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At the Health IT Summit in Denver, Parsing the Complexities Around Creating a Cybersecurity Culture

July 20, 2017
by Mark Hagland
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At the Health IT Summit in Denver, healthcare IT leaders and experts discussed the ongoing challenge of creating cultures of security in patient care organizations

As the leaders of patient care organizations move forward to try to get a handle on the growing wave of cybersecurity threats hitting them daily, one of the overarching challenges they’re facing is how to create a culture of cybersecurity. At the Health IT Summit in Denver, held this week at the Ritz Carlton Denver, a panel of healthcare IT leaders and experts dived into this issue, parsing its nuances and complexities, for an audience of fellow healthcare IT leaders.

The panel was moderated by Mitch Parker, executive director, information security and compliance, at Indiana University Health (Indianapolis). Parker was joined by panelists Michael Mercer, chief security officer, Denver Division, at the Federal Bureau of Investigation (FBI); Sheryl Rose, senior vice president and CIO, at the Denver-based Catholic Health Initiatives; Brian Sterud, vice president of information technology and CIO, Faith Regional Health Services (a 131-bed community hospital in Norfolk, Nebraska); and David Finn, a former CIO, and currently the health information technology officer at the Mountain View, California-based Symantec Corporation.

Early on in the discussion, Parker asked his panelists, “How do you make security meaningful in a clinical setting?” “Data is data,” said the FBI’s Mercer. “It’s all the same. We want to protect information, we don’t want it to get out there, we don’t want adversaries to get access to it; we want to protect it.”

“I agree,” said Finn, “but the problem with healthcare is that we have a couple of interesting dichotomies; healthcare is an industry where we need to share information, whether it’s a reference lab, a durable medical equipment company, etc. And we haven’t made the shift yet to understanding how we should protect it. And the second shift we haven’t yet made yet is that we don’t yet understand the (monetary) value of this data. The bad guys are looking at these pieces of data across huge spectrums, and they’re using the data in ways we haven’t thought about. And we need to catch up with this and train people that this is not only important for providing care, but that it has value” to our adversaries—in other words, to cybercriminals.

Referencing the many years she had spent in the financial services industry as an IT executive before coming into healthcare, Catholic Healthcare Initiatives’ Rose said, “In financial services, it seems as though it was a black-and-white thing. We did our training, we told our employees what they needed to know. But it’s different in healthcare. My biggest day-to-day fear is that I’m going to end up being like Charlie Brown’s teacher, saying, ‘Wha wha wha’”—referencing the cartoons in which the children didn’t hear what their elementary school teacher was saying to them. “And with 105 hospitals and thousands of employees, it’s hard to get the message across,” she said. “So I try to find champions—physicians, nurses, everyone” who might be champions for IT security, “because they’re going to listen to those people more than to Cheryl Rose in the corporate office. We need to engage them, because, to your point, David, they’re going to click on that link.”


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“The last year or two has made it so much easier at the executive level, because everybody gets it now,” Sterud said of his community hospital organization. “And our board gets it, and they’re actually asking for (education) now. Awareness right now is amazing.”

“How do you make security part of the underlying process of application development?” Parker asked.

“For me, the devil’s always in the details,” Rose said. “And about four years ago now, we started to do very specific training for specific groups. It’s better if I niche the training and make things more relevant to specific groups of end-users. And that’s a big time-suck. But it requires the day-to-day [work], trying to engage and infuse ourselves into those groups so that they get it, so that when we walk away, they’ll continue forward. It can’t just be a policy or a standard.”

“I became a CIO in 2000 in a turnaround situation,” Finn noted. “And this is pre-privacy and security rule, but we knew it was coming, so we started targeted training around IT around security, and built security into our training. One important thing was addressing the issue of elevated accounts and security levels. You do have to draw a hard line. And I used to tell my IT staff, look, you’re not in technology, you’re in healthcare. We’re in patient care, and we have to protect patients first, and if you have to use a longer password, or change your password, so be it. And the change management element of building that into every process, was a big deal for us in IT.”

“Coming from a smaller health system, how does all this look, Brian?” Parker asked. “Being a smaller organization, we don’t do actual co-development; we do do system configurations,” Sterud replied. “And maybe I’ve been lucky from a staff perspective. Patient care still needs to happen in a way that’s also secure. So sometimes, I have to remind our IT staff that making people take extra steps, is a burden. So I have almost the opposite problem in that regard.

“Mike, what are your thoughts on this?” Parker asked. “I concentrate on the users more than anything else,” Mercer said of his work at the FBI with healthcare organizations. “We’ve always heard that old adage that users are the weakest link; I turn that around and tell our users, you’re our last defense. And when you click on an email or go to a link, that’s when something bad is going to happen. And if you lose a mobile device, it’s going to be on you. So making the users part of the solution rather than part of the problem, has worked really well. People are actually afraid to click. We do have a lot of good defenses in our network; and our employees know, even if you did click on something, tell us.”

“One of the things we did last year was to tell our people, if you see something, you’re required to say something,” Parker reported. And you can achieve greater organizational coordination. So, next question, how do you bring cybersecurity into the culture of your organization. And what incentives can you bring into this?”

“There are certain things that are non-negotiable,” Rose said firmly. “And when it comes to physician practices, if you’re going to connect as a new member of our family, there are certain things you have to do before you can connect. But then, on an ongoing basis, having the boots on the ground is much more important than having the talking heads in the national office. So one of the first things I did in my job was putting in regional security officers in. And what they prioritize their workload to be and how they message to their users, they have to be the bridge to the national security organization, but they’re allowed a lot of flexibility. And how things are done in Kentucky versus Tacoma or Fargo, may be very different; and I’m not going to get into the middle of that.”

Finn said, “To Cheryl’s point, one of the things I did—we had MSOs [management service organizations] and a health plan, and I was the CIO over them, but they operated independently. So I went to our HR VP, and for everyone who supervised people, we built privacy and security into their jobs. That was a massive effort.” What’s more, he added, “the health plan was working on building it into every 12,000-person job in the plan. I left before that process had been completed. But we developed specific security criteria, we did desk checks; and we empowered them to implement security within their individual offices—the managers. They’re not only your last line of defense, but also your first line of defense. And if they’re not engaged, you’re not going to get anywhere.”

“We have a few affiliated hospitals,” Sterud said, “where there’s not that formal authority. But the other thing we lose sight of sometimes in healthcare, is that we’re all connected. Even the smallest hospital we have—with a daily census averaging less than 1—well, if they’re breached, we’re all affected. So it’s important to make sure that everyone is moving forward together. The tough part is reaching out to smaller facilities with very little or no staff, and oftentimes, we’re doing things to help them out. But in the end, it works.”

“And I’ve worked with critical access hospitals, and there’s a huge difference between working with a critical-access hospital and a major academic medical center,” Parker noted.

“I’ve found that communication goes a long way,” Mercer said. “I can’t get too technical with my folks, because they can’t get technical. Just let them know that if they do something, this is how it will affect them. I’m always trying to turn people from a ‘department of no’ to a ‘department of yes.’ And can we work something out here, for this particular situation? Just know that there may be an adversary out there trying to get information out of us.”

Education, Training, Awareness

“We’ve talked about education, training, and awareness,” Finn said. “Those are actually three separate things, all of which have to happen. Awareness is an every-moment-of-every-day situation. We had a weird situation where the yard service ended up picking up some face sheets, and using them as mulch! And this has to be a living, breathing thing, and when Petya comes out or WannaCry comes out, if you’re not using that kind of occasion to explain things to people, you’re losing an opportunity.”

“I’ve found that to be very true,” Parker said. “Let’s put it this way: Target got compromised because of an HVAC vendor. Meanwhile, what are some tips and tricks around creating security steering committees?”

“As I said, I started as a privacy and security officer, and then was made a CIO,” Finn said. “But when I moved to that organization, it was 2000, and they had actually put together a pretty good steering committee, with the CFO, COO, and chief marketing officer, but hadn’t met in months. And I went to each one of the executives, and said, here’s the deal: we have to do HIPAA, and you don’t want to do it. But we have to. So we’ll have meetings every month, and I’ll tell you what you need to do. But when I call you in the middle of the month and we have an issue, you can’t ignore me, you’ll have to help me. They all agreed to that; they came to the monthly meetings, and they complied and helped when needed. So it’s giving that right mix; you have to understand who needs to be on that steering committee; it all starts with governance. And our chief nursing officer hated to talk about security, but she worked with us. Her sole request was, ‘Don’t call the computers on wheels, COWs; we’ve renamed them to WOWs!’ So it’s all about figuring out how to get done what needs to be done.”

“We stood up an IT security committee,” Sterud said. “couple of things we did well—one was the makeup of the group. The other thing was that I made clear that we had a lot of work to get done. So when we started getting going, they all knew that we had a lot to do. And we made sure we had HR involved—there are a lot of things with onboarding and terminations. And we got facilities on board. And at that time, biomed was not reporting to us; it is now. But we got them on board. And by the way, biomed really needs to report to IT now. And we got compliance on board, too. And you need to celebrate successes, too. So we’ve done a lot of important things over the course of the past five years, and we still have a lot of things to do. But things are moving forward, and it’s kind of self-governing at this point.”

“When I came seven years ago, there was an appetite for security,” Rose said. “I was blessed; we built a great security committee at national; and we had the same thing filtering down from there. And I spent years in financial services working successfully with steering committees. And it depends on the personalities of the people involved. But one thing that happened a few years back that was fantastic, was that a CMO had moved to a different market. And out of the blue, he called me and said, ‘Hey, I’m getting settled, and what should I know?’ And how great is that? When they’re engaged, it’s great, because I’m not just throwing scare tactics and metrics out there all day long.”

“We’ve all got Facebook accounts, and Twitter accounts, and LinkedIn accounts,” Finn noted. “And we might think that our Gmail accounts have nothing to do with our work; but the bad guys are already connecting our information. So we’ve got to get people to rethink. And to your point, Cheryl, yes, it’s engaging people, and sharing things with them that resonate with them.”

“And it’s important to keep in mind,” Parker added, “that your average home now contains more computers and devices than your average medical office did ten years ago.”


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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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