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HIMSS Arranges a Roundtable Discussion on Cybersecurity

September 11, 2017
by Mark Hagland
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HIMSS senior director of health IS Rod Piechowski shares perspectives on cybersecurity with reporters

Following up on the August 9 release of the results of the 2017 HIMSS Cybersecurity Survey, published by the Chicago-based Healthcare Information and Management Systems Society (HIMSS), HIMSS leaders organized a cybersecurity roundtable for the healthcare IT press on Friday, September 8, at its Chicago headquarters.

During the roundtable, Rod Piechowski, senior director, health information systems, at HIMSS, answered questions from the assembled members of the press, and elaborated his thoughts on some of the survey’s findings. The survey was conducted online between April and June, and obtained responses from 126 U.S.-based health information security professionals. Among those who responded, 54 survey respondents indicated that they worked at the “executive management” level, 51 said they worked at the “non-executive management” level (defined as “mid-level or senior management, but not executive-level”), and 21 were “non-management,” including “analyst, specialist, etc.”

In addition, 79 respondents said they have primary responsibility for information security in their organizations; 32 said they have “some responsibility” for information security; and 15 indicated that they “sometimes, as needed,” have such responsibility. Meanwhile, with regard to their organizations, 63, or 50 percent, work in acute-care provider organizations; 15, or 11.9 percent, work in non-acute-care provider organizations; 10, or 7.9 percent, work in “business associate” organizations; and 38, or 30.2 percent, work in “other” organizations, which can be health IT vendors, consulting firms, or payer organizations.

Among the key findings of the survey:

>  With regard to the percent of their overall healthcare organization’s budget that is currently allotted to cybersecurity, 11 percent said more than 10 percent; 17 percent said 7-10 percent; 32 percent said 3-6 percent; 36 percent 1-2 percent; and 7.9 percent indicated zero percent.


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>  Asked whether their organization employed a “senior information security leader”—someone with a chief information security officer (CISO) title or similar, 60 percent indicated that their organization had designated such an individual.

>  Asked whether or not they had an insider threat management program, 40 percent indicated that they had such a program and that it was formal, with formal policies in place; 35 percent have such a program, but indicated that it is “informal”; 21 percent have no such program; and 5 percent didn’t know whether they had one or not.

>  Asked how often their organization conducted a security risk assessment, 9 percent indicated daily; 10 percent, once a month; 8 percent, once a quarter; 7 percent, once every six months; 51 percent, once every year; 1 percent, once every two years; 2 percent, once every three years; 2 percent, less often than every three years; 6 percent conduct no security risk assessments; and 6 percent didn’t know.

>  With regard to penetration testing 3 percent of respondents indicated that their organization performed penetration testing daily; 7 percent, weekly; 18 percent, monthly, 38 percent, yearly; 9 percent, “other”; 15 percent said their organization did not perform penetration testing; and 10 percent didn’t know.

>  With regard to the variety of cybersecurity frameworks available, 62 percent of respondents said that their organization uses the NIST Cybersecurity Framework; 25 use the ISO framework; 25 percent use the HITRUST framework; 22 percent use the Critical Security Controls framework; 11 percent use the COBIT framework; 8 percent use a framework from another organization; 12 percent use no cybersecurity framework; and 2 percent did not know.

>  Meanwhile, with regard to cloud-based computing, the following were the top concerns of hospital-based survey respondents: ownership of data (53 percent); lack of cybersecurity (53 percent); lack of geographical restrictions (44 percent);lack of transparency (42 percent); insider threat (41 percent); costs and fees (37 percent); migration of data (37percent); lack of physical security (27 percent); and lack of availability, and downtime (25 percent).

>  Among non-hospital respondents, the results were somewhat different, and were as follows: insider threat (44 percent); lack of cybersecurity (41 percent); ownership of data (36 percent(; costs and fees (32 percent); lack of physical security (26 percent); migration of data (24 percent); lack of transparency(21 percent); lack of geographical restrictions (18 percent); and lack of availability, and downtime (18 percent).

Piechowski, dialoguing with the healthcare IT journalists present on Friday, was asked about perceptions of the risk of cloud computing in healthcare, and whether hesitation on the part of some CIOs to move further into cloud computing, could be attributed to IT security concerns. “Yes,” he said, in response to a question, “a lot of healthcare organizations are moving into the cloud; and, while on the one hand, it takes away the burden of having to maintain an IT department, on the other hand, there are trust issues.”

Rod Piechowski

Is there going to be a responsible way for healthcare organizations to make sure their data is secure? “I’ll say as a caveat, there are no absolutes, in all honesty,” Piechowski said. “But you can do your due diligence. You can ask cloud providers, what security framework do you use, what is your security approach? One of the biggest failures,” he said, “is the failure of organizations to patch their systems. And that’s a double-edged sword, because once you change your system, you don’t know what that affects. So a lot of organizations are taking a more cautious approach, doing regression testing—did this affect something else? This is also an issue with medical devices. They just issued a firmware update for Abbott, which used to be St. Jude’s; and these are implanted devices. It becomes a patient safety thing. So risk assessment is huge.”

Asked about insider threats, Piechowski said that “People aren’t that aware of insider threats, and a lot of organizations have a tendency to believe that that can’t exist in their organization, and we know that the opposite is very true. There are a couple of different types of insider threats. One is unintentional; the other is the obviously intentional, malevolent, approach, and those exist in any organization.” Asked whether insider-based actions might be under-reported, he said, “Yes, I think you’re onto something there. Organizations do not even want to admit that they’ve been breached. They’re required to report a breach if more than 500 records have been breached. Then they get put on the wall of shame, so a lot of organizations want to keep the internal-type threats under wraps. That comes from not wanting to expose more about your organization’s vulnerabilities. I’ve worked at organizations where people did things and got caught, and they didn’t call the Tribune. You’re right, this is something that organizations like to keep quiet. So this is an area where they can share things,” he said, referencing both some of the information-sharing taking place among HIMSS members, and also in other settings.

With regard to public collaboratives around cybersecurity, Piechowski said, “Yes, there are some beginning steps towards information-sharing about these cyber-risks. So there are a few [collaboratives] out there, and they are trying to establish themselves as an environment that can be trusted, even if the whole idea of the information-sharing organization is completely solidly organized and ethical, there are still organizations that might not want others within that network to know what’s going on.”

Might HIMSS as an organization create a forum for cybersecurity information-sharing? “Yes,” he said, “we’ve considered that kind of thing. HHS [the Department of Health and Human Services] has a group that they’ve convened, and they’re sharing information outbound.”

Asked about the implementation of programs to leverage analytics for behavioral monitoring, Piechowski said, “It can be done. It does add another layer of complexity, because you have to collect all that data and then analyze it. And if you see someone accessing files or data that they shouldn’t have access to, that’s obviously a red flag. And access control is super-important, but it’s also complicated to manage. I think it’s a good approach. It works with software. If you’ve got an operating system that is on guard, so to speak—this application doesn’t have the right to access this, this person doesn’t have the right to access that. And the whole BYOD [bring your own device] phenomenon adds a lot of complexity to it.

CISO Issues

Asked about the forward evolution of the CISO role, Piechowski said, “It’s a positive change. It’s moving in the right direction. It shows that the awareness campaigns are taking off. It shows that boards are taking security seriously. Even if you look at the CIO role, for years, the CIO reported into finance/the CFO role, and only recently began reporting to the c-suite. And one of the things we’re asking for at the federal level is to elevate these roles, so they have portfolios within and outside the government, to help hospitals and physicians.” What’s more, he said, “Generally, you’ll be seeing more security-related roles at the executive level. And it isn’t just the clinical data, it’s the administrative data as well.”

What about artificial intelligence and machine learning, and the potential for AI and machine learning to support cybersecurity strategies? “I think it’s going to be really cool,” Piechowski said. “How well it works and how it’s managed, and how much power we cede to AI, is a question for the ages. This is a really interesting time, and the fact that we’ve even gotten to the point where we can talk daily about AI and machine learning in our lifetimes, is a really interesting thing. And you’re going to be seeing a lot of talk about putting an AI eye on cybersecurity.”

What’s more, Piechowski said, “AI will be able to process so much more data and identify risky types of behaviors, and patterns that indicate potential threats. In the old days, somebody would get into a system and shut it down, or get in and steal some data and get out. And now we’re seeing these attacks evolve over much longer timeframes. First, you lay this brick and sit around for a couple of months, and see if the organization discovered that or not. With AI, we’ll start to notice that more. On the flip side,” he cautioned, “what can be used for good, can also be used for evil. And once AI and other technologies are commonly used, you’ll see ‘bad’ AI being used as well.”

Piechowski was asked what role he thought was most appropriate for the federal government, with regard to establishing standards for cybersecurity practices. “We work a lot with NIST,” he said, referring to the National Institute of Standards and Technology, within the Department of Commerce. “NIST is very good at actually creating those kinds of things, at the behest of the government; they’re really good at creating a cybersecurity framework. I think right now, the government is also trying to encourage an environment where information can be shared, and start to reduce the barriers to the kind of sharing that’s required. So I think you’ll see a lot more effort going into that.”

Asked to opine on the profit motive in ransomware-driven criminality, Piechowski said, “Yes, ransomware really has become a franchise phenomenon now. You can purchase a kit online to develop ransomware. And you give the creators of the software a cut. And they’re making it attractive, because they’re only asking for 10 percent. People are making millions of dollars in a month.”

What about the fact that only 27 percent of patient care organizations are conducting risk assessments quarterly or more often than quarterly? “Risk assessments can be very complex,” Piechowski commented. Once a year is a minimum best practice. The HIPAA security rule requires that you do it. And if you think daily is too frequent [an interval], in essence, it’s not. The best ‘best practice’ is that risk assessment needs to be an ongoing operation.”

What’s more, Piechowski noted, “Data is the new everything. All organizations depend on it.” Having one’s information systems shut down entirely is now a devastating event for many organizations in many different industries, he noted. “Some organizations can go a day or a week without it, but in other fields, companies could go bankrupt if they’re down even five minutes. So security… and one way to approach this is to get the board and the c-suite to understand that it isn’t just an information technology responsibility. IT is the way we move all the facts and value of our organization around, and we have to protect that. This is about our business sustainability and credibility with our customers.”


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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.

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, And, 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,” he 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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