defend itself.

The first step in understanding cyber-readiness is understanding one’s organization’s risk posture.  More than 70 percent of healthcare organizations across the country have adopted the NIST Common Security Framework (CSF) to assist them in building and evaluating their cybersecurity programs.  The CSF, like all other industry frameworks, references as one of its first requirements the completion of a thorough risk assessment.  Even HIPAA got this one right by requiring an enterprise risk analysis as the first step towards compliance.  A properly performed risk analysis not only identifies where we may have vulnerability, but it also helps inform our selection and provision of controls which are the building blocks of our program.  Without a risk assessment we could potentially spend too much or too little on security and have gaps we’re not aware of.  In my 40 years of involvement with information security, risk assessment has always been the first step to building appropriate protections for the network, systems and information. 

Mac McMillan

The recent recommendation by the American Medical Association (AMA) to the Department of Health and Human Services (HHS) to do away with the risk assessment requirement for providers was received with such astonishment.  Could the AMA really be that clueless regarding the importance of determining risk to patient information and systems supporting healthcare operations in 2018?  I think the term used most accurately to describe their recommendation was in fact ridiculous.  No one is naïve to the fact that all of the regulatory compliance around HIPAA is a huge cost to small providers and difficult for many of them to manage.  But let’s separate the need for compliance from the need for cybersecurity for a second.  Small businesses are a far bigger target today for hackers than ever before, and any business regardless of size that is connected to the Internet is susceptible to all the same threats.  You simply cannot ignore this threat and the risks it poses to the business, or in this case the practice, without consequence.  So even if HIPAA didn’t exist, the AMA’s recommendations are ill-advised.  Businesses large and small need to know what risks they face, and conducting a proper risk assessment is how you accomplish that. 

Next, we need to put this knowledge to work for the organization by addressing gaps in controls and defenses identified from that risk analysis as it relates to the business.  It’s true we can never really anticipate every situation or threat that is out there, especially the ones not known yet, but we can do a better job of what we call cyber hygiene.  The practice of managing the enterprise more responsibly.  Employing best practice around how we build systems, configure systems, make changes, apply patches, control access, etc.  Investing in the technology and services necessary to provide adequate protection for critical assets.  Think in terms of people, information, technology and facilities.  There is a new tool recently developed by the SEC and DHS that helps to express cyber risk in terms of impacts to the business.  The Cybersecurity Resilience Review (CRR) takes the NIST CSF and redefines it in terms of risks to the business from cybersecurity incidents.


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Finally, understanding and impoving readiness is embodied in rapid incident response. When incidents occur, and they will, the biggest enemy that organizations have is the time it takes to identify, react and respond and a lack of organization.  Effective response does not happen without resources, detailed planning, exercise and discipline.  When a cyber event happens, an organization’s detection capabilities are what provide early alert, hopefully reducing the time the attacker has to do harm or the malware has to spread, but it's the organization’s ability to react quickly that allows it to identify, isolate and stop the attack, and then begin the process of recovery.  It's the incident response planning that permits this, the scripting of run books, the up-to-date inventories of assets, the backups of systems and data, the documented roles and responsibilities that are practiced and understood and the organizations resolve to act swiftly.  Incident response needs to be thought through carefully, documented and practiced over and over again for this to be possible.  This too is a part of today’s digitized, automated and hyperconnected business environment.  There is an old saying, “those that fail to plan, plan to fail” , but planning is not adequate alone when dealing with cyber events.  The saying needs to be amended, “those who fail to commit, fail to plan, fail to practice…will fail.”  When this happens confidence in the business is shaken and the person we least want to let down, the patient, could be affected. 

Understanding readiness for cyber events is a critical business requirement for all organizations regardless of size.  Performing risk assessments, implementing controls and proper protections and having a solid well planned and practiced incident response capability are critical twenty-first century business requirements for anyone whose business relies on data and information systems.  And whether you are a group practice or a large health system, knowing your cybersecurity resilience is important.

Mac McMillan is founder and CEO of the Austin, Texas-based CynergisTek consulting firm.





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OCR Fines Providers for HIPAA Violations, Failure to Follow “Basic Security Requirements”

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) for a number of 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, OCR also fined a Colorado-based hospital, Pagosa Springs Medical Center, $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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