Cybersecurity threats continue to grow by the day in U.S. healthcare, alarming patient care organization leaders, and compelling healthcare IT leaders to step up their cybersecurity efforts. That subject, the mushrooming of cyber threats, was top of mind on Thursday in San Jose, California, during a panel discussion on the topic at the Health IT Summit in San Jose, being held at the Westin San Jose in downtown San Jose.
The discussion, under the title “A Deeper Dive: Understanding and Preventing the Next Generation of Cyber Threats,” was moderated by Tom Andriola, vice president and CIO of the University of California Health. He was joined by Rao Mikkilineni, Ph.D., a professor of IT security at Golden Gate University; Ari Entin, CIO at Natividad Medical Center; M.K. Palmore, an assistant agent in charge in the San Francisco field office of the FBI; and Rich Campagna, senior vice president of products and marketing at Bitglass.
Early on in the discussion, in explaining why the healthcare industry has become the most targeted of U.S. industries, Mikkilineni noted that “The biggest threat has shifted away from the financial services industry to healthcare, as credit cards have become more secure, and as the internal landscape in healthcare has shifted and become much more difficult to secure.”
panelists (l. to r.) Entin, Palmore, Campagna,
Mikkilineni, and Andriola, at the HIT Summit
“Banks say the biggest area of vulnerability for them is working with affiliate banks and other partners,” Andriola said. “We talk about the healthcare world and interoperability; we haven’t built the walls and responses that financial services has,” which could better secure our data.
“We’ve had high-profile attacks on us,” Andriola said, noting the large number of hacks of healthcare organizations in the past couple of years. “What does this look like from your perspective?” he asked FBI agent Palmore. “Rao talked about an expansion of threats,” Palmore said. “There are new technologies being developed to make patients’ lives better, but the attack surface is expanding to increased vulnerabilities. And to cyber-criminals, these vulnerabilities become something that they spend quite a bit of time and effort on,” he said.
“I go to a lot of conferences like this,” Palmore continued, “and we spend a lot of time talking about the technology piece and very little time talking about the human piece of this. I will tell you that in 20 years of law enforcement, I have never seen criminals more diligent than cyber-criminals. They are very diligent, and very good at what they do. They’ve figured out how to hack and how to quickly monetize things via the dark web; they’ve created an ecosystem via the dark web. Criminal enterprises used to be man-made and man-operated systems. Now, criminal enterprises span the globe. The actors typically don’t know each other and have never met face to face; they’ve figured out how to interact and pay each other, typically through the use of digital currencies. But the ecosystem they’ve developed, quite frankly, is one that law enforcement has not developed an effective response for.”
In that context, Palmore said, “It’s not uncommon for a cybercriminal to very effectively monetize. The other threat you guys have to worry about, frankly, is nation-states. Nation-state actors have figured out how to exploit your information systems, get access to data, and use it. And so as you’re building these new technologies and exploring new ways to bring new benefits to your patients and certainly to your staffs, you’d better have people to help you figure out how to secure your systems, because there’s someone out there working to” hack them.
What community hospital CIOs need to do
The incentives for cybercriminals to flock to attacking healthcare targets are simply too powerful to leave the healthcare industry unscathed, Entin emphasized. “When the pot at the end of the rainbow is like a swimming pool of gold for some of these ventures, the motivation is huge” for cybercriminals to take on the healthcare industry, he said. So understanding that you can’t completely protect yourself, is important,” he said. “Especially as a 172-bed county hospital, we can’t afford a huge team of experts,” he said. Instead, “We need to be able to evaluate risks and get really informed about how we can mitigate risks and control them, and to some extent, transfer your risks. There are certain things I can put in place to control my risks or reduce my footprint,” he said.
Importantly, Entin noted, the cybercriminals out there are “looking for that quick hit, sending you the phishing email that leads to encryption, while also ranging up to the more sophisticated attacks. I’ve seen them come in through email, and many are very carefully targeted,” he testified. “And they’re looking for easy targets. They’re looking for organizations that haven’t done all the security work they’ve needed to. We’re not Target or Anthem, we’re a community hospital,” he said. But, he added, “If you’re fully patched, they’re going to move on to easier targets. So for me, it’s about looking at those most common threat vectors, and making yourself secure enough.”
FBI agent Palmore noted that, unfortunately, the healthcare industry continues to offer easy targets for cybercriminals. “The cyberthreat actors are absolute experts on return on investment; they know exactly which path to take, which is the path of least resistance,” he said. “Whatever is the cheapest path for them—spear-phishing, low-level engineering—that’s the path they’ll take. So you have to be on almost a continuous awareness campaign with your staffs. And the quality of the phishing emails they send out has been rising. And quite a few of the breaches we respond to, in the post-mortem, we find quite often that the entry point was spear-phishing. If you’ve researched the click rate for phishing emails, you’ve probably found the click rate hovering somewhere around 80 percent of clicking. And the more people know about these potential vectors, the less likely they are to hit you.”
Devices in peril
“We’re in a very disruptive time right now in terms of the shifts taking place in technology,” Andriola told his fellow panelists. “So what can we do about those shifts?”
“When you bring your own devices into your IT, it opens up a whole host of issues,” Mikkilineni said, referring to the BYOD phenomenon. “So you need to constantly train and educate. You need regular internal training, combined with controlling your BYOD devices.”
And the risks are multi-dimensional, Campagna noted. “OCR”—the Office of Civil Rights, in the Department of Health and Human Services—“fined a healthcare system $650,000 for loss of an iPhone that contained 200 patient records on that device. And what struck me was that that phone was completely unencrypted and open.”
“On the topic of BYOD, as has been a common theme on this panel, even getting down to basics and stopping a lot of these things from happening, can be very useful,” Andriola said. “In terms of cloud, moving to cloud-based applications can actually be a huge opportunity for patient care organizations.” He noted that while no one in healthcare has the funds available to the Microsoft Corporation, which he said spends more than one billion dollars a year on IT security, what is noteworthy, he said, is Microsoft’s ongoing willingness to spend extensively in that area, as “their existence absolutely depends on their security.”
“We have to adhere to the fundamentals,” Palmore stressed. “Time and time again, in the post-mortem leads to the fundamentals: strong password management and effective two-factor authentication. Quite frankly, two-factor authentication, when used correctly, will avert so many problems. And when it really gets down to it, if you want to identify where your greatest areas of weakness are, look to the fundamentals: creating and maintaining good password authentication.”
And, along the dimension of business, Entin emphasized that “You need to look at information security not only from a technical perspective, but also to look at your contracts” with vendors. “If there is a breach, who is liable? There are very standard liability clauses built into contracts that say that you’re on your own if something happens. So you need to work with your legal team to require your business associates to be liable for protecting data.”
And, per what kinds of password protocols to pursue, Palmore said that “I do realize as a user that it is a pain to demand constant changes in passwords, but it’s absolutely worth the protection it provides. So yes, absolutely disallow prior passwords; get folks into using passphrases instead of passwords… And 15 characters is the optimum length for a password. The odds are something like 100 million to 1 against criminals’ ability to break such a password.”