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At iHT2-Seattle, One CISO Offers a Comprehensive View of the Current IT Security Risk Environment

August 16, 2016
by Mark Hagland
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Cris V. Ewell, Ph.D., CISO at UW Medicine in Seattle, shares his perspectives on the daunting constellation of IT security challenges in the current environment

It is very important to break down the elements and steps involved in creating a robust and effective data security strategy in any patient care organization. That was the message that Cris V. Ewell, Ph.D., the chief information security officer at UW Medicine IT Services, in Seattle, told attendees Tuesday morning at the Health IT Summit in Seattle, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella).

Dr. Ewell’s presentation, entitled “Healthcare Information Security Practices: Why are we failing?” was the opening keynote address at iHT2-Seattle, and challenged attendees, who are gathered at the Marriott Seattle Waterfront in downtown Seattle, to consider, and perhaps reconsider, how they are allocating resources and strategizing around assets, as they pursue healthcare IT and data security strategies in the current, unsettled operational environment in U.S. healthcare.

Ewell encouraged his audience to think carefully about assets, data, and intelligence, and to focus their efforts thoughtfully and strategically, when it comes to IT and data security in the present environment. Among the key points he stressed, under the question, “What are some things I can do?” were the following:

>  Adopt a repeatable and transparent risk management framework and methodology

>  Identify and prioritize assets and related risk-mitigation efforts


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>  Implement an intelligence program

>  Develop aggressive risk transfer strategies

> Minimize the electronic attack surface in one’s organization

>  Advance processes around incident response and management

>  Ensure that the CISO in the organization has defined accountability and responsibility

“There is no shortcut” to developing a truly robust overall strategy for enterprise-wide IT and data security, Ewell told his audience. What’s more, the bigger and more complex the patient care organization, the more challenging it becomes to create and execute a truly comprehensive strategy, across the layers and dimensions of one’s organization, and across the complexities of people and processes.

One of the absolutely key elements in all this is developing a comprehensive risk management program for IT assets, Ewell told his audience. Among the key points he referenced in a slide in his presentation was around the core elements in a successful risk management program, which he said include the following:

>  Concentrate protection efforts across the entire organization

>  Be nimble enough to adapt to new threats

>  Be risk-based and not compliance-driven

>  Involve executive management and the board in your risk management program

And none of this is easy. “At the University of Washington, which is a complex organization, it is hard to get to an enterprise-level risk assessment, given that we have 14 entities, and many other departments, that are involved in ePHI [electronic protected health information],” Ewell said. Meanwhile, on the one hand, he supports the idea of bringing in outside consultants to help with processes around enterprise-level risk assessment—but he immediately adds that, “When you bring in an outside firm to do a risk assessment for you, what they will provide you is a technical risk assessment, not a true enterprise-wide risk assessment. They will tell you about your ‘things,’ not your processes,” he emphasized. “Only you and your team internally can really assess your processes.”

In addition, Ewell noted, “Our adversaries are changing. They know what’s going on” in the industry, and are closely following trends and developments in healthcare IT. They are also becoming increasingly sophisticated, as they seek ways to infiltrate and compromise organization’s network infrastructures. For example, he said, cybercriminals are closely monitoring the social media activity of individuals, especially those who are on the staffs of patient care organizations. “They’re watching your LinkedIn profile to see what’s in it,” he stated. And the more information they can find in end-users’ professional and personal accounts, the more readily they can tailor attacks and intrusions.

Of course, in all this, Ewell emphasized, a core perpetual threat remains the fact that end-users working in patient organizations continue to click on phishing e-mails, opening e-mails and attachments that lead to malware, including ransomware, attacks. To some extent, he said, there is an inevitable level of vulnerability in this area, given the human factors involved. In fact, he said, “People who work in healthcare want to help other people; and the cybercriminals know that and use that to their advantage.” It’s the social engineering aspect of humans, particularly humans working in patient care organizations, that will always be a point of vulnerability with regard to data and IT security, he said.

“Not a once-a-year thing”

One element in all this that is clear, Ewell said, is the need to change thinking and culture around data and IT security. “You cannot do this in a vacuum. And you need to get executive management and board support” in order to get not only the funding, but also the organizational support, to make IT security strategy work across any patient care organization. “There is risk, and what you need to do is to bring this up to your organization’s board, and ask the board members directly how much risk they’re willing to accept.”

Furthermore, he told his audience, “You should be doing all of this before you’re under attack. I’ve been at UW for six months now, and we’re doing risk assessments every single day. And that’s a whole change of culture. It was also a change of culture at Seattle Children’s when I was there.” Referring to Drex DeFord, a healthcare IT consultant who was CIO at Seattle Children’s during the same time that he was the organization’s CISO, Ewell hailed DeFord for being a strong partner with him around IT security strategy development and execution when they were both working at that hospital together.

Fundamentally, Ewell said, “risk management is not a once-a-year thing.” In fact, he stressed, “It needs to be an everyday thing. We have to constantly think, where is our risk? Where is it going? What kinds of controls do we have in place? What threats are emerging? What attacks are already happening?

And in doing that risk assessment, we look at threat actors, attack vectors, organizational risk, threats, aspects or targets, context for predictive analytics, and capabilities,” he said. One of the weaknesses in most patient care organizations, he added, is that “Most organizations focus only on capabilities.”

But, he said, “It is very important to ask the question, why do threat actors want our data? Where is our data? How is our data protected?” and other essential questions. In that regard, Ewell noted, I’ve started creating dashboards and reports. One thing we didn’t have when I joined UW was a risk mitigation plan. Now we can create one on the fly—one that includes threats, impacts, vulnerabilities, what we need to do to fix those risks—and we can do that at any time for any area. That’s what you need to do. Give me your risk assessment, give me your last risk assessment, give me your risk mitigation plan, give me your policies, give me your processes and procedures.”

In that context, Ewell said, “I create risk charts for our board and our executive team, charting our risk across the enterprise, and express where I’m concerned and where we need to change some of our practices.” The processes around that infrastructure have proven to be very successful, he noted.

Meanwhile, when it comes to assets, Ewell said that knowing one’s organization’s assets is not a straightforward thing; it is also not a simple or easy thing. “You need to begin with the process of asset profiling and inventory listing,” he said. “The first thing you need to do is to find out where all your assets are,” and that can turn out to be a long, complex, and difficult process. It is important to be able to understand the “attack surface,” meaning a mapped-out understanding of the range and particulars of threat risks. Among other elements, he noted, are the range of assets, including intellectual property; key services and products; applications; business partners; key individuals; and data. In turn, data includes the types of data involved; the volume of that data; and applicable laws and compliance requirements around all of the data.

One key element in all this is intelligence, as in intelligence-gathering, Ewell said. “This is a hard area, because you can consume your entire staff doing nothing but intelligence. And this is not just about news feeds,” he said. “Many vendors provide news feeds. And you can get inundated with an enormous amount of data, several gigs a day. But the whole purpose of this is to provide forecasting. I’m trying to figure out where the attacker will attack first.”

Attack vectors include the following: authorized account misuse; cryptographic and password attacks; data interception; denial of service; implied trust exploitation; malicious malware, misjudgment, or error; operating system and application vectors; physical attacks; social engineering issues; and supply chain compromise.

In the end, what should healthcare IT leaders do? “Begin by coming to an understanding of your information security and risk framework,” Ewell advised. “Discover and prioritize your assets, and understand what your high-risk assets are. Start with your data centers: do you even know 100 percent of the assets you have in your data centers? Develop dashboards; understand your threats; develop a continuous risk management and improvement process; and maintain a series of checks and balances” in terms of balancing the need for security with the need for data access.

Above all, Ewell urged his audience, “Do something. Determine the place to start.” As a CISO, he said, “I can’t fix everything. I can’t fix the world. I can do certain things. And I can work with my vendors.” It is extremely important to understand, he added, that “This is hard. You cannot simply download this list from the Internet.  You can’t download an easy threat list. You have to do this work. This is not something you can download. And it’s continuous. This is not a one-time, once-a-year event. It has to be built into everything that you and your team do, and what your CIO does, and your medical staff, and your organization. This is an institutional problem,” he added.

And, in response to a question from Healthcare Informatics following the presentation, regarding what advice he would give hospital and health system CIOs, Ewell said this: “Recognize that it’s a partnership. You as the CIO have most of the financial and human resources. But the CISO, who may not report to you, has the authority for data and IT security. So it has to be a really good partnership. What’s more,” he said, “it’s very important to understand that you’ve got to get the security built into your implementations from the start. Don’t think that you can just ‘bolt on’ the security later; if you didn’t have the time to build the security into your information systems and applications the first time around, you won’t have the time to fix it later.”


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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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Report: 30 Percent of Healthcare Databases Exposed Online

December 10, 2018
by Heather Landi, Associate Editor
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Hackers are using the Dark Web to buy and sell personally identifiable information (PII) stolen from healthcare organizations, and exposed databases are a vulnerable attack surface for healthcare organizations, according to a new cybersecurity research report.

A research report from IntSights, “Chronic [Cyber] Pain: Exposed & Misconfigured Databases in the Healthcare Industry,” gives an account of how hackers are tracking down healthcare personally identifiable information (PII) data on the Dark Web and where in the attack surface healthcare organizations are most vulnerable.

The report explores a key area of the healthcare attack surface, which is often the easiest to avoid—exposed databases. It’s not only old or outdated databases that get breached, but also newly established platforms that are vulnerable due to misconfiguration and/or open access, the report authors note.

Healthcare organizations have been increasingly targeted by threat actors over the past few years and their most sought-after asset is their data. As healthcare organizations attempt to move data online and increase accessibility for authorized users, they’ve dramatically increased their attack surface, providing cybercriminals with new vectors to steal personally identifiable information (PII), according to the report. Yet, these organizations have not prioritized investments in cybersecurity tools or procedures.

Healthcare budgets are tight, the report authors note, and if there’s an opportunity to purchase a new MRI machine versus make a new IT or cybersecurity hire, the new MRI machine often wins out. Healthcare organizations need to carefully balance accessibility and protection.

In this report, cyber researchers set out to show that the healthcare industry as a whole is vulnerable, not due to a specific product or system, but due to lack of process, training and cybersecurity best practices. “While many other industries suffer from similar deficiencies, healthcare organizations are particularly at risk because of the sensitivity of PII and medical data,” the report states.

The researchers chose a couple of popular technologies for handling medical records, including known and widely used commercial databases, legacy services still in use today, and new sites or protocols that try to mitigate some of the vulnerabilities of past methods. The purpose of the research was to demonstrate that hackers can easily find access to sensitive data in each state: at rest, in transit or in use.

The researchers note that the tactics used were pretty simple: Google searches, reading technical documentation of the aforementioned technologies, subdomain enumeration, and some educated guessing about the combination of sites, systems and data. “All of the examples presented here were freely accessible, and required no intrusive methods to obtain. Simply knowing where to look (like the IP address, name or protocol of the service used) was often enough to access the data,” the report authors wrote.

The researchers spent 90 hours researching and evaluated 50 database. Among the findings outlined in the report, 15 databases were found exposed, so the researchers estimate about 30 percent of databases are exposed. The researchers found 1.5 million patient records exposed, at a rate of about 16,687 medical records discovered per hour.

The estimated black-market price per medical record is $1 per record. The researchers concluded that hackers can find a large number of records in just a few hours of work, and this data can be used to make money in a variety of ways. If a hacker can find records at a rate of 16,687 per hour and works 40 hours a week, that hacker can make an annual salary of $33 million, according to the researchers.

“It’s also important to note that PII and medical data is harder to make money with compared to other data, like credit card info. Cybercriminals tend to be lazy, and it’s much quicker to try using a stolen credit card to make a fraudulent purchase than to buy PII data and run a phishing or extortion campaign. This may lessen the value of PII data in the eyes of some cybercriminals; however, PII data has a longer shelf-life and can be used for more sophisticated and more successful campaigns,” IntSights security researcher and report author Ariel Ainhoren wrote.

The researchers used an example of hospital using a FTP server. “FTP is a very old and known way to share files across the Internet. It is also a scarcely protected protocol that has no encryption built in, and only asks you for a username and password combination, which can be brute forced or sniffed

by network scanners very easily,” Ainhoren wrote. “Here we found a hospital in the U.S. that has its FTP server exposed. FTP’s usually hold records and backup data, and are kept open to enable backup to a remote site. It could be a neglected backup procedure left open by IT that the hospital doesn’t even know exists.”

According to the report, hackers have three main motivations for targeting healthcare organizations and medical data:

  • State-Sponsored APTs Targeting Critical Infrastructure: APTs are more sophisticated and are usually more difficult to stop. They will attempt to infiltrate a network to test tools and techniques to set the stage for a larger, future attack, or to obtain information on a specific individual’s medical condition.
  • Attackers Seeking Personal Data: Attackers seeking personal data can use it in multiple ways. They can create and sell PII lists, they can blackmail individuals or organizations in exchange for the data, or they can use it as a basis for further fraud, like phishing, Smishing, or scam calls.
  • Attackers Taking Control of Medical Devices for Ransom: Attackers targeting vulnerable infrastructure won’t usually target healthcare databases, but will target medical IT equipment and infrastructure to spread malware that exploits specific vulnerabilities and demands a ransom to release the infected devices. Since medical devices tend to be updated infrequently (or not at all), this provides a relatively easy target for hackers to take control.

The report also offers a few general best practices for evaluating if a healthcare organization’s data is exposed and/or at risk:

  • Use Multi-Factor Authentication for Web Applications: If you’re using a system that only needs a username and password to login, you’re making it significantly easier to access. Make sure you have MFA setup to reduce unauthorized access.
  • Tighter Access Control to Resources: Limit the number of credentials to each party accessing the database. Additionally, limit specific parties’ access to only the information they need. This will minimize your chance of being exploited through a 3rd party, and if you are, will limit the damage of that breach.
  • Monitor for Big or Unusual Database Reads: These may be an indication that a hacker or unauthorized party is stealing information. It’s a good idea to setup limits on database reads and make sure requests for big database reads involve some sort of manual review or confirmation.
  • Limit Database Access to Specific IP Ranges: Mapping out the organizations that need access to your data is not an easy task. But it will give you tighter control on who’s accessing your data and enable you to track and identify anomalous activity. You can even tie specific credentials to specific IP ranges to further limit access and track strange behavior more closely.


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