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At the HIT Summit in Cleveland, a Closer Look at How Cybersecurity Issues Impact Clinicians

March 28, 2018
by Mark Hagland
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At the Health IT Summit in Cleveland, health IT leaders parsed some of the challenges around helping to guide clinicians and others forward around meeting cybersecurity threats

When it comes to working with physicians and other clinicians, and other end-users, in their organizations, how are healthcare IT leaders advancing cybersecurity in patient care organizations these days? Part of the answer to that question was embedded in the title of a panel discussion on Tuesday in Cleveland, during the Health IT Summit, sponsored by Healthcare Informatics, and unfolding this week at the Hilton Downtown Cleveland. “It Takes a Village: Collaborating to Secure Your Organization” was the title of the panel discussion, which was led by Pamela Banchy, R.N., CIO at Western Reserve Hospital in Cuyahoga Falls, Oh.

Banchy was joined by David Kaelber, M.D., Ph.D., CMIO and vice president of health informatics at Cleveland’s MetroHealth System; Karen Martinko, MetroHealth’s IS security officer; Keith Duemling, information security officer at Lake Health in Painesville and surrounding towns in northeast Ohio; and Ricky Aldridge, who spent more than 20 years in healthcare IT security, before recently shifting to Diebold Nixdorf, a North Canton, Oh.-based corporation in the financial services equipment and software area, as cloud security architect.

“Frequently, clinicians see security as an inconvenience—it’s their perception that we’re keeping them from caring for patients,” Banchy said early in the panel discussion. “They’re not understanding why you can’t have USBs connected to computers, for instance. And if you understand the business, you know how we can help collaborate together. So what I’ve heard through my career is, make it easier, don’t make it harder. And of course, who’s responsible for security? We all are. And you do your penetration testing, and inevitably find the few individuals who fall for the phishing email, right?”

“In terms of phishing, yes, I agree, that’s probably the weakest link at MetroHealth, and we’ve undertaken a variety of efforts to make them aware that you can’t just open every email, click on every link,” Martinko said. “So in addition to articles we’ve put on our Internet, around phishing. And we thought we were making some really significant strides in helping to educate people; unfortunately, we got some results that weren’t so great, so we’ll be making some more changes.”

“From the clinicians’ side, security is viewed as making things harder for them to do. We tried to cut down on the Internet sites people could go to, trying to create a kind of ‘white list.’ But there are unintended consequences of blocking some things that people need, in order to do their normal jobs. How do you find that balance? We’ve seen that it’s got to be a collaborative effort. And you have to make a decision, thinking it’s the best decision you can make at the time, and then adjust accordingly. For instance,” he said, “we went with IronKeys [encrypted flash drives], but that was a tough transition. And now we’re going through some things around passwords—you’ve got to have 12 passwords now, and better passwords. And the thing is, as a physician, you’re not seeing the upside of the system being more secure. If you own your own practice, you can see both the upside and downside of being secure. In a small practice, it’s really hard to keep up with the security issues, in a constantly changing environment.


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“Do you find that many users will look for and develop and try to use workarounds?” Banchy asked her fellow panelists. “

“Information security has to be adaptive, and we have to adapt to the needs of the clinical staff, to see what their needs are,” Duemling responded. “We have to make adaptations, so that people don’t feel they have to go around us to do their work. That give and take is critical, in my view.”

“I absolutely agree,” said Martinko. “One of the things we’ve been doing at Metro recently is applying some additional governance layers. We’re actually taking some of the security solutions we need funding for, and communicating that to a diverse series of folks, to help us move forward. We talk about why we want to deploy a particular technology, what the benefit will be, and how it will be maybe use things for the users and staff.”

“We try to communicate what we’re doing and why, without making it too technical,” Aldridge said. “And now at my new job, I use my marketing department, and the marketing department actually does a good job for me. Because I can’t be the person to give the controls and communicate the controls at the same time, because they won’t want to listen to me. Big communications should be done with a good PR background,” he asserted.

“Security is often seen as a dis-enabler,” Aldridge continued. “But in reality, everything you want to do, we can do; we just need to make it secure. But reach out to PR. Because I need to communicate to the whole organization. Like with phishing. At Akron Children’s, we worked on that. And our monthly or weekly communications to the whole organization, we gave them numbers, and we gave those numbers to leadership, so they knew what we were doing and why. So communicating with your user base is probably the number-one thing you can do.”

“As CMIO, I really want it to be a partnership; and what we might consider a workaround, might be a new weakness you didn’t anticipate,” Kaelber noted. “And my view of HIT in general is that there’s no way in the design and testing phase, that you can come up with every possible scenario. So you’ve got to go live, and then fix things, but you need really good relationships around all this, to make it work.”

“What types of structured governance models have you found to be a good or best practice?” Banchy asked.

“We’ve made a lot of changes just in the past year,” Martinko reported. “But we have different panels now. We do have physicians who are members of those panels; so they are involved, and we bring forward projects we’re looking towards. Doctors sit on the panel that IS is involved with. A lot of times,” she noted, “there have been things we’ve talked about, and when I’ve explained the benefits, the doctors have actually been rather enthusiastic supporters of what we’ve been trying to do. And per what Dr. Kaelber has said, as we roll out new technologies, we do include doctors in our pilots and pilot planning, and that helps us.”

“And the other thing I’ve seen that’s been really positive,” Kaelber added, “is that five to seven years ago, security was seen as purely an IS technical function; but there’s an evolving recognition at MetroHealth and presumably at other places, too, that everybody has a role in this. We’re really making sure we’re engaging not only the technical people, but some of the marketing people, the compliance people, some of our training folks, technical folks. Because at the end of the day, security really is the job of everyone. But it’s a continuing process.”

“I think that clinical informatics is an important group, with growing importance,” Aldridge asserted. “They help to engage clinicians, and in reality, they convert IT-speak to clinical speak. Because we’re not thinking from a caregiver standpoint, but from a pure IT standpoint.”

“And the patients’ information is our responsibility,” Banchy noted. “And all of us are, have been, or will be patients. And so having an understanding of all the roles across the enterprise, anybody who has that information, is really key.”

What will happen, going forward, as the emerging world of APIs evolves forward? “That’s where I’m actually operating right now,” Aldridge said. “We’re basically shifting and lifting, moving everything to the cloud. And an API—you have one system here that knows all its data, and a system over there that knows all its data, and you can basically write a script to create an easy way to share data. In the cloud, everything is API-driven. We’re building a lot of APIs for the ATM machine. Pretty soon your ATM machine will be software as a service. Sounds crazy, but it’s going to happen. So how we’re trying to security around those is that, within your cloud providers, there’s a way to do key management. Key management is the first thing you’ve got to implement. You need to make these API calls, to manage them across the life cycle. And there’s a life cycle around when an API is built, deployed, secured, etc.”

What’s more, Aldridge noted, “A lot of companies are actually offering API security. Healthcare is going to start to see a lot of APIs. And as you move to the cloud, you’re going to have to get used to APIs. And as the government pushes open APIs, one of the reasons they did that—back in the day, hospitals were connecting one to one. So they’re pushing all the EHRs to use an open API, as EHRs go to the cloud. That’s how data will be moved between data points, so you basically need to get hooked up with API security vendors like Apogee, MuleSoft, etc.”

“And I think that from a governance standpoint, one way to approach that would be to essentially treat information moving from an API to another entity, as being to a third party, and work with that API as a business partner,” Duemling said. “It’s not perfect, but it’s one way to look at it.”

“Back in the day, you had all these security products, and none of them talked to each other. Now, all of them have an open API, so if you use products like Phantom, Command, those products sit in the middle and make systems talk,” Aldridge noted. “So now if you saw something that looked like malware, you’d have to call the PC person, etc., to run an antivirus on the system. Now, with open APIs, you could send data to the firewall and automatically block it, and your firewall guys wouldn’t have to do anything.”



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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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