In San Diego, a Rigorous Look at What’s Being Learned from the WannaCry and NotPETYA Attacks | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

In San Diego, a Rigorous Look at What’s Being Learned from the WannaCry and NotPETYA Attacks

February 4, 2018
by Mark Hagland
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At the Health IT Summit in San Diego, healthcare IT security leaders parsed some of the dramatic cyberattacks of the past year, and what’s been learned from them

On Friday, February 2, day 2 of the Health IT Summit in San Diego, sponsored by Healthcare Informatics, the event focused fully on cybersecurity issues, with a several presentations and panel discussions touching on important issues.

On Friday morning, Sri Bharadwaj, director, information services, and CISO, at UC Irvine Health (Irvine, Calif.), led a panel entitled “Ransomware Risks: What We Learned From NotPETYA and WannaCry.” Bharadwaj was joined by Stan Banash, CISO of Children’s Hospital of Orange County (Orange, Calif.); Chris Convey, vice president, IT risk management CISO, Sharp Healthcare (San Diego); Jason Johnson, information security officer, Marin General Hospital (Greenbrae, Calif.); and Christian Abou Jaoude, director of enterprise architecture and Scripps Health (San Diego). As has been widely noted, the May 2017 cybersecurity attack dubbed “WannaCry” grabbed storylines internationally and across the healthcare landscape as tens of thousands of hospitals, organizations, and agencies across 153 countries had their data held hostage, while the June PETYA/NotPETYA attack unleashed further damage worldwide.


panelists (l. to r.): Bharadwaj, Banash, Convey, Abou Jaoude, and Johnson

“I was actually at a Healthcare Informatics conference” when the global WannaCry attack hit last May, Bharadwaj noted, referring to the Health IT Conference in Chicago. “I was speaking on a panel that morning, in Chicago, and this thing hit us. I got a frantic call, and I was on the phone call. For the first ten minutes, I said, OK, I’ll try to figure that out. That became six hours. I almost missed my flight home that day. It was one call after the other, providing updates, communication, etc. But we did not shut down the Internet, our Outlook, or any feedback back to the end users. We got the most hit from our medical devices. It was fairly easy to patch stuff and get stuff done, but we realized that our realm of exposure encompassed all sorts of things—who the heck knew that the parking system was running on a Windows 98G? Who knew that the cafeteria system was running an old version of Windows so old that we had to figure out what it was? So how can we learn from this?” he asked his fellow panelists.

“The key questions,” Banash said, “are, are you managing your risk? Do you understand your attack surfaces? What vectors are you vulnerable to? When this started out, no one knew what was going on; it was crazy. If you had one of those maps in your security center, it was all lit up, and it looked like ‘War Games.’ Initially, we thought it was via email, and we were chasing emails, but when we found out it was SMB vulnerability, we were able to chase that down. We were hit, but there was no successful attack on us. But understanding what was in your environment—it never became more important than on that day. And those MRI machines running on Windows XP—those machines are million-dollar pieces of equipment; it’s hard to justify new purchases to the board. I would say we were lucky; I’d like to say we manage things well, but we did get lucky.”

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Asked about connections with law enforcement, Abou Jaoude said, “We do have a direct contact with law enforcement; we also have a protocol that we follow that’s been well-established. We followed those procedures, but the same thing happened to us: there wasn’t much information available during the first couple of days” following the WannaCry attack. “So I went out and read as much as I could about it, read articles to see whether there was something different about this. So we enacted that process, sent out notifications, and then a few days later, everyone learned what had happened.”

“I think we got lucky,” Sharp’s Convey said, “because this started in other parts of the world. Here in the US, we got lucky. I was at Millennium Healthcare then. SMB [Server Message Block] was blocked, that was the first thing. And then, how are our backups protected? And then patching. And it turns out, the basic security hygiene was needed. Look at what happened at NHS. And to be honest, we hadn’t patched as well as we could have. It’s hard to do, especially in the healthcare space, because you’ve got to test, and you don’t want to bring down patient care.”

“Let’s talk about communication; that’s one thing we’re always told we’re not good at in healthcare,” Bharadwaj said. “So, with regard to the oral process of communication, how did you talk to your c-suite?”

“As soon as we knew what was going on,” Banash said, “I reported to our CIO. But the first thing we needed to do was to kick off our incident response plan; and the easiest way to do that is to notify your management team. And, as you said, communication’s tough, we’re not always the best communicators. And in situations like that, you have to find a balance between over-communicating and under-communicating. You don’t want to be that CISO who’s freaking people out. As a CISO, if the only time you’re communicating with your c-suite is when something’s gone wrong, that’s not a good thing.”

“And in some respects, we won’t know what to communicate, because we don’t know what’s going on,” Bharadwaj noted.

“We went through that same struggle with Meltdown and Specter, which is that we didn’t really know what’s going on; no one did,” Marin General Hospital’s Johnson said. “So the main thing is communication. And when something like this is blasted out on CNN, everyone freaks out. I was getting calls from all sorts of people, nurse leaders, etc. I had to say, ‘Breathe, breathe.’ And I report to the CTO. And the c-suite told my CIO and CTO, you can do everything you need to do—if you need to shut things down, just do it. And so having that trust and confidence from the c-suite, was great. Because so often, we’re the redheaded stepchildren.”

Taking care of staff members’ home computing, too

“Here’s one thing we did that was different: we emailed everyone in the organization, and asked them to go check their computers at home,” Bharadwaj reported. “Many assumed we were going to take care of their desktops at work; but many had information stored in their home computers, which could get hit. So I told them, guys, go home, get your updates in, and make sure your home computers are protected. We will protect the computers in the hospital. So it’s important to communicate with your staffs. So a lot of people took time off in the afternoon, went home, and took precautions. We talked to the CEO about this, and said, look, I need to protect the organization, yes, but I also need to protect our employees. That was something we did that was a little bit different. We felt we needed to do that.”

“I’ll add to that: the lines are blurring between what we do at work and at home,” Banash said. “I have one mobile device that I use for work and personally. The lines are blurring. Things are blurring now: whether it’s remoting in; or whether your mom sends you an email at work, or you think it’s your mom, anyway.

“And we give them practical tips where they can print them out, take them home, etc.,” Johnson added. “We sent out a tip that said something like, here’s a secure storage place for your passwords, here’s how you should secure your home devices. We communicate with them regularly on those topics.”

“And we need to elevate this to a national level as well,” Bharadwaj said. “NH-ISAC announcements share information. I get pounded with information daily; I have to filter that and provide information to people. And after WannaCry, we got Petya/NotPetya.”

“We kind of treated the situation the same,” Scripps’ Abou Jaoude said. “And we had instituted an ongoing patching cycle—we have 3,000-4,000 servers, and we have a very rigid process that we follow, to patch things at least quarterly. The second thing has to do with our process of response in the wake of these incidents: we have a scripted, blueprinted process in place; meetings need to be called, reporting has to take place, on the IS side, the reporting side, etc. Chris mentioned about blurring the lines, but also, as we push applications into the cloud, into hosted environments, to same extent, you lose the possibility of having full control.”

“You bring up a very good point,” Bharadwaj said. “I was talking to another CISO, who expressed strong opposition to migrating to the cloud. And I said, look, we cannot sit back and become dinosaurs. But we’re still behind on things. And as we are hit with more attacks—and it’s nearly a year and a half since these big attacks—people are now getting paranoid—I’m seeing that happen. And I had a c-suite person send me an email saying, I got this email, but I’ not sure whether it’s really Bank of America or not. But that’s inevitable.”

Further, Bharadwaj said, “Meanwhile, switching gears from WannaCry and Petya, there are other things we can do. We advocate on network segmentation, to make sure we’ve done things right. We hope we’ve done network segmentation on the device side; but it takes a lot of time and effort. Can we talk about network segmentation?”

“When I think about segmentation, it’s data sensitivity, it’s locality, it’s location,” Convey said. “There’s an art and a science to it. Groups of IoT elements should probably be segmented off; medical devices should probably be segmented off. We’re looking at micro-segmentation. [In the manual network segmentation world], “[Y]ou have to go out and configure every switch and router, but now you can use logical networking, and software-based networking, and that’s where the industry’s going,” he went on. “And micro-segmentation is where things need to go. Because patching medical devices is a constant headache. So the logical choice is network segmentation and micro-segmentation.”

“We definitely had some struggles around segmentation,” Abou Jaoude said. “The question is, how can we break out the application from the use, from the site? We deployed firewalls in all our major sites, to make sure any outbreak would be contained and localized. And we tried to make sure that interdependencies in the apps traversed a very specific path. The biggest change and problem is when you present applications within the data center itself. A data center person might be working within Citrix and think an application is local to them when it’s not. So it’s not been easy.”

Unifying disaster recovery and business continuity strategy

When one audience member asked about how the panelists viewed the disaster recovery and business continuity aspects of this work, Convey noted that “The process of backing up is easy, but recovering is really, really hard.”

“From a business continuity and DR perspective,” Abou Jaoude said, “the biggest problem people have is that they back up their systems on tape or otherwise, and they back up and find out the data isn’t there. So we do regular data integrity checks to make sure the data is there. And we are 90-plus-percent virtualized. And the content is sitting in an alternate data center, so that we don’t need to reconfigure from a network configuration standpoint. It’s automated, not automatic. But one of the things we realized is that we need to have a pipe large enough to move the data and systems. And there should never be a scenario where you can’t use a manual process to get things done. You have to be prepared for that.”

“On the business continuity piece, one thing I’m working on now is to get senior leadership to understand that it’s not just an IT problem, and we need a business plan,” Marin General Hospital’s Johnson offered. “If I can only bring up 20 of our systems, [the members of the c-suite will] need to tell me which 20 systems to bring up. And one of our affiliate partners got hit with ransomware last summer; and they manage our billings for our clinics, etc. And their backups and everything got encrypted. So it’s 11:30 at night, and my CIO calls me and says, this company just got hit by ransomware, you’ve got to get back to the hospital right now. The security was actually the easiest thing to do. But then it took three weeks of 12-hour days to rebuild Allscripts from the ground up. And between that and the WannaCry, it’s helping our organization to understand that this is not an IT problem.”

Another audience member, Clark Kegley, the assistant vice president of information services at Scripps Health, who had participated on panels the previous day, said, “Historically, IT was assigned the disaster recovery part, and the business had the business continuity part. How do you bridge that gap?” he asked the panel.

“At Sharp,” Convey responded, “we go around and talk with the various leaders of the various segments of our organization. And part of this job is going around and really talking to the leadership and saying, we don’t mean to scare you, but this is where we need your help. There’s no way I can think of to approach this, other than with that level of cooperation.”

“About a year and a half ago, our board listed disaster recovery as a key issue for the organization,” CHOC’s Banash noted. “At that time, when I was brought into the conversation, the COO was already involved. And I was able to shift the conversation rom DR and to business resiliency. And in the end, they put together a steering committee for business resiliency; and we’ve created a new position for business resiliency, under the COO. And so that issue has been addressed.”

 “We think of disaster recovery and business continuity only when there’s an issue,” Bharadwaj noted. “We think of the value of our car when it stops running; we think of the value of our phone’s battery when it dies. And so this is not a technology discussion; it’s a business discussion that has to happen at the c-suite level.”

 

 


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Healthcare’s “RegTech” Opportunity: Avoiding a 2008-Style Crisis

September 21, 2018
by Robert Lord, Industry Voice, Co-Founder and President of Protenus
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In the financial crisis of 2007 to 2009, the financial industry suffered a crisis of trust. A decade later, banks and other financial institutions are still working to regain the confidence of consumers and regulators alike. In 2008 and 2009, while working at one of the world’s top hedge funds, I had a front-row seat to the damage that occurred to our economy, watching as storied corporate institutions fell or were gravely damaged. Today, as co-founder of a health technology company, I see healthcare is approaching a similarly dangerous situation. We must get ahead of the curve to avoid disaster.

Like finance, healthcare is a highly-regulated industry where non-compliance can result in severe financial and reputational consequences for healthcare companies, and severe impact on people’s lives. We deal with HIPAA, MACRA, HITECH, and hundreds of other foreboding acronyms on a daily basis. A lot of attention goes to the terrific and important work of clinical decision support, wellness apps, and other patient care technologies, but problems in the back office of hospitals must be addressed as well. One of these problems is the amount and complexity of healthcare regulation, and our healthcare system’s inability to keep up.

In finance, where I spent the early part of my career, the adoption of what is termed “RegTech” (regulatory technology) was driven by the increasing complexity of financial technology and infrastructure sophistication.  As trades moved faster, and as algorithms, processes and organizations became more complex, the technologies needed to ensure regulatory compliance had to move in tandem.  The crisis we experienced in 2008 was partially the result of the inability of the industry’s regulatory capabilities to keep up with the pace of technological change.  In many ways, the industry is still playing a catch-up game.

As healthcare professionals, looking to the lessons learned by our colleagues in finance can help us predict patterns and stay ahead of the curve. Right now, I’m seeing alarming parallels to challenges faced in finance a decade ago.

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Robert Lord

The burden of regulation across our industry is simply staggering.  Thirty-nine billion dollars of regulatory burden is associated with healthcare annually, which is about $1,200 per patient, per year. Despite this high cost, we still have $1 trillion of fraud, waste and abuse in our healthcare system. With so much regulation, why are we seeing so little yield from that burden? In many cases, it’s because we’re merely checking boxes and not addressing core risks؅. Like finance, there was a great deal of effort on compliance with regulations, but not enough attention on addressing important systemic risks.

This is not to say I am against good regulation; in fact, many regulations serve to protect patients and improve care. The problem is that there are so many demands on healthcare systems, that compliance and regulation is often reduced to checking boxes to ensure that minimum defensible processes are built, and occasionally spot-checking that things look reasonable. We currently have nowhere near 100 percent review of activities and transactions that are occurring in our health systems every day, though our patients deserve nothing less. However, unless overburdened and under-resourced healthcare providers and compliance professionals can achieve leverage and true risk reduction, we’ll never be able to sustainably bend our compliance cost curve.

Systemic problems are often not discovered until something goes horribly wrong (e.g., Wall Street every decade or so, the Anthem data breach, etc.). Today In the financial industry, RegTech provides continual, dynamic views of compliance or non-compliance and allows management, compliance professionals and regulators to check compliance in real-time. They can view every record, understand every detail, and automate investigations and processes that would otherwise go undetected or involve lengthy and labor-intensive reviews.

The real promise of these new capabilities is to allow compliance professionals and regulators to perform the truest form of their jobs, which is to keep patient data secure, ensuring the best treatment for patients, and creating sustainable financial models for healthcare delivery. RegTech will open up lines of communication and help create conversations that could never have been had before—conversations about what’s not just feasible for a person to do, but what’s right to do for the people whom regulation seeks to protect.

No longer bound by limited resources that lead to “box-checking,” compliance officers can use new and powerful tools to ensure that the data entrusted to them is protected. At the same time, healthcare management executives can be confident that the enterprises they manage will be well served by risk reducing technological innovation.  Patients, the ultimate beneficiaries of healthcare RegTech, deserve as much.

Robert Lord is the co-founder and president of Protenus, a compliance analytics platform that detects anomalous behavior in health systems.  He also serves as a Cybersecurity Policy Fellow at New America.

 


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HIPAA Settlements: Three Boston Hospitals Pay $1M in Fines for “Boston Trauma” Filming

September 20, 2018
by Heather Landi, Associate Editor
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Three Boston hospitals that allowed film crews to film an ABC documentary on premises have settled with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) over potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

According to OCR, the three hospitals—Boston Medical Center (BMC), Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital (MGH)—compromised the privacy of patients’ protected health information (PHI) by inviting film crews on premises to film "Save My Life: Boston Trauma," an ABC television network documentary series, without first obtaining authorization from patients.

OCR reached separate settlements with the three hospitals, and, collectively, the three entities paid OCR $999,000 to settle potential HIPAA violations due to the unauthorized disclosure of patients’ PHI.

“Patients in hospitals expect to encounter doctors and nurses when getting treatment, not film crews recording them at their most private and vulnerable moments,” Roger Severino, OCR director, said in a statement. “Hospitals must get authorization from patients before allowing strangers to have access to patients and their medical information.”

Of the total fines, BMC paid OCR $100,000, BWH paid $384,000, and MGH paid $515,000. Each entity will provide workforce training as part of a corrective action plan that will include OCR’s guidance on disclosures to film and media, according to OCR. Boston Medical Center's resolution agreement can be accessed here; Brigham and Women’s Hospital's resolution agreement can be found here; and Massachusetts General Hospital's agreement can be found here.

This is actually the second time a hospital has been fined by OCR as the result of allowing a film crew on premise to film a TV series, with the first HIPAA fine also involving the filming of an ABC medical documentary television series. As reported by Healthcare Informatics, In April 2016, New York Presbyterian Hospital (NYP) agreed to pay $2.2 million to settle potential HIPAA violations in association with the filming of “NY Med.”

According to OCR announcement about the settlement with NYP, the hospital, based in Manhattan, violated HIPAA rules for the “egregious disclosure of two patients’ PHI to film crews and staff during the filming of 'NY Med,' an ABC television series.” OCR also stated the NYP did not first obtain authorization from the patients. “In particular, OCR found that NYP allowed the ABC crew to film someone who was dying and another person in significant distress, even after a medical professional urged the crew to stop.”

The OCR director at the time, Jocelyn Samuels, said in a statement, “This case sends an important message that OCR will not permit covered entities to compromise their patients’ privacy by allowing news or television crews to film the patients without their authorization. We take seriously all complaints filed by individuals, and will seek the necessary remedies to ensure that patients’ privacy is fully protected.” 

OCR’s guidance on disclosures to film and media can be found here.

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Independence Blue Cross Notifies 17K Patients of Breach

September 19, 2018
by Rajiv Leventhal, Managing Editor
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The Philadelphia-based health insurer Independence Blue Cross is notifying about 17,000 of its members that some of their protected health information (PHI) has been exposed online and has potentially been accessed by unauthorized individuals.

According to an article in HIPAA Journal, Independence Blue Cross said that its privacy office was informed about the exposed information on July 19 and then immediately launched an investigation.

The insurer said that an employee had uploaded a file containing plan members’ protected health information to a public-facing website on April 23. The file remained accessible until July 20 when it was removed from the website.

According to the report, the information contained in the file was limited, and no financial information or Social Security numbers were exposed. Affected plan members only had their name, diagnosis codes, provider information, date of birth, and information used for processing claims exposed, HIPAA Journal reported.

The investigators were not able to determine whether any unauthorized individuals accessed the file during the time it was on the website, and no reports have been received to date to suggest any protected health information has been misused.

A statement from the health insurer noted that the breach affects certain Independence Blue Cross members and members of its subsidiaries AmeriHealth HMO and AmeriHealth Insurance Co. of New Jersey. Fewer than 1 percent of total plan members were affected by the breach.

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