At the Health IT Summit in Beverly Hills, UW Medicine CISO Cris Ewell Urges Attendees to Get Proactive About IT Security | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

At the Health IT Summit in Beverly Hills, UW Medicine CISO Cris Ewell Urges Attendees to Get Proactive About IT Security

November 12, 2017
by Mark Hagland
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UW Medicine CISO Cris Ewell, Ph.D., issued stern warnings about healthcare data and IT security issues

Under the title “Protecting Large-Scale Network Infrastructure with Complex User Groups,” Cris Ewell, Ph.D., CISO of the University of Washington Medical Center (UW Medicine), opened the second day of the Health IT Summit in Beverly Hills, held November 9 and 10 at the Sofitel Hotel Los Angeles at Beverly Hills.

“We have a problem,” Ewell began, speaking both of the data and IT security challenges facing UW Medicine, and patient care organizations across the U.S. “We look at the environment of the U of Washington—I have 2 million devices connecting to my system every year; I have an 80-gigabyte pipe. Lots of broadband coming into the university. We’ve got 200,000-plus medical devices. 40,000 employees on the medicine side; 26,000 more on the university side. And of all those devices, I probably only control about 30 percent of them. And of course, as we read in the papers, we’re seeing attacks all the time.”

Ewell framed broadly the cybersecurity issues facing patient care organizations in the U.S. right now. “Back in 2009, we were losing a lot of stuff—a lot of paper,” he said. “But now, we seem to have figured out how to secure our paper and devices better. But unfortunately, in place of that, our adversaries have figured out that healthcare is a great target for compromising our system and gaining unauthorized access to our data. So what are we looking for? Theft of credentials is a top issue,” he said. “We had about 1.3 billion credentials exposed in 2017; and that’s a terrible credential. And I’m seeing the outcome of that. Our users have very poor practices, in using passwords across accounts. And our adversaries are getting in and compromising our system. One stat I read is that 98 percent of web traffic logging in, is using compromised credentials.”

Importantly, Ewell noted, “The majority of your traffic on your site is adversaries trying to compromise credentials on your site. Most of the activity? Phishing. It is highly successful, because it is easy and low-cost. And we do training, and testing. And I do studies on this, since we’re a research institution, and I still see our students, faculty members, clinicians, and staff, clicking on links—the day after a phishing training. I will admit that the adversaries are becoming really, really clever about mimicking our website, etc. And our clinicians are very, very busy. Imagine if you’re a resident and you get an email saying, I need you to read this clinical journal article and discuss it with me. And what will that busy resident do? They’ll click on the link.

“And then you get to the breach element itself,” he continued. “And they aren’t necessarily after the target for their number-one access. I see tremendous lateral movement going on with these adversaries. We have a very big student population at U of Washington, and they’re on similar networks. And the adversaries will go to the easiest point to get in; so they’ll go into student networks; then compromise those credentials, use them to get into a domain that’s harder to get into, and then try to get to the crown jewels of the organization.”

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Looking at what specifically to be concerned over, Ewell told his audience, “The three big categories I most worry about are organized crime, hostile nation states, and even hacktivists. And we’re seeing very advanced tactics. And it’s really easy to promise medical devices. And we’re seeing them use these credentials to get in, and then write custom code. We’re actually tracking several right now throughout the university. And these individuals are actually on shift work, and we can see two shifts working—it’s mostly Europe and Asia. And we can see that type of work, and different types of code working. And so we’re seeing this level of sophistication, and you’re going to see that also.”

Now, what to do about legacy systems? “In one of our labs, one of the DNA sequencers was compromised. We still have Vista systems,” Ewell noted. “in fact, the DNA sequencers still run on Vista, and none of them are being patched. And Alumina, in their manual, basically said, you can’t patch. And you can’t even install anti-virus or anti-malware systems. Or you can install it, but after your DNA sequencing. And the difficulty with a lot of these medical devices is that they were designed for one function. So how do we balance the functioning of the device with the need to protect access to data?” As a result, he said, “We’ve had about a dozen medical devices impacted by malware over the past year.”

Where are the physical vulnerabilities? In infusion pumps, and in the Pyxis medication management system, Ewell said. “We found one device system that had over 1,400 vulnerabilities on the system. And the reality is that we have to live with outdated software, for the life of the software. And the sequencers: they cost from $80,000 to $400,000, and we have 30 of them. It’s unlikely we’ll get a check for $400K to replace them all at once. And then diagnostic imaging modalities: MRIs, etc. And how do we actually patch these devices so they’re not vulnerable?”

Meanwhile, Ewll noted, “A document was produced for the British Parliament about the WannaCry attack. It’s a fantastic read. And the fact is, the National Health  Service people knew about the vulnerability of the system before the attack. 34 percent of their healthcare system was impacted. Imagine if we had had 34 percent of the U.S. healthcare system impacted. They had 595 general practitioners’ systems impacted. Eight organizations. Over 19,000 patient appointments were cancelled, and many organizations were turning patients away. That’s a real problem: there’s impact to patient care that we’re now seeing, from these attacks. And that report is a great one to give to your board, while asking, how do we start turning these things around?”

Ewell noted that, “here in the U.S., Hollywood Presbyterian Hospital [executives] paid $17,000 in bitcoin to get themselves out of trouble. Meanwhile, about $143,000 that was gained by the WannaCry attack” in U.S. healthcare. But, he quickly added, “as a state government organization, we at the University of Washington will never pay. And the researcher or physician or whatever” who has made the mistake that has led to the malware attack—“you’re out of luck. But unfortunately, some people are paying for these things. And even if you think you can pay for this, your money is just a key. You may not get your system back.”

“Another problem,” Ewell said later on in his presentation, “is too much connectivity, and doing it too soon. I would love to say that I contact everyone, contact our department. But that’s just not the case. We’re seeing it from the point of, too soon, and not knowing how to protect the devices, or just too much connectivity. Every single medical device comes very connectible now. So we put them all onto a separate network. But many have to communicate with an EMR. So we need to resolve that.”

It will be years before the healthcare industry catches up to the sophistication of the financial services industry with regard to data and IT security, Ewell told his audience. But there are things that healthcare leaders can and should be doing now. “How do we protect all this stuff? I’m very big on creating a risk management protection framework for your whole organization,” Ewell said. “Start picking a framework and implementing it. You can’t just go down a HIPAA checklist or a NIST framework and think you’re protected, because you aren’t. And I’ll never stand up here and say, I know where 100 percent of the assets of the University of Washington are. I have high confidence about where most of our data assets are; but not all. But it’s a method and a process we keep working on every year. And it’s about really understanding where the devices are.”

Meanwhile, he said, “With regard to networks, we have to create an entirely different architecture for protecting data. How do we start creating virtual networks, and really start segmenting networks, to allow for systems to talk to each other as necessary, but no more. Unfortunately, clinical information systems weren’t set up to accommodate this. So, how can we do things differently within our networks in healthcare, to make sure that if an adversary gets access to one server, they can’t get access to your entire system? And, in terms of data protection, I think encryption is very good, but it has to be done well. Some organizations make the mistake of storing encryption keys on the same server. We have to do better at key storage and key management,” he added.

 


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Healthcare’s “RegTech” Opportunity: Avoiding a 2008-Style Crisis

September 21, 2018
by Robert Lord, Industry Voice, Co-Founder and President of Protenus
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In the financial crisis of 2007 to 2009, the financial industry suffered a crisis of trust. A decade later, banks and other financial institutions are still working to regain the confidence of consumers and regulators alike. In 2008 and 2009, while working at one of the world’s top hedge funds, I had a front-row seat to the damage that occurred to our economy, watching as storied corporate institutions fell or were gravely damaged. Today, as co-founder of a health technology company, I see healthcare is approaching a similarly dangerous situation. We must get ahead of the curve to avoid disaster.

Like finance, healthcare is a highly-regulated industry where non-compliance can result in severe financial and reputational consequences for healthcare companies, and severe impact on people’s lives. We deal with HIPAA, MACRA, HITECH, and hundreds of other foreboding acronyms on a daily basis. A lot of attention goes to the terrific and important work of clinical decision support, wellness apps, and other patient care technologies, but problems in the back office of hospitals must be addressed as well. One of these problems is the amount and complexity of healthcare regulation, and our healthcare system’s inability to keep up.

In finance, where I spent the early part of my career, the adoption of what is termed “RegTech” (regulatory technology) was driven by the increasing complexity of financial technology and infrastructure sophistication.  As trades moved faster, and as algorithms, processes and organizations became more complex, the technologies needed to ensure regulatory compliance had to move in tandem.  The crisis we experienced in 2008 was partially the result of the inability of the industry’s regulatory capabilities to keep up with the pace of technological change.  In many ways, the industry is still playing a catch-up game.

As healthcare professionals, looking to the lessons learned by our colleagues in finance can help us predict patterns and stay ahead of the curve. Right now, I’m seeing alarming parallels to challenges faced in finance a decade ago.

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Robert Lord

The burden of regulation across our industry is simply staggering.  Thirty-nine billion dollars of regulatory burden is associated with healthcare annually, which is about $1,200 per patient, per year. Despite this high cost, we still have $1 trillion of fraud, waste and abuse in our healthcare system. With so much regulation, why are we seeing so little yield from that burden? In many cases, it’s because we’re merely checking boxes and not addressing core risks؅. Like finance, there was a great deal of effort on compliance with regulations, but not enough attention on addressing important systemic risks.

This is not to say I am against good regulation; in fact, many regulations serve to protect patients and improve care. The problem is that there are so many demands on healthcare systems, that compliance and regulation is often reduced to checking boxes to ensure that minimum defensible processes are built, and occasionally spot-checking that things look reasonable. We currently have nowhere near 100 percent review of activities and transactions that are occurring in our health systems every day, though our patients deserve nothing less. However, unless overburdened and under-resourced healthcare providers and compliance professionals can achieve leverage and true risk reduction, we’ll never be able to sustainably bend our compliance cost curve.

Systemic problems are often not discovered until something goes horribly wrong (e.g., Wall Street every decade or so, the Anthem data breach, etc.). Today In the financial industry, RegTech provides continual, dynamic views of compliance or non-compliance and allows management, compliance professionals and regulators to check compliance in real-time. They can view every record, understand every detail, and automate investigations and processes that would otherwise go undetected or involve lengthy and labor-intensive reviews.

The real promise of these new capabilities is to allow compliance professionals and regulators to perform the truest form of their jobs, which is to keep patient data secure, ensuring the best treatment for patients, and creating sustainable financial models for healthcare delivery. RegTech will open up lines of communication and help create conversations that could never have been had before—conversations about what’s not just feasible for a person to do, but what’s right to do for the people whom regulation seeks to protect.

No longer bound by limited resources that lead to “box-checking,” compliance officers can use new and powerful tools to ensure that the data entrusted to them is protected. At the same time, healthcare management executives can be confident that the enterprises they manage will be well served by risk reducing technological innovation.  Patients, the ultimate beneficiaries of healthcare RegTech, deserve as much.

Robert Lord is the co-founder and president of Protenus, a compliance analytics platform that detects anomalous behavior in health systems.  He also serves as a Cybersecurity Policy Fellow at New America.

 


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HIPAA Settlements: Three Boston Hospitals Pay $1M in Fines for “Boston Trauma” Filming

September 20, 2018
by Heather Landi, Associate Editor
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Three Boston hospitals that allowed film crews to film an ABC documentary on premises have settled with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) over potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

According to OCR, the three hospitals—Boston Medical Center (BMC), Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital (MGH)—compromised the privacy of patients’ protected health information (PHI) by inviting film crews on premises to film "Save My Life: Boston Trauma," an ABC television network documentary series, without first obtaining authorization from patients.

OCR reached separate settlements with the three hospitals, and, collectively, the three entities paid OCR $999,000 to settle potential HIPAA violations due to the unauthorized disclosure of patients’ PHI.

“Patients in hospitals expect to encounter doctors and nurses when getting treatment, not film crews recording them at their most private and vulnerable moments,” Roger Severino, OCR director, said in a statement. “Hospitals must get authorization from patients before allowing strangers to have access to patients and their medical information.”

Of the total fines, BMC paid OCR $100,000, BWH paid $384,000, and MGH paid $515,000. Each entity will provide workforce training as part of a corrective action plan that will include OCR’s guidance on disclosures to film and media, according to OCR. Boston Medical Center's resolution agreement can be accessed here; Brigham and Women’s Hospital's resolution agreement can be found here; and Massachusetts General Hospital's agreement can be found here.

This is actually the second time a hospital has been fined by OCR as the result of allowing a film crew on premise to film a TV series, with the first HIPAA fine also involving the filming of an ABC medical documentary television series. As reported by Healthcare Informatics, In April 2016, New York Presbyterian Hospital (NYP) agreed to pay $2.2 million to settle potential HIPAA violations in association with the filming of “NY Med.”

According to OCR announcement about the settlement with NYP, the hospital, based in Manhattan, violated HIPAA rules for the “egregious disclosure of two patients’ PHI to film crews and staff during the filming of 'NY Med,' an ABC television series.” OCR also stated the NYP did not first obtain authorization from the patients. “In particular, OCR found that NYP allowed the ABC crew to film someone who was dying and another person in significant distress, even after a medical professional urged the crew to stop.”

The OCR director at the time, Jocelyn Samuels, said in a statement, “This case sends an important message that OCR will not permit covered entities to compromise their patients’ privacy by allowing news or television crews to film the patients without their authorization. We take seriously all complaints filed by individuals, and will seek the necessary remedies to ensure that patients’ privacy is fully protected.” 

OCR’s guidance on disclosures to film and media can be found here.

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Independence Blue Cross Notifies 17K Patients of Breach

September 19, 2018
by Rajiv Leventhal, Managing Editor
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The Philadelphia-based health insurer Independence Blue Cross is notifying about 17,000 of its members that some of their protected health information (PHI) has been exposed online and has potentially been accessed by unauthorized individuals.

According to an article in HIPAA Journal, Independence Blue Cross said that its privacy office was informed about the exposed information on July 19 and then immediately launched an investigation.

The insurer said that an employee had uploaded a file containing plan members’ protected health information to a public-facing website on April 23. The file remained accessible until July 20 when it was removed from the website.

According to the report, the information contained in the file was limited, and no financial information or Social Security numbers were exposed. Affected plan members only had their name, diagnosis codes, provider information, date of birth, and information used for processing claims exposed, HIPAA Journal reported.

The investigators were not able to determine whether any unauthorized individuals accessed the file during the time it was on the website, and no reports have been received to date to suggest any protected health information has been misused.

A statement from the health insurer noted that the breach affects certain Independence Blue Cross members and members of its subsidiaries AmeriHealth HMO and AmeriHealth Insurance Co. of New Jersey. Fewer than 1 percent of total plan members were affected by the breach.

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