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At the New York HIT Summit, Diving into Uncharted Cybersecurity Waters

September 27, 2016
by Rajiv Leventhal
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Expert panelists discuss new data protection trends and strategies as threats continue to ramp up
Leading cybersecurity experts in the New York area collectively met at the local HIT Summit on Sept. 27, sponsored by Healthcare Informatics, to discuss how the healthcare cybersecurity landscape has changed, and how hospitals and health systems could better protect their data as threats get more sophisticated. 
The panel discussion, held at the Convene in New York City's downtown financial district, included several cybersecurity experts: Vikrant Arora, assistant vice president, and chief information security and risk officer at NYC Health + Hospitals; Todd Regow, senior vice president and CIO at Healthix, Inc., a New York City-based health information exchange (HIE); Matt Webster, CISO at Healthix; and Keith Richard Weiner, R.N., information systems security officer at New York-Presbyterian/Queens and adjunct professor at Molloy College. The panel discussion was moderated by Healthcare Informatics Editor-in-Chief Mark Hagland. 
Hagland kicked off the conversation by noting how the healthcare security landscape has changed, even from just six months ago. The panelists were asked what the biggest threats are and how prepared the industry is in addressing them, to which Healthix's Webster responded, "There are over a million pieces of malware out there" on a regular basis, specifically referring to "customized malware," which is becoming quite common as attackers target a particular organization for their next victim. He said that in healthcare, the threats have increased since medical records bring back a greater return on the black market than credit cards do.
NYC Health + Hospitals' Arora agreed that the healthcare industry is a unique one for cybersecurity in that when a Target or Home Depot store gets breached, customers can shop elsewhere if they so choose. But in healthcare, when Anthem got breached for example, its customers were not able to simply walk away and choose another insurer due to regulations in place. "You cannot change your medical identity, the drugs you are taking, or your medical condition," Arora said. You're at risk as long as you're alive. That makes healthcare very unique." And, Healthix's Regow added that $362 per medical record is now a going rate on the black market. "It's an arms race and I don't know if we will win that since these people have more time, energy and resources than those who are trying to protect the data," Regow said. 
Indeed, only two years ago as Hagland noted, most threats were on an individual level, but now there is organized hacking  and millions of pieces of malware, including ransomware. "What's interesting is that the bad guys are running fast and we're trying to catch up. Awareness is spiking as breached organizations get reported in the media," Hagland said, specially referring to the major breach at MedStar Health earlier this year, in which a large integrated health system had to switch from electronic records to paper for some time, having a direct impact on patient care. 
"We are running out of Americans who have yet to have their data stolen," said New York-Presbyterian's Weiner. "You might get identity theft protection for two years, but it doesn't get erased after that. He added that signature-based anti-malware  is "something to get used to." He continued, "In terms of a whole network shutting down, you don't want to go back to pen and paper. When you look at the Hollywood Presbyterian [breach], I met their CIO and the first thing that popped into my mind was, why not go to backup? But the backup system was affected too, as was the anti-virus [software]. You can have the best plans in place, but even those get hit," Weiner said. 
Smarter Approaches
The panelists agreed that behavioral monitoring strategies, in which organizations monitor their users at a high level, are critical. There are different ways to approach behavior, Webster said. Roughly 25 percent of breaches occur through phishing, but for advanced attackers like nation states, that number could be much higher, in the 60 to 90 percent range, he said. "So make sure you pay attention to people's behavior, but also to machine behavior," he said, noting that there are applications on the market that can help an organization monitor behaviors." Webster also mentioned security operation centers (SOC), advanced monitoring systems that generate security reports across by looking at business activity, network traffic, and actionable events. But Webster noted that SOCs "might not pick up certain logs or sources that are in encrypted tunnels," he said," adding that an SOC is only one part of the process since data can travel outside of the center. 
Weiner, meanwhile, recommended that healthcare IT leaders engage in network segmentation, in order to protect key segments of organizations' electronic health records (EHRs). "He also advised to avoid "having all your eggs in one basket or the keys to the kingdom in one place." If malware gets in to one system, there needs to be preventions in place so it doesn't jump to other systems, he said.
Hagland added that rethinking credentials is also important. "It's tended to be loose relative to what it needs to be now going forward. And that involves a culture change, too. You have to explain to people that yes, we are clamping down, and not everyone will have same the level of authorization anymore," he said. And, Arora strongly advised committing to a framework, be it NIST [National Institute of Standards and Technology], ISO [International Organization for Standardization], or any framework that "allows your approach to be holistic." He said, "When you present a framework to your stakeholders, it shows that you are doing your due diligence even if your board doesn't fully understand cybersecurity." Hagland added, "It took years for hospital boards to understand the value of IT and data; now you need to get them to understand the value of protecting the data." 
Arora also posed a question to attendees on if security really adds value when clinicians are trying to deliver care. About half of the audience raised their hands in the affirmative, but that also meant that half considered security "fairly useless" when it comes to improving patient care," as Arora said. "I deal with doctors all the time who think [that security does nothing for care delivery]." As such, Arora said the problem is not primarily a technical one. "Malware has become advanced, but most of the time you will get hit with something basic. Yes, they have the capability for customized malware if they really are interested in you, but that's not [the norm]," he said. "We need to articulate what the actual risk is from a cybersecurity incident. There is nothing exceptional about ransomware; it encrypts your files. Why would you not have a backup? These are basic things. You need leadership from the board and you have to get through to the people who are using the technology and get them to understand the true risk," he said. 
For strategies specific to each organization represented on the panel, Weiner emphasized the need to balance convenience with security. He gave an anecdote in which he once had to give a username and password that was long, random, and complex, and if he presented it wrongly he had to send the company a fax, and wait three days for a response. Indeed, "You need to make compliance easy enough," he said. "One thing I assign my organization to do is to enter two-factor authentication for email, the VPN [virtual private network] and for accessing the EHR from the outside." He went on to add that an 80-year-old-woman, a demographic that might struggle with added technology requirements, even said the two-factor process was an easy and simple step.
Webster noted the importance of "covering the basics," so making sure to disable the account of an employee who leaves the organization. Reviews are important too, from a security or IT standpoint, he said. "Make sure you check the account when someone leaves, and check with human resources. Don't have accounts just left out there. If you don't [review], they might have access to the data center for another three to four years. That's scary," Webster said. 
At  NYC Health + Hospitals, Arora discussed the replacing of a legacy EHR with a new one across 26 hospitals. "We see 1.5 million patients every year and have been in business for 100 years. So we were worried about data being moved form one system to another and one person to another," he said. Arora explained the organization's data loss prevention technology that it implemented, which shows when data gets moved from a computer to a smartphone, for example, or whenever sensitive data flows within the system. 
The Evolving CISO Role
With multiple CISOs on the panel, Hagland asked them about the biggest challenges involved in this growing role in healthcare. Most of the security experts agreed that there is no silver bullet for the CISO reporting structure, as factors can vary, from what type of organization it is to how mature it is to what kind of budget there is to what the risks are. 
Arora said he is reporting to the CIO, which means he can influence things as a team member rather than as an outsider. Weiner, meanwhile, is seen as somewhat of an independent at New York-Presbyterian, and reports to everyone from the vice president of IT to legal to clinical to leadership, and to the board. "It's important to be multidisciplinary and collaborative. Security touches so many different points so it's important to be connected," he said. 
Hagland concluded by noting that physician consolidation will only continue to increase in the future of healthcare. "You have one and two-doctor practices without a CISO," he said. "What small physician office manager can do network segmentation? That just won't happen. And the same could be the case for small hospitals, too: many small hospitals will end up choosing to be absorbed by integrated health systems, with one factor being the burden of developing comprehensive IT security strategies and executing them."

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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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