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Health IT Security Nuances and Complexities the Focus of First Panel Discussion at iHT2-Nashville

August 11, 2016
by Mark Hagland
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Healthcare IT leaders looked at a broad range of IT security issues during the first day of iHT2-Nashville

The nuances and complexities of mastering the current healthcare IT security environment took center stage during the first panel discussion of the day on Thursday, August 11, as the Health IT Summit in Nashville, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella) got underway at the Sheraton Downtown Nashville, in Nashville, Tenn.

Following an opening keynote address by Steven J. Stack, M.D., an emergency physician from Lexington, Ky. And the immediate past chair of the American Medical Association, which focused on physicians’ frustrations with electronic health records (EHRs), a group of industry leaders turned to healthcare IT security, in a panel discussion entitled “Security & Data Protection: High Tech & High Touch,” which was chaired by Glenn Pearson, principal in the consulting firm Pearson Health Tech Insights, LLC.

Pearson was joined on the panel by Patricia A. (Patty) Lavely, senior vice president and CIO at Gwinnett Medical Center (Lawrenceville, Ga.); Edward (Ed) McKinney, information security officer at Floyd Medical Center (Rome, Ga.); and Roy Wyman, a partner in the Nashville law firm of Nelson Mullins Riley & Scarborough LLP. The panel covered a broad range of discussion areas.

Pearson began by asking discussants, “How high a priority is security for most organizations right now?”

McKinney referenced a recent survey conducted by the CIT Group. “The CIT Group did a survey of senior health executives,” he said, “and in their survey, it was 88 percent a concern. And 90 percent said in the boardroom, IT security was becoming a very common topic that they were having to address. The thing that worries me a bit,” he said, “is when it’s not in the news. Right now, the malware/ransomware is definitely getting everyone’s attention, but we’ve got to be thinking about what we’re doing. It can’t just be a trend of attention to ransomware,” but rather, he stressed, the leaders of patient care organizations need to continue to focus strongly on healthcare IT security for the foreseeable future.


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“Are boards of directors getting interested now?” Pearson asked. “Yes,” said Wyman. “A board hired me as their chief privacy officer in my most recent past position. They told the CEO, you’re not doing enough” to focus on healthcare IT security, he recounted. As a result, he said, “They brought in a CISO, a chief privacy officer, and others. So yes, I think that boards are becoming more aware. And I think boards are seeing more liability [that they might face as a result of their participation in hospital and other patient care organizations]; and they’re saying, hey, this isn’t just something I can put on my resume, this is something I have to do well,” he said, citing the federal Sarbanes-Oxley legislation that puts liability on directors for actions of the organizations they help to govern.

“I love that you mentioned Sarbanes-Oxley and that connection,” Pearson said. And, turning to Lavely, he asked, “Patty, how has your situation evolved at Gwinnett?” “Interestingly, it has related to the board,” Lavely responded. “Our board has gotten more involved and taken more of an interest and more of a leadership role than they ever have. And our work seems to be driven by our board of directors. And that’s been true for us in the past three years. And I think our overall workforce is becoming more educated, partly because of our efforts, and partly because of the efforts of the news media.”

In fact, Lavely said, mainstream news media coverage of IT and data security has helped her and her team, “Particularly because more people are having their identities stolen; so that when you start talking about security at work, people can relate it back to their own lives.”

Turning to Wyman, Pearson said, “Roy, you’re probably in touch with lots of different organizations. On the flip side, do you quantify in any way how many boards are not aware? How widespread is not being involved?”

“I don’t know the percentages,” Wyman said. “But what I’m seeing is that in the larger organizations, boards are very much aware; it’s on the front burner. I get calls every week” for help with a lot of basic issues, he said. “I had a call yesterday from someone saying, we’re buying up physician practices. But they had no chief compliance officer, had no idea what policies to implement. Part of this is that the burden is so high that organizations just push it all off. They say, we’ll wait until we’re bigger. But the problem is that you’re seeing physician practices being hit with fines of up to $750,000, not because there’s been a breach, but because they don’t have business associate agreements signed, and for other technical issues. And that’s waking people up.”

“So the expansion of [regulatory mandates] is making people more aware?” Pearson asked. “Yes, organizations are realizing they don’t have all the security and privacy policies and practices in place that they need,” Wyman responded.

Balancing security and end-user access

One of the issues that came up in the discussion was balancing end-user access to data and systems, with the need to improve IT security, in patient care organizations. “How do you balance that out, as a CIO?” Pearson asked Lavely. “There is a balance; I’m not sure I know what it is yet,” she said. “But access is an inherent area of vulnerability; we can’t lock it down. So one of our concerns right now is that we give access right now to many people who are outside of our sphere, and control, so to speak. They’re with physician practices whose physicians are members of our medical staff. So that’s a huge area of vulnerability.” “And how do you handle that?” Pearson asked. “The only way to handle that is to hire an army of people checking in on them, and to do random audits,” Lavely responded. “But there may be a six-month gap where someone has left a medical practice, and no one has checked in on that. Or Susie leaves, and hands her access to Sarah. And no one knows. So it’s a problem.” “And there are so many people out there who add so many layers to this,” Pearson offered. “Yes,” said Lavely. “Yesterday, we heard that there has to be a human firewall; and that’s a huge gap in that firewall” when it comes to end-users in patient care organizations.

“We’re doing spot checks on vendors,” McKinney noted. “We’re putting in place certain products that really lock down on access, so that vendors and other parties that need to connect, so that they’re really locked down on other systems connected to us. We’re doing it after the fact, but you really have to do system security checks early on. So we’re trying to get into the life cycle early on, so we can interject that security.”

“And that’s why people in patient care organizations so often hate me,” Wyman said, “because I’m always having to say no. I was working with a client that was working with a pharmacy hub, which was controlling processes around patients getting specialty medications. And I told them, I believe you’re violating HIPAA. And I got a call from the hub within an hour saying, if you don’t release that data, children will die. And you don’t get that call that often as a lawyer. But there are times when there is a tension between the regulatory environment and real life. And you’ve got to work things out. Often, lawyers get blindered, and we shut things down as a natural inclination. I’d much rather be in front of a jury saying, we did the right thing, than to be in front of a jury saying, well, we followed HIPAA.”

“I’m an information security officer, and you want to get people to buy into the process,” McKinney said. “There are times when you have to say no, but you really want to find ways to say, we can do this better.” “And we have to continually listen to our end-users and hear the experience we’re imposing on them, because we are imposing so many things on them,” Lavely emphasized. “As Dr. Stack said, the IT department doesn’t know that what they think they gave us, is actually what they gave us. And if we’re not standing at their shoulder, we don’t see that.”

“Do executives and boards understand how vulnerable everything is?” Pearson asked, referring to the full panoply of information systems, medical devices, mobile devices, and all devices. “I’m not sure that healthcare executives necessarily do understand, except for around medical devices, because so much attention is being focused on it,” Lavely responded. “We have a community board. And one of our members is a business owner, and another is a financial executive for a very large telecom company, which is great for me. And they’re great, because they’re champions for security on the board.”

“And my sense is that this is one of the last areas that healthcare executives would think about—the Internet of things,” Pearson said. “Would you agree, Ed?” “I agree,” McKinney said. “But you have to look at it the way you would look at any device. You look at the storage of the data, at how well the data is encrypted at rest, and in transit. You just have to look at it from those basics, and do the best you can. And also, per what Patty is saying, many times, security is an afterthought; it’s been bolted on and not baked in.”

CISOs and CIOs

“You’re a CISO, which is still a relatively new position,” Pearson said. “How do you see the trends evolving for the position?” “To give you an example,” McKinney said, “There’s a recruiting firm that’s very active in this area, and they’re seeing a 68-percent increase this year over last year in the hiring of CISOs. On the other hand, they’re also seeing a 50-percent rate in CISOs leaving their positions, which means that there’s obviously a lot of turnover taking place right now.” “So how can CIOs and CISOs best work together?” Pearson followed up.

“It’s important to remember,” McKinney responded, “that security is a team sport. The CISO is there to make sure on a daily basis, an hourly basis, of security for the organization. From the moment you get up to the moment you go to bed, you’re thinking about security. And in today’s world, we don’t have the luxury of being in a world without vulnerabilities. So, given that security is a team sport, the CISO is always trying to wave the banner of security, but also to work with the team, and cheering on every effort that touches on security. That’s how we get things done.”

“How much authority does the CISO typically have?” Pearson followed up. “Again, it’s a team sport,” McKinney emphasized. “You want folks to buy into the security. You want a steering committee so that when they start looking at security with you as a committee, they go back into their workplace and see the issues facing them. So it’s about helping people to keep the focus around security.”

Wyman made the point that “I just want to say that what I’ve seen in a number of situations is that you get the CISO parachuting into a company, and out there on her own. And the CISO goes in and says, OK, now I’m responsible to do all this, and it’s just me, and I can’t do anything without the CIO helping me. And the CIO has been given no input, and says, OK, I’ve got all these projects to do, and security comes out of my project, and he’s not reporting to me. And we don’t need him fudging with my stuff. So I think,” he said, “that it’s really important CISOs have the resources and the buy-in. And I think CIOs honestly need to get over themselves on this. And make sure that the CISOs have the resources, because this man or woman is making me look good.”



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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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