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Information Security Expert Predicts that the “Enron of Data Breaches” is Coming

July 31, 2017
by Rajiv Leventhal
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Although there are steps that can be taken to improve healthcare cybersecurity, one consultant fears that the worst is yet to come
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Recent major cyber attacks on the healthcare community, such as Petya and WannaCry, have created unprecedented levels of fear on IT security professionals. In fact, a cybersecurity report from HIMSS last month noted that these two vulnerabilities in particular continue to affect various industries around the world, only adding to the growing concern. And while much of the focus has been how these attacks have impacted larger organizations in recent months, there hasn’t been a whole lot of discussion on how their small-practice brethren could be affected.

Indeed, small physician practices can fall victim to ransomware and many other types of cyber attacks, as they don’t often have the budget for proper protection to fend off hackers. But experts in the field do attest that there are some low-cost ways they can combat an attack without breaking the bank.

Helping smaller practices in this regard is Jorge Rey, director of information security and compliance at advisory firm Kaufman Rossin. Rey is primarily responsible for the firm’s compliance with federal and state cyber security and privacy information laws and regulations. Recently, Rey spoke with Healthcare Informatics about steps smaller physician practices can take to better protect their data in addition to broader cybersecurity trends he is seeing. Below are excerpts of that discussion.

What are the main things you are working on these days as it relates to healthcare cybersecurity?

We’re an accounting firm, and I work in the consulting division where I specialize on HIPAA [the Health Insurance Portability and Accountability Act] and HITECH [the Health Information Technology for Economic and Clinical Health] consulting. Under those areas, we focus on small and large practices, hospitals and business associates (BAs). We assist clients with their HIPAA compliance requirements, whether it is doing risk assessments, policy and procedures implementation, penetration testing, vulnerability assessments, or technical assessments, so we are helping them translate the requirements of the rules into actionable items that they can use in their operations while still complying. 


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How ready and prepared are most of your clients?

A lot of the organizations have at least something in place, so it’s not like they’re all starting from scratch. It is now about looking at what they have in place and figuring out how they can improve upon that. For example, everyone has a computer with some type of anti-virus, and by doing that you are at least accomplishing being effective with one of the requirements. Depending on how big the organization is might depend on how sophisticated its firewalls are, but everyone pretty much has some type of firewall. They are already backing up their data, too. But when you specialize into different departments, that’s where you start to identify the gaps. 

What’s most concerning for your clients today?

We do have small physician practices who are completely unaware of the requirements. In their minds HIPAA is still a privacy issue, so when you talk to them they think they are HIPAA-compliant because they have a form at the front of the medical office [for patients]. But what they don’t understand is that even after that form, you need to keep the information secure, too. A lot of physician practices are ignorant on the rules and requirements, and that creates concerns. So we spend time trying to educate the doctors or office administrators on the requirements and what they need to do, and that could become overwhelming for them.

As far as the bigger companies, they have more employees and an IT department, so educating the board and senior management about why you need to spend money is probably the biggest issue. So in both cases it is about education.

We are constantly reading about hackers, laptops being stolen, and ransomware, and all of these are huge issues, but not everyone deals with the same threats. It depends on their environment. A lot of people have a false sense of security—they think they are compliant because their laptop is encrypted, but they don’t have the BA agreements and don’t even know that they need them.   

Looking beyond HIPAA and other requirements, true defense is much more than that, right?

Compliance doesn’t necessarily mean security; you could be in compliance with the rules, but that doesn’t mean your information is completely secure. You can have the policies in place, everyone trained, and have all of the things that might pass an audit, but you can still be exposed.

One of the rules requirements is that you need to perform a risk analysis of your health information, be it electronic or paper. Sometimes, and perhaps often, you don’t do a good assessment of that risk analysis, so you fill out the forms and you move on. We often identify that the risk assessment [that was performed] did not truly identify the threat, so you did not truly look at the controls you had in place or should have had in place.

One of the biggest issues we’re seeing out there is phishing—it’s the way ransomware is getting downloaded and the way we are getting hacked. We still see that people don’t have phishing training at all. We know what the biggest threat we have as an industry is, but we are not educating the people who click those links. And then you go back to the board and tell them that they need to spend money on training, and they look at you and ask why they need to spend on that since everyone already knows not to click [bad links]. That’s where the biggest disconnect is.

When you talk about smaller practices, how can they combat attackers without the resources that larger organizations have?

There is no better way to understand the risks than training. The physicians really need to understand what the risks are, and sometimes you need a consultant to help identify that. There have been a few times when we have gone to a physician office and the practice has one server where it keeps all of the sensitive data, and that data is being backed up externally to a different drive. But that’s it.

We understand that they can’t spend thousands of dollars to have the server outside of the office somewhere, but how about we at least lock that server so it can’t be stolen? If we are backing up to another source, are we making sure that information is at least being encrypted? These questions can be asked by someone who has the right expertise and who can give them the [best] advice. So I think going that route, hiring someone who understands security to help them, is the best solution. I will often see physicians spending money on XYZ firewall because their IT guy recommended it, but most of the time you don’t need that—you need to encrypt your backups instead.

In the wake of WannaCry, what impact could a global cyber attack of this nature have on U.S. healthcare organizations?

One of the biggest issues we see in healthcare is that we have old legacy systems from a Windows perspective. We still see medical devices using Windows XP. WannaCry is exploiting old configurations of old servers with old Windows software.

You hear all the time that cybersecurity will get worse before it gets better in healthcare. Do you agree with this?

We have not seen the biggest attack yet, even though we have seen a few really big ones in the last year. I think eventually we will see the Enron of data breaches in which you will see a systemic catastrophic impact on not just an industry, but an entire nation. And at that moment a different approach to cybersecurity will develop. We see oversight right now with people getting fined, and it’s a whole legal battle with consultants and lawyers, but we have not seen something that has created a systemic issue across a nation.




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OCR Fines Providers for HIPAA Violations, Failure to Follow “Basic Security Requirements”

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) for a number of 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, OCR also fined a Colorado-based hospital, Pagosa Springs Medical Center, $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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