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A Healthcare Security Expert Breaks Down the Evolving Role of the CISO

September 7, 2017
by Heather Landi
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Information technology leaders at patient care organizations are facing an evolving cybersecurity threat landscape, with accelerating threats in the wake of recent, massive attacks on organizations worldwide.  The need for stronger cybersecurity is now on most healthcare organizations’ radars, more so than even just a few years ago.

As healthcare organization leaders across the country look to ramp up their cybersecurity strategies and implementations, chief information security officers (CISOs) are becoming part of the bigger picture. As Healthcare Informatics Managing Editor Rajiv Leventhal reported back in April, CISOs within healthcare organizations—not too long ago a position with a limited role—have now become a part of the broader senior leadership team, experts say. A HIMSS Analytics and Symantec study released in February found that even though cybersecurity budgets are increasing, 65 percent of surveyed healthcare organizations are still spending less than 6 percent of funds on security. What’s more, those survey findings indicate that the majority of healthcare organizations still have five or fewer employees allocated to IT security, although two-thirds of participating organizations do have a chief information security officer (CISO), which most often report to the CIO.

Mac McMillan, chairman, CEO and co-founder of CynergisTek, an Austin, Texas-based information security and privacy consulting firm focused on the healthcare IT industry, spoke with Healthcare Informatics Associate Editor Heather Landi about the evolving role of the healthcare CISO and the skills and expertise that every CISO should have to be effective, and why that goes beyond just technical expertise in security. Below are excerpts from that interview, edited for length.

 How do you see the CISO role in healthcare organizations evolving?

The CISO is an interesting role because, to do it effectively and be successfully, you have to be one part technologist, one part business leader and one part psychologist, in a sense. What I mean by that is that the CISO has to understand the technology and the threats well enough to understand what the organization needs to do to protect its system, operations and its information. But, they also have to be able to translate that into business jargon; they have to be able to speak the language of the business. They should be a business leader because the organizations are not going to spend money on security if they don’t see how it fits into the strategic plan of the business and don’t see how it contributes to the business being successful. You’ve got to be able to go in and say ‘Look, there’s a reason why we need to invest in security and we need to invest in this technology or invest in these people or invest in this service or this process and it’s because it’s going to be make our business more resilient, it’s going to make our business more capable and it’s going to ensure that our business can continue to operate and avoid those risks that are affect our ability to deliver our primary mission in terms of care and earn revenue.’ And at the same time, when I say part psychologist, they should be able to learn how to navigate a senior staff and other business leaders who have their own priorities and their own objectives that they are trying to accomplish and figure out how best to interact and work with those people. You need to be able to motivate these senior leaders as well as the workforce, in general, to just be more aware and more open to the idea of doing things differently as it relates to being more safe or secure in their practices and systems. It’s not just a technologist’s role anymore. It’s not just the smart IT engineer who knows something about security, that’s not going to cut it; you need somebody who is a business leader.


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Mac McMillan

Are you seeing changes in the reporting structure with the CISO reporting outside of IT?

We see that in some organizations; we haven’t seen it in a wholesale fashion. I wonder where we have to get to before that happens. Quite frankly, I’m not a huge proponent one way or the other, as long as the CISO is visible and has a reporting chain up through whatever the IT governance process is for security through the audit committee or the board; as long as there is visibility and that person’s voice is not muffled, and they get support, then it can work no matter where they are. But in most organizations, many of the CISOs I talk to around the country say they are still challenged by the fact that they do report within IT, and they do have to compete with the rest of the IT budget. They say that they don’t have a budget of their own, per se, which is something I think organizations should do—they should break their security budget out and understand what their security spend is and understand what that means to the organization.

I came out of an environment in the government, and, as a director of security, I reported to the director of the agency; I didn’t report to IT. The CIO and I were peers, and we had to work together to get the mission done. I personally think that is the best approach. I think we’re at a point now where people should be asking the question, ‘Does the CISO belong in IT, or should they have a separate reporting chain?’ It’s still isn’t happening, in a wholesale fashion. Generally, it’s only in the largest organizations where we see the CISO begin to move out and report up through compliance or some other organization.

You mentioned that the CISO should have business acumen as well. Are you seeing the need to create an alignment between security and the business of the organization?

In some organizations, we absolutely are beginning to see CISOs who are realizing that their job is to be part of the business, not just part of security or IT. And those CISOs are getting out there and are beginning to work with their counterparts and their peers in the organization and recognizing that managing risk is understanding how the workforce is interacting with systems and using systems and what their workflows look like and where those risks really are. And the CISOs that are doing that are being the most effective.

For patient care organizations looking to fill the CISO position, what skills and expertise should they be looking for?

They should be looking for individuals who understand the basic concepts of business planning; they should be looking for folks who understand how to manage a budget; they should be looking for individuals who understand how to manage people; they should look for people who have good skills in writing and communicating orally, because a lot of what you do as a CISO is educating the organization on why it’s important for them to pay attention to the things that they need to pay attention to. There are a lot of skills that are, quite frankly, akin to a business leader that the CISO needs to add to their bag of tricks. They should be looking at individuals with X number of years of experience in managing security with the appropriate certification. Once that individual has learned the technology and once they’ve learned the basics of cybersecurity, they also need to develop those business skills.

There currently is a cybersecurity skills gap in the healthcare industry, right? What can healthcare organizations do to recruit qualified candidates?

There is absolutely way more demand than there is adequate supply. Now that organizations are actively looking for people with these skillsets, and organizations are beginning to understand what that means in terms of what kinds of qualifications these individuals need to have, they are beginning to realize that a lot of people out there are calling themselves CISOs, or calling themselves security people, but they don’t measure up. It’s like anything else; whenever there is a situation that we have now, where you’ve got way more opportunity than you have people, then you going to have a lot of people who are going to try to get into that field. Healthcare organizations need to carefully vet those candidates to make sure you’re getting somebody who is really qualified for that job and not just somebody who’s been in IT for the last 15 years and is looking for a way to move their career along.

I think you’d find that less than 50 percent of healthcare organizations with a true CISO. We still have a lot of organizations with people who are wearing that title as a secondary duty or they are wearing that title and they really don’t have any experience in that role. We see this all the time, where they hire somebody or they move somebody over from IT and name them a CISO, that doesn’t mean that they are a legitimate CISO.

Healthcare organizations can use a qualified recruitment source to help them. Or, if they are going to recruit themselves, then the organization leaders can ask somebody to assist them, such as a security vendor that they already work with, or an outside vendor, to help them look at candidates, look at resumes and review their qualifications.

Are there challenges with healthcare organizations offering competitive compensation in order to recruit and retain qualified CISOs?

That’s a huge challenge right now. This is not an area that healthcare has a lot of experience at recruiting in. Because of the supply and demand situation that we’re in right now and because of the additional certifications and experience that individuals need to have to be truly qualified CISOs, they tend to attract a higher dollar from a compensation perspective. Right now, anybody has the qualification is very mobile; there is a lot of opportunities for individuals with the right skill sets and the right experience. Healthcare organizations have a hard time recruiting them and retaining them because they haven’t accepted the fact that they will have to pay these people more than a regular IT person. The industry is going to have to recognize that this is an advanced skillset that these individuals have. This is somebody who has gone above and beyond the typical IT training and developed these additional skills around cybersecurity. They are very valuable and you’re going to have to pay more for them.

I think, eventually, what we’re going to see is more of an outsourced model, or a service model, around security because we just don’t have enough professionals in this space to fill every job that is out there.


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Targeting Third Party Risk: Leading CISOs Detail Efforts to Secure the Healthcare Supply Chain

December 18, 2018
by Heather Landi, Associate Editor
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Healthcare information security leaders are faced with the dauting challenge of securing information systems and data at a time when the cyber threat landscape is evolving rapidly and becomingly increasingly complex.

Most patient care organizations’ supply chains are filled with third parties who support the care delivery process and require access to patient information. Properly vetting and monitoring these third parties is a major challenge, and in some cases, insurmountable for many organizations who simply don’t have the expertise or resources, according to healthcare IT security leaders.

Many healthcare chief information security officers (CISOs) have found that effectively assessing the security posture up and down the supply chain is expensive given the complexity of the risks posed by privacy and security concerns, as well as an everchanging regulatory landscape. Currently, the process of managing third-party risk is often inefficient and time-consuming, for both vendors and providers, while still leaving organizations vulnerable to security threats.

During a recent webinar, sponsored by HITRUST, focused on healthcare cybersecurity and managing third party risk, John Houston, vice president, privacy and information security at the 40-hospital UPMC health system in Pittsburgh, outlined a number of factors that have made third-party risk management increasingly challenging and complex.

“There has been a fundamental change in IT, and a rapid move to the cloud. At the same time, we all see an increasingly complex cyber threat landscape where the threats are more sophisticated, and the technology solutions are more sophisticated as our business requirements are changing. It’s an increasingly complex landscape,” Houston said.


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He further noted, “As a result, there is a lot of confusion about how we best ensure our information is secure and available, and what is reasonable in terms of trying to achieve that. And finally, we are all worried about risk, and the biggest risk is patient safety. We worry about the cost of litigation and penalties, but first and foremost, we need to think about ensuring that we are able to deliver the best care to our patients.”

The stakes are changing, Houston noted, as federal regulators are investigating and penalizing organizations for failure to monitor third parties’ security practices, and hackers are increasingly targeting medical devices, he said.

“From a CISO perspective, we need to ensure that we are applying proper oversight over all of this. We can’t assume third parties are doing the right thing,” he said.

What’s more, healthcare organizations are increasingly reliant on cloud technology. A year ago, Nuance Communications, a provider of voice and language tools, was knocked offline when the company was hit with the Petya ransomware virus.

“I was around during Y2K, and about 95 percent of all our applications at UPMC, we ran within the data center, on premise. About 95 percent of newly acquired applications were run on on-premise, there was little on the cloud. In that environment, it falls upon the entity to secure data within its possession,” he said.

Contrast that with today’s environment, as Houston noted that “very little of what we acquire today runs on-premise. In some way, shape or form, at least one copy of the data is in the cloud.”

Studies have estimated that by 2023 no more than 25 percent of applications will be run on-premise in an organization’s data center, with about 75 percent run in the cloud, Houston said. “Many copies of our data end up in the cloud, and it’s not just one cloud provider. We get services from a lot of different vendors, all of which are in the cloud. That speaks to the fact we, as CISOs, can no longer directly secure our own information. We are dependent upon third parties to secure our data for us. We can’t simply trust that they are going to adequately secure that information.”

From a healthcare CISO’s perspective, a vendor’s IT and data security practices should be at least as effective as the provider’s security posture, Houston said. “I should expect nothing less. As soon as I expect less, that’s a sign of defeat.”

Across the healthcare industry, ineffective security, compliance and assurance methods drive cost and confusion within organizations and across third parties, according to IT leaders.

While most healthcare organizations are taking the right steps to monitor and screen vendors and their products and services during the pre-selection and on-boarding phases and are also conducting security risk assessments, it’s still not enough to protect IT systems, data, and, most importantly, patients, said Taylor Lehmann, CISO at Wellforce, the Burlington, Mass.-based health system that includes Tufts Medical Center and Floating Hospital for Children. “We are still seeing breaches, and the breaches are still coming after we do all this screening,” he said.

“We’re not being effective and it’s difficult to be effective with the current paradigm,” Houston added.

From the CISO’s perspective, there are inefficiencies in the third-party supply chain ecosystem. Suppliers are commonly required by their customers to respond to unique questionnaires or other assessment requests relating to their risk management posture. Vendors often must fill out questionnaires with 300-plus questions. What’s more, there’s no assurance or audit of the information the vendor provides, and the process is completely inefficient for suppliers who are audited 100 times annually on the same topics, but just different questions, Lehmann and Houston noted. What's more, the security assessment often occurs too late in the process.

“We’re creating a lot of waste; we’re taking time away from our organizations and we’re taking time away from suppliers,” Lehmann said. “The current way we’re doing supply chain risk management, it doesn’t work, and it doesn’t scale, and there is an opportunity to improve.”

To address these issues, a group of CISOs from a number of healthcare organizations established the Provider Third Party Risk Management (TPRM) Initiative to develop a standardized method to assess the risk management posture of third-party suppliers to healthcare firms. Launched this past August, the founding member organizations for the Provider TPRM Council include Allegheny Health Network, Cleveland Clinic, University of Rochester Medical Center, UPMC, Vanderbilt University Medical Center and Wellforce/Tufts University. Working with HITRUST and PwC, the Council aims to bring uniformity and consistency to the process while also reducing the burden on providers and third parties.

The healthcare industry, as a whole, will benefit from a common set of information security requirements with a standardized assessment and reporting process, Lehmann noted.

In the past four months, the governing members have been expanded to include Nuance, The Mayo Clinic, Multicare, Indiana University Health, Children’s Health Dallas, Phoenix Children’s Hospital, and Banner Health.

The Provider TPRM initiative is increasing membership and gaining momentum as security leaders from both healthcare providers and their suppliers embrace the unified approach, Lehmann said.

One of the goals for the Council is to address the inefficiencies found in the third-party supply chain ecosystem. By reducing the multiple audits and questionnaires, the financial savings will allow business partners to invest in substantive risk reduction efforts and not redundant assessments, the Council leaders say.

“By reducing wasted effort and duplication, suppliers will find their products and services will be acquired more quickly by healthcare providers. This will also reduce the complexity of contracts and provide third parties with better visibility regarding the requirements to do business with providers,” said Omar Khawaja, VP and CISO of Allegheny Health Network and Highmark Health. Khawaja’s organization is a founding participant and governing member of the Provider TPRM initiative.

As part of this initiative, going forward, provider organizations that join the effort will require third-party vendors to become HITRUST CSF Certified within the next two years, by September 2020. The HITRUST CSF Certification will serve as the standard for third parties providing services where they require access to patient or sensitive information and be accepted by all the Council’s organizations. HITRUST CSF is an industry privacy and security framework that is continuously evolving with the changing cyber landscape.

 “After September 1, 2020, third parties without certification cannot do business with participants,” Khawaja said.

Houston added, “We recognize that there are limitations in our current processes, and what we’re putting in place is at least as good or better than what we’re already doing. This will lead to faster onboarding, less waste, better transparency, and simpler compliance.”

By choosing to adopt a single comprehensive assessment and certification program, healthcare organizations represented by the council are prioritizing the safety, care, and privacy of their patients by providing clarity and adopting best practices that their vendors can also adopt, while providing vendors the expectation of what it takes to do business with their organizations.

“It provides transparency,” Houston said “It sends a message to suppliers that we’re an open book about what it takes to do business. That’s powerful.”

Moving forward, the Provider TPRM initiative will focus on adding business associates to the effort to increase membership and impact, Lehmann said. “The simple fact is, many of us are pushing this through our supply chain and there are organizations that may not have a process or low maturity process. But, through the efforts of council members, more suppliers will show up, which is means safer products are possible to purchase.”

Further, the program will likely develop additional requirements on vendors such as breach response and monitoring security threats and alerts observed as third-party vendors.

The Council also plans to focus on certification programs for smaller vendors. “A lot of innovation in healthcare is coming from smaller companies, and we understand there is a gap between what those companies can do with respect to cyber. We’re not lowering our standards, but we want to be thoughtful and create a certification program for those areas. We want to do business and we need a vehicle to bring them in in a safe and secure way,” Lehmann said.

“We want to build a community of health providers working together, business associates working together, to share information,” Lehmann said. “We want to better inform ourselves and align other programs, like cyber insurance, to enable more effective planning throughout the supply chain. The things we learn through these relationships can translate to other aspects of our organizations.”

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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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