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The Right Way to Present a Business Case for Cybersecurity

August 19, 2016
by Bob Chaput, CEO, Clearwater Compliance
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There’s an ever-increasing number of threats to healthcare information.  Healthcare information is more valuable and visible than ever; and, at the same time, more vulnerable than ever.  You feel responsible and, as the CISO, you are responsible for its security.  Conducting a comprehensive, bona fide risk assessment can be an effective first step in building credibility with the executive team and board and, therefore, in building a business case for cybersecurity investments in your organizations.  In addition to conducting the risk assessment, you should:

  • Find a sponsor on the executive team to use as a sounding board on risk appetite, sufficiency and understandability of supporting information and recommendations on mitigating risks.
  • Build a cross-functional team to help identify and respond to threats and vulnerabilities to include representatives from any function that has access to protected health information (PHI) or is involved in procedures for providing or terminating access to PHI.
  • Change the technology language you and your team use from “compliance and information security” to “patient safety and quality of care” – these words will resonate more with CEOs and other functional leaders you’ll want on your side.   

In order to get the funds needed to shore up an information security program, CISOs need to develop a comprehensive and compelling business case for doing so. Consider the following steps:

  1. Conduct a comprehensive, bona fide risk analysis of all assets that create, receive, maintain or transmit ePHI.

Examine all the threats and vulnerabilities to those assets and underlying media, assess the ability of the controls in place to minimize exploitation. Identify the media where the PHI “lives,” for example, laptops, desktops, servers, back-up tapes, flash drives.  Detail the threats to that media, for example, environmental threats like hurricanes; structural threats like power outages; accidental threats like errant of misdirected emails; and intentional threats like ransomware attacks.  Bona fide, comprehensive risk analysis considers numerous “asset-threat-vulnerability” combinations.

  1. Rate each risk in terms of the likelihood of a compromise of the confidentiality, integrity or availability of the information.

By using a scale from 1 to 5 (5 being the highest likelihood), you can begin the risk-ranking process.  There are a number of data sources that you might use to assess the likelihood of a compromise:

  • Threats and Threat Sources
    • Data from the Health and Human Services (HHS) website listing all reported breaches of 500 or more records. Examine what threats have exploited what vulnerabilities that may exist in your own environment.  As of June 23, 2016, 20 percent of the breaches of 500 records or more reported on the HHS website this year are attributed to hospitals, clinics and health systems.  Thirty-seven percent of those breaches were due to hacking or IT incidents: email (6), network server (1), and desktop computers (3). 
    • Information from other best practice websites and sources regarding emerging threats and vulnerabilities.
    • Security or privacy incidents that have been reported in your own organization may identify threats that have not yet been addressed.
  • Vulnerabilities—among many potential weaknesses in controls, consider
    • Insufficiently documented and enforced policies and procedures
    • Lack of practices regarding system back-up, workforce access, updating patching
    • Undocumented of untested disaster recovery and business interruption plans
    • Limited and ineffective workforce training and security awareness programs
  • Controls
    • Typically categorized as administrative, physical and technical, control sets can be found in sources such as:
      • NIST 800-53
      • ISO 27001
      • CCS CSC
  1. Rate each risk in terms of the impact of a compromise of the confidentiality, integrity or availability of the information.  Think of impact in terms of loss or harm.

There are basically two ways you can calculate by impact of a breach: 


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  • Using the annually-updated average cost of a data breach conducted by the Ponemon Institute and sponsored by various companies.  In 2016, the study was sponsored by IBM and the average cost of a data breach was determined to be $158 per record.  So the impact for a breach would be calculated on the number of records that would be involved in the compromise of each asset.  Just to put it in perspective, for the first five months of 2016, the number of breached records per hospital or health system due to hacking or IT incidents on the HHS website totaled 9,572, making the average cost due to hacking or IT incident for each breached organizations $1.5 million.  The only problem with this approach is that the calculation does not include all costs that would be incurred because of the difficulty in doing so, such as reputational repercussions, business disruption, or the loss and replacement of an executive leader or other key workforce members. 
  • Calculating the cost of a breach specifically for your organization.  The elements of that exercise are outlined in a free report from the American National Standards Institute (“ANSI”) entitled The Financial Impact of Breached Protected Health Information – A Business Case for Enhanced PHI Security.  This thoughtful calculation will be more persuasive as it will be specific to your organization.

Since no studies have been done on the cost of recovering from ransomware, the bottoms-up calculation could be prepared by considering these factors (details of which may be found in the ANSI report mentioned above):

  • Payment of the ransom: this may be the smallest expense to be dealt with, although ransom demands are expected to increase significantly.
  • Forensics: this cost can vary depending on the number and types of systems involved and the complexity of the recovery of evidence.  IT forensics has provided a range of $100 to $600/hour depending on the services being provided.  “Examination and reporting can be completed in less than 20 hours and the total analysis usually totals less than $8,000 for a single hard drive.”
  • Mitigation: 72 percent of organizations infected with ransomware required a minimum of two days to restore access to their data and a third required five days or more, according to a study by Intermedia.  The time and cost associated with recovery: containing the infected systems, wiping them complete and then restoring them must be included in the impact calculation.  Recovery is measured in terms of how much data can an organization afford to lose (i.e. 1 hour or 24 hours) and how long can an organization operate without an asset or group of assets being available before it impacts the bottom line (i.e. 1 hour or 24 hours.)
  • Remediation: updated and tested disaster recovery and business interruption plans, back-up procedures, workforce training, business disruption, replacement of leaders held accountable, public relations costs and lost business due to reputational damage.
  • Fines and Penalties:  Office for Civil Rights (OCR) fines and identity theft services, and possibly lawsuits, following ransomware attacks that include the transfer of information out of the organization’s environment to a command server elsewhere.
  1. Compare your risk-ranking of your risks to your organization’s risk appetite

Translate your impact calculations for each risk into the scale from 1 to 5 (with 5 being the highest impact).  Multiply the likelihood ranking and the impact ranking to produce a risk-ranking of your risks from 1 to 25.  Test the waters on your organization’s risk appetite by developing remediation plans for any risks with a score higher than 14, which would include calculation results from a 3*5 or a 4*4. 

  1. Develop and recommend thoughtful remediation plans

Information risk management and thoughtful remediation planning involves risk-rank ordering all the organization’s identified risks, prioritizing this list from the most significant to least significant risks and using the organization’s risk appetite to draw an initial “line in the sand” to identify which risks will be accepted.  Then the organization must make decisions about avoiding, mitigating and/or transferring those risks that exceed an organization’s risk appetite. 

Only by submitting a compelling business case for doing so can CISOs increase their chances for greater investments in information security.

Bob Chaput is widely recognized for his extensive and in-depth knowledge of healthcare compliance and cyber risk management. Chaput is CEO of Clearwater Compliance and has supported hundreds of hospitals and health systems to successfully manage healthcare’s evolving cybersecurity threats and ensure patient safety.


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Targeting Third Party Risk: Leading CISOs Detail Efforts to Secure the Healthcare Supply Chain

December 18, 2018
by Heather Landi, Associate Editor
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Healthcare information security leaders are faced with the dauting challenge of securing information systems and data at a time when the cyber threat landscape is evolving rapidly and becomingly increasingly complex.

Most patient care organizations’ supply chains are filled with third parties who support the care delivery process and require access to patient information. Properly vetting and monitoring these third parties is a major challenge, and in some cases, insurmountable for many organizations who simply don’t have the expertise or resources, according to healthcare IT security leaders.

Many healthcare chief information security officers (CISOs) have found that effectively assessing the security posture up and down the supply chain is expensive given the complexity of the risks posed by privacy and security concerns, as well as an everchanging regulatory landscape. Currently, the process of managing third-party risk is often inefficient and time-consuming, for both vendors and providers, while still leaving organizations vulnerable to security threats.

During a recent webinar, sponsored by HITRUST, focused on healthcare cybersecurity and managing third party risk, John Houston, vice president, privacy and information security at the 40-hospital UPMC health system in Pittsburgh, outlined a number of factors that have made third-party risk management increasingly challenging and complex.

“There has been a fundamental change in IT, and a rapid move to the cloud. At the same time, we all see an increasingly complex cyber threat landscape where the threats are more sophisticated, and the technology solutions are more sophisticated as our business requirements are changing. It’s an increasingly complex landscape,” Houston said.


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He further noted, “As a result, there is a lot of confusion about how we best ensure our information is secure and available, and what is reasonable in terms of trying to achieve that. And finally, we are all worried about risk, and the biggest risk is patient safety. We worry about the cost of litigation and penalties, but first and foremost, we need to think about ensuring that we are able to deliver the best care to our patients.”

The stakes are changing, Houston noted, as federal regulators are investigating and penalizing organizations for failure to monitor third parties’ security practices, and hackers are increasingly targeting medical devices, he said.

“From a CISO perspective, we need to ensure that we are applying proper oversight over all of this. We can’t assume third parties are doing the right thing,” he said.

What’s more, healthcare organizations are increasingly reliant on cloud technology. A year ago, Nuance Communications, a provider of voice and language tools, was knocked offline when the company was hit with the Petya ransomware virus.

“I was around during Y2K, and about 95 percent of all our applications at UPMC, we ran within the data center, on premise. About 95 percent of newly acquired applications were run on on-premise, there was little on the cloud. In that environment, it falls upon the entity to secure data within its possession,” he said.

Contrast that with today’s environment, as Houston noted that “very little of what we acquire today runs on-premise. In some way, shape or form, at least one copy of the data is in the cloud.”

Studies have estimated that by 2023 no more than 25 percent of applications will be run on-premise in an organization’s data center, with about 75 percent run in the cloud, Houston said. “Many copies of our data end up in the cloud, and it’s not just one cloud provider. We get services from a lot of different vendors, all of which are in the cloud. That speaks to the fact we, as CISOs, can no longer directly secure our own information. We are dependent upon third parties to secure our data for us. We can’t simply trust that they are going to adequately secure that information.”

From a healthcare CISO’s perspective, a vendor’s IT and data security practices should be at least as effective as the provider’s security posture, Houston said. “I should expect nothing less. As soon as I expect less, that’s a sign of defeat.”

Across the healthcare industry, ineffective security, compliance and assurance methods drive cost and confusion within organizations and across third parties, according to IT leaders.

While most healthcare organizations are taking the right steps to monitor and screen vendors and their products and services during the pre-selection and on-boarding phases and are also conducting security risk assessments, it’s still not enough to protect IT systems, data, and, most importantly, patients, said Taylor Lehmann, CISO at Wellforce, the Burlington, Mass.-based health system that includes Tufts Medical Center and Floating Hospital for Children. “We are still seeing breaches, and the breaches are still coming after we do all this screening,” he said.

“We’re not being effective and it’s difficult to be effective with the current paradigm,” Houston added.

From the CISO’s perspective, there are inefficiencies in the third-party supply chain ecosystem. Suppliers are commonly required by their customers to respond to unique questionnaires or other assessment requests relating to their risk management posture. Vendors often must fill out questionnaires with 300-plus questions. What’s more, there’s no assurance or audit of the information the vendor provides, and the process is completely inefficient for suppliers who are audited 100 times annually on the same topics, but just different questions, Lehmann and Houston noted. What's more, the security assessment often occurs too late in the process.

“We’re creating a lot of waste; we’re taking time away from our organizations and we’re taking time away from suppliers,” Lehmann said. “The current way we’re doing supply chain risk management, it doesn’t work, and it doesn’t scale, and there is an opportunity to improve.”

To address these issues, a group of CISOs from a number of healthcare organizations established the Provider Third Party Risk Management (TPRM) Initiative to develop a standardized method to assess the risk management posture of third-party suppliers to healthcare firms. Launched this past August, the founding member organizations for the Provider TPRM Council include Allegheny Health Network, Cleveland Clinic, University of Rochester Medical Center, UPMC, Vanderbilt University Medical Center and Wellforce/Tufts University. Working with HITRUST and PwC, the Council aims to bring uniformity and consistency to the process while also reducing the burden on providers and third parties.

The healthcare industry, as a whole, will benefit from a common set of information security requirements with a standardized assessment and reporting process, Lehmann noted.

In the past four months, the governing members have been expanded to include Nuance, The Mayo Clinic, Multicare, Indiana University Health, Children’s Health Dallas, Phoenix Children’s Hospital, and Banner Health.

The Provider TPRM initiative is increasing membership and gaining momentum as security leaders from both healthcare providers and their suppliers embrace the unified approach, Lehmann said.

One of the goals for the Council is to address the inefficiencies found in the third-party supply chain ecosystem. By reducing the multiple audits and questionnaires, the financial savings will allow business partners to invest in substantive risk reduction efforts and not redundant assessments, the Council leaders say.

“By reducing wasted effort and duplication, suppliers will find their products and services will be acquired more quickly by healthcare providers. This will also reduce the complexity of contracts and provide third parties with better visibility regarding the requirements to do business with providers,” said Omar Khawaja, VP and CISO of Allegheny Health Network and Highmark Health. Khawaja’s organization is a founding participant and governing member of the Provider TPRM initiative.

As part of this initiative, going forward, provider organizations that join the effort will require third-party vendors to become HITRUST CSF Certified within the next two years, by September 2020. The HITRUST CSF Certification will serve as the standard for third parties providing services where they require access to patient or sensitive information and be accepted by all the Council’s organizations. HITRUST CSF is an industry privacy and security framework that is continuously evolving with the changing cyber landscape.

 “After September 1, 2020, third parties without certification cannot do business with participants,” Khawaja said.

Houston added, “We recognize that there are limitations in our current processes, and what we’re putting in place is at least as good or better than what we’re already doing. This will lead to faster onboarding, less waste, better transparency, and simpler compliance.”

By choosing to adopt a single comprehensive assessment and certification program, healthcare organizations represented by the council are prioritizing the safety, care, and privacy of their patients by providing clarity and adopting best practices that their vendors can also adopt, while providing vendors the expectation of what it takes to do business with their organizations.

“It provides transparency,” Houston said “It sends a message to suppliers that we’re an open book about what it takes to do business. That’s powerful.”

Moving forward, the Provider TPRM initiative will focus on adding business associates to the effort to increase membership and impact, Lehmann said. “The simple fact is, many of us are pushing this through our supply chain and there are organizations that may not have a process or low maturity process. But, through the efforts of council members, more suppliers will show up, which is means safer products are possible to purchase.”

Further, the program will likely develop additional requirements on vendors such as breach response and monitoring security threats and alerts observed as third-party vendors.

The Council also plans to focus on certification programs for smaller vendors. “A lot of innovation in healthcare is coming from smaller companies, and we understand there is a gap between what those companies can do with respect to cyber. We’re not lowering our standards, but we want to be thoughtful and create a certification program for those areas. We want to do business and we need a vehicle to bring them in in a safe and secure way,” Lehmann said.

“We want to build a community of health providers working together, business associates working together, to share information,” Lehmann said. “We want to better inform ourselves and align other programs, like cyber insurance, to enable more effective planning throughout the supply chain. The things we learn through these relationships can translate to other aspects of our organizations.”

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Florida Provider Pays $500K to Settle Potential HIPAA Violations

December 12, 2018
by Heather Landi, Associate Editor
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Florida-based Advanced Care Hospitalists PL (ACH) has agreed to pay $500,000 to the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) to settle potential HIPAA compliance failures, including sharing protected health information with an unknown vendor without a business associate agreement.

ACH provides contracted internal medicine physicians to hospitals and nursing homes in west central Florida. ACH provided services to more than 20,000 patients annually and employed between 39 and 46 individuals during the relevant timeframe, according to OCR officials.

Between November 2011 and June 2012, ACH engaged the services of an individual that claimed to be a representative of a company named Doctor’s First Choice Billings, Inc. (First Choice). The individual provided medical billing services to ACH using First Choice’s name and website, but allegedly without the knowledge or permission of First Choice’s owner, according to OCR officials in a press release published last week.

A local hospital contacted ACH on February 11, 2014 and notified the organization that patient information was viewable on the First Choice website, including names, dates of birth and social security numbers. In response, ACH was able to identify at least 400 affected individuals and asked First Choice to remove the protected health information from its website. ACH filed a breach notification report with OCR on April 11, 2014, stating that 400 individuals were affected; however, after further investigation, ACH filed a supplemental breach report stating that an additional 8,855 patients could have been affected.

According to OCR’s investigation, ACH never entered into a business associate agreement with the individual providing medical billing services to ACH, as required by the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, and failed to adopt any policy requiring business associate agreements until April 2014. 

“Although ACH had been in operation since 2005, it had not conducted a risk analysis or implemented security measures or any other written HIPAA policies or procedures before 2014. The HIPAA Rules require entities to perform an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of an entity’s electronic protected health information,” OCR officials stated in a press release.

In a statement, OCR Director Roger Severino said, “This case is especially troubling because the practice allowed the names and social security numbers of thousands of its patients to be exposed on the internet after it failed to follow basic security requirements under HIPAA.”

In addition to the monetary settlement, ACH will undertake a robust corrective action plan that includes the adoption of business associate agreements, a complete enterprise-wide risk analysis, and comprehensive policies and procedures to comply with the HIPAA Rules. 

In a separate case announced this week, a Colorado-based hospital, Pagosa Springs Medical Center, will pay OCR $111,400 to settle potential HIPAA violations after the hospital failed to terminate a former employee’s access to electronic protected health information (PHI).

Pagosa Springs Medical Center (PSMC) is a critical access hospital, that at the time of OCR’s investigation, provided more than 17,000 hospital and clinic visits annually and employs more than 175 individuals.

The settlement resolves a complaint alleging that a former PSMC employee continued to have remote access to PSMC’s web-based scheduling calendar, which contained patients’ electronic protected health information (ePHI), after separation of employment, according to OCR.

OCR’s investigation revealed that PSMC impermissibly disclosed the ePHI of 557 individuals to its former employee and to the web-based scheduling calendar vendor without a HIPAA required business associate agreement in place. 

The hospital also agreed to adopt a substantial corrective action plan as part of the settlement, and, as part of that plan, PSMC has agreed to update its security management and business associate agreement, policies and procedures, and train its workforce members regarding the same.

“It’s common sense that former employees should immediately lose access to protected patient information upon their separation from employment,” Severino said in a statement. “This case underscores the need for covered entities to always be aware of who has access to their ePHI and who doesn’t.”

Covered entities that do not have or follow procedures to terminate information access privileges upon employee separation risk a HIPAA enforcement action. Covered entities must also evaluate relationships with vendors to ensure that business associate agreements are in place with all business associates before disclosing protected health information. 


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Eye Center in California Switches EHR Vendor Following Ransomware Incident

December 11, 2018
by Rajiv Leventhal, Managing Editor
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Redwood Eye Center, an ophthalmology practice in Vallejo, Calif., has notified more than 16,000 patients that its EHR (electronic health record) hosting vendor experienced a ransomware attack in September.

In the notification to the impacted patients, the center’s officials explained that the third-party vendor that hosts and stores Redwood’s electronic patient records, Illinois-based IT Lighthouse, experienced a data security incident which affected records pertaining to Redwood patients. Officials also said that IT Lighthouse hired a computer forensics company to help them after the ransomware attack, and Redwood worked with the vendor to restore access to our patient information.

Redwood’s investigation determined that the incident may have involved patient information, including patient names, addresses, dates of birth, health insurance information, and medical treatment information.

Notably, Redwood will be changing its EMR hosting vendor, according to its officials. Per the notice, “Redwood has taken affirmative steps to prevent a similar situation from arising in the future. These steps include changing medical records hosting vendors and enhancing the security of patient information.”

Ransomware attacks in the healthcare sector continue to be a problem, but at the same time, they have diminished substantially compared to the same time period last year, as cyber attackers move on to more profitable activities, such as cryptojacking, according to a recent report from cybersecurity firm Cryptonite.

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