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Health IT Security Luminary Mac McMillan Offers Views on Accelerating Data Dangers

August 11, 2016
by Mark Hagland
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Mac McMillan tells CHIME/AEHIS LEAD Forum attendees that IT security threats are accelerating alarmingly

This is part 1 of a two-part series on the presentation August 10 by Mac McMillan of the CynergisTek consulting firm, at the CHIME/AEHIS LEAD Forum event in Nashville. This article covers a portion of McMillan’s presentation; part 2 will cover the concluding portion of McMillan’s address, as well as his exclusive interview with Healthcare Informatics that immediately followed his speech on Wednesday.

Mac McMillan, the CEO of the Austin, Tex.-based CynergisTek consulting firm, and one of the healthcare industry’s IT security luminaries, offered a bracing view of the current IT security landscape to those attending the CHIME/AEHIS LEAD Forum Event, being held Monday, August 10 at the Sheraton Downtown Nashville, in Nashville, Tennessee, and co-sponsored by the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), and its subsidiary association, the Association for Executives in Health Information Security (AEHIS), and by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC umbrella).

McMillan shared his perspectives on what he sees as a very challenging health IT security environment going forward, in a speech entitled “Developing and Managing an Ongoing Risk Management Program.” The risk management perspective on the current health IT security landscape is important, he emphasized. “One of the things I’ve learned is that the teams that win, study the enemy, have a good plan, and can execute,” McMillan told his audience, beginning his speech by sharing a personal story. “Everybody in my family has always been involved in athletics,” he noted, “and most have been in the Marines or the Army. And my oldest daughter actually took it to the highest level. She graduated as an All-American in volleyball. She’s a ‘lobero.’ The lobero is the most aggressive person on the court; they’re always digging out the spikes that the other team is throwing you, so you can help someone send it across the net. And thing that made her so good is that she would study behaviors of the next team that her team was about to play. And she would have every player on the other team pegged, as to what they were like, so she knew where she would have to go. She had set the record for “digs” by the time she had graduated, in the NCAA. She studied her enemy, she studied the other side. And she and her team would work together to plan their moves against each upcoming competitor. Women’s volleyball is so exciting, because they get aggressive, and they work as a team.”

Mac McMillan

So, McMillan said, “My daughter’s volleyball team worked hard, practiced, and executed. And that’s the same thing that our military does as well, and that other organizations do that win. And all of this applies to where we are today with regard to cybersecurity. The reality is that we’re in a fight,” he said. “The fact is that your organization has something valuable that someone wants to take away. And if you don’t want them to take it away, you need to understand who they are and what they’re after. And you   need to prepare and work as a team. And executing on cybersecurity is similar to how teams in volleyball and in the military work. This is a team sport. And it’s one that requires good strategy. In the case of healthcare, it’s the CIOs and CISOs in this industry who will develop that strategy and defend their organizations against the bad guys.”


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Darker threats emerging every day

Meanwhile, referring to an infamous case that emerged into public view in June, when a hacker claimed to have 655,000 patient records, allegedly obtained by hacking into three different healthcare databases, and which he claimed to offer for sale on the dark web, McMillan said that, “The next time that an adversary comes to you and offers you an opportunity to cover this up and make it go away for a small fee to prevent the leak, don’t take the offer. This guy is a classic criminal, and is offering you the chance to buy your data back and to cover it up for you. But what will happen? Blackmail. Fortunately, nobody’s bought into this guy’s scenario,” he said of that situation. Yet such situations, in which hackers acquire protected patient data and in some cases attempt to sell it, are indicative of the broader landscape of bad actors constantly attempting to sabotage the clinical information systems of U.S. patient care organizations.

“But that’s who we’re up against,” McMillan told his audience. “When you look at the threat environment we’re up against today, we absolutely have got to get a handle on this and realize that it is real, it is growing, and it is not going away. The minute we decided to digitize all our information and automate all our processes, we became as susceptible as any other industry, to cybercrime.” As a result, he said, healthcare IT leaders must be realistic about the fact that cyber-extortion, cyber-espionage, hacktivism, and targeted attacks, are going to be a part of the IT security landscape for the foreseeable future. As a result, he said, “We need to adopt an offensive posture. And it’s an asymmetrical dynamic: we have to win 100 percent of the time, whereas the hackers only have to win a part of the time in order to learn more with each successful attack or hack. Symantec says there are 340 million variations on malware now,” he noted.

What’s more, the landscape is constantly mutating, McMillan said. “We had 54 zero-day attacks last year, meaning that no system would have recognized that malware. Except that every version of malware has a behavioral signature that is unique. And every signature can be good, bad, or unknown. The problem is that when we focus on the old known viruses, the new ones get by our protections and cause us problems. We’re going to have to go to those advanced solutions that give us the ability to move forward.”

Inevitably, then, McMillan said, “We’ll have to focus on anomalies. So we need to do a better job of managing our environments, of keeping our environments up to date. Obsolete systems, end-of-life systems that can’t be patched, do nothing for us, from a security perspective. And we need to make sure we’re hardening our systems and configuring them against all known risks, and keep them patched.” Fascinatingly, he said, “Ninety-eight percent of attacks last year took advantage of a known vulnerability that was either a year or more old, meaning, there was a patch available for it, a configuration somebody could have made, a service someone could have used, but we didn’t. They’re counting on our being too tired and too busy to keep up normal maintenance.”

A metaphor of battleships

McMillan shared with his audience a metaphor he said he wanted them to consider.
“It’s important to think about the metaphor of compartmentalization, and the way that battleships are built. They’re built in tight compartments, so that when one compartment is hit, the ship and go on,” he said. “We’ve seen many breaches this year that have turned into many bad situations, and in most cases, it was because they couldn’t stop things fast enough” once an information system had been infected or invaded. “I talked with one hospital that had a zero-day virus that had emanated from their core, and literally, within two hours, three-quarters of their systems were infected, because of a lack of segmentation.

What might some of the solutions be? Among them, McMillan said, is to execute on a strategy of holding cyber-drills. “Some hospitals are beginning to do cyber-drills,” he noted, “and that’s a good thing. If people know each other, know their roles, they’ll be able to execute well. It’s like the baseball team that just comes together for a game and has never practiced. It’s no different here: what we execute and practice, is what we do. We need to make sure we have the right practices.”

A second key, McMillan said, is that “We can’t do this alone anymore, we really can’t.” The time has come to bring in expert outside consultants, he said, to do “monitoring, auditing, and analysis. “You always need outside help. Whenever I try to monitor myself, what do I learn? Nothing new. But when I go outside, I can get help that will help me see what I’m missing. We need to think about outsourcing things like log management, IDS [intrusion detection system] management, network monitoring. Those organizations looking at thousands of organizations across the globe, have the ability synthetize logs. Almost every hospital produces tens of thousands of logs a month. And it’s difficult to synthesize, in-house.”

What’s more, McMillan said, one factor that is transforming the landscape is the massive advances in computing capability that are taking place now and that are bound to accelerate within the next decade. “By 2025, we are going to have calculating ability to where laptops will process information at the 10 to the 9th power, or 10 trillion calculations a minute,” he noted. “What that means is that our industry will be turned on its head because of innovation; but security will be turned on its head, too. Ten years from now,” he predicted, “any system based on rules is going to be totally obsolete. Because when we have processing speeds that fast, and broader connections, any system that has to stop a packet and interrogate it to figure out if it’s good or bad is not going to be able to do it—unless vendors can figure out some new kind of artificial intelligence to do that. And I’m hearing that they’re nowhere near that. So we have to move away from rules-based technologies to behaviorally based technologies that detect anomalies in real time.”

Part 2 of this two-part series will cover the conclusion of Mac McMillan’s Aug. 10 speech, as well as his exclusive interview with HCI. That article will appear on this website soon.


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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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