GUEST BLOG: Just Say No | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation


July 25, 2017
by Mac McMillan
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There are some very urgent steps that healthcare IT security leaders need to take, right now, in the face of constant malware threats, says Mac McMillan

Recently, I had the occasion to see firsthand the devastating effects of a serious malware attack that took a majority of a hospital’s systems offline, forcing them to use work arounds to maintain some semblance of operations. The impact before it’s over is likely to be incredibly costly for that organization. Days later we heard the announcement of another hospital taken down by ransomware. And then there was NotPetya which turned out to be a directed denial of service attack designed to destroy the systems and data it infected. There was no magic key to decipher or roll back its effects. All of this just reinforces the need to get more vigilant about our cybersecurity and to just say no to the things that keep us from being secure.

1.      Get your head in the game. We have thousands of malware attacks every day, crashing into our perimeters looking for the one mistake we have made, which is all the attackers need to get in. Just in the past few weeks, we saw several hospitals suffer massive ransomware attacks and a worldwide attack of new strain of WannaCry (Petya) that seeks not financial gain, but more sinisterly to destroy systems and data. Organizations hit by this new malware have woken up to the real dark side of hacking – attacks with the sole aim to destroy their systems and their data. Yet many will just say, wow glad that was not us, we dodged another one. The question is will you dodge the next? Will you instead ask IT if that had been us, how would we have fared? Don’t be afraid to say no to those who think cybersecurity is just an IT issue. It’s a leadership issue.

2.      Get fanatical about vulnerability management. And I mean all aspects; hardening, patching, configurations, change control, testing…all of it. There is nothing exciting about this work, no one will argue that, but it is critical and those who do not give it attention are destined for excitement…just not the type they bargained for. More than 90% of hacks take advantage of a vulnerability more than one year old. Meaning someone could have patched it, disabled it, closed it, etc. and did not. The attacker only has to get lucky once to find that mistake, whereas we have to get it right all of the time. Maintenance and administration are hugely important to defending the enterprise, we can no longer afford to neglect them. Don’t be afraid to say no to sacrificing maintenance and administration for up time.

3.      Get rid of old IT. Obsolete, unsupported software, browsers, operating systems are all magnets for malware. Many of the victims of WannaCry learned this firsthand as they watched the Windows XP systems still deployed in their environments succumb. Refresh schedules have to stay ahead of obsolescence in order to remove this threat. Where that is not possible, we need to employ other means of isolating these systems by separating them from or putting additional protections between them and the network or the Internet. Don’t be afraid to say no to unsafe usage of obsolete IT or to purchases of systems with obsolete software.

4.      Get the best defenses. Traditional security technologies have proven they alone are no match for the new attacks being thrown at the enterprise. All you have to do is just look at Mirai, WannaCry, and most recently NotPetya to realize this fact. You need to invest in next generation firewalls, advanced malware detection, email and web gateways, virtual honeypots, and other newer technologies. Investment is necessary. Security costs, but lack of security or no security costs significantly more. Just ask anyone who has been the victim of a serious malware attack. Don’t be afraid to say no to those that say we can do the job with what we have.


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5.      Get limited. We’ve known forever that the best way to protect something is to limit the number of people who have access to it. That is doubly true for access with elevated privileges. The overwhelming majority of the damaging attacks we’ve witnessed took advantage of weak access practices or exploited someone’s administrative level permissions. That happened because there are too many, they are weakly controlled, and they are not monitored or audited regularly. Employ two-factor authentication on all remote, web and administrative level access. Eliminate all elevated privileges through vaulting. If you can’t do that, then eliminate all administrative access possible and monitor what remains. Don’t be afraid to say no to access for convenience.

6.      Get buoyant. The reason a naval vessel can withstand battle is because the ship is compartmented. Each compartment can be sealed off to stop the impact of the damage to another. Networks employ a concept called segmentation that can achieve this same effect when attacked, but only if that segmentation is real. Simply deploying VLANs does not segment the network securely. We need to start deploying access controls on segments, use segmentation firewalls and better configuration of network devices managing traffic. With the right technologies, detecting events, and the right segmentation, we can stop, isolate and limit the impact of attacks to protect critical assets and information. Don’t be afraid to say no to just doing it the easy way.

7.      Get everything backed up. When we talk about backing things up, we often focus on the data alone, which is a huge mistake as many are learning. We also think of backups as having an electronic copy of information on a system. We need to redefine our definition of backup to include everything we need to reconstitute the enterprise, baseline images, configurations, current applications and the data. Secondly, we need to make sure that we have a copy that is air gapped from the rest of the enterprise so that when the unthinkable happens, we have what we need to rebuild. Many victims of malware attacks have had to rebuild from the bare metal, meaning reloading the basic operating system, reloading applications, reapplying configurations and reloading data.  Not having up to date information about any aspect of the current environment can grind that recovery process to slow pace. Don’t be afraid to say no to those who say we can’t take something offline long enough to back up.

8.      Actively monitor. The computing environment that we operate in today generates millions of log events per day, week, and month depending on the size of the organization involved, but regardless of where you fit it, it is not possible for your staff to monitor this activity manually. This is an area where organizations need to seek out a partner, a professional SOC capable of monitoring, alerting and providing early warning - often hours before an event will likely affect you. This is not something most healthcare organizations can do effectively even with tools. Don’t be afraid to say no to unrealistic expectations.

9.      Get organized. Fire drills have never particularly been anyone’s favorite activity, but well organized ones that end quickly or ones that worked in a real crisis were appreciated and made a difference. Responding to cyber incidents is no different. You need a process, you need people who know how to run it, you need the right equipment to support them, you need a communications plan, you need the right responders, you need to stop the event, isolate the intruder/infection, analyze/investigate the cause, eliminate the attacker, restore the enterprise and all the while continue to operate.  This will not happen by accident. Plan, train, exercise, perform, learn. Don’t be afraid to say no to those who say we don’t have time to practice.

Get confident. Create the cybersecurity strategy that gives the organization the confidence to handle whatever comes without impacting the mission. Knowing that you have a better than average chance of seeing events before they can do real damage, you can respond to mitigate the attack,  forcing the attacker to work for whatever they get, and in the worst-case, you can reconstitute quickly and efficiently provide real confidence in your computing environments. It also provides the confidence to just say no to ransom demands. Paying a ransom only guarantees a positive outcome for the attacker, which just further incentivizes them to go after others. Spend that money elsewhere like better defenses, better warning, better responding or better recovery.

Mac McMillan is president and CEO of the Austin, Texas-based CynergisTek consulting firm.

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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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