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At Texas Health Resources, A Strategic Approach to Evolving Cybersecurity Challenges

November 14, 2017
by Heather Landi
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With a fast-evolving cyber threat environment and a continuous flood of healthcare data breaches, chief information security officers (CISOs) at hospitals and health systems face mounting pressure to safeguard their organization’s networks as well as critical clinical and financial data. Healthcare CI­SOs face complex and challenging issues with respect to information security, including rapidly evolving mal­ware threats, insider data breaches and the increasing use of medical Internet of Things (IoT) devices across their organizations.

In addition to security-focused projects, CISOs are of­ten involved in enterprise-wide technology initiatives as well. At Texas Health Resources (THR) this past year, C-suite executive leaders have been focused on a massive data center migration initiative. THR is an integrated health system based in Arlington, Texas with more than 350 points of access, including 29 hospital locations that are owned, operated or joint-ventured with THR, 100 outpatient facilities and 250 other community ac­cess points, including the Texas Health Physicians Group clinics. THR has more than 24,000 employees and the system serves more than 7 million residents across 16 counties throughout North Texas.

The health system’s CISO, Ron Mehring, says the or­ganization is migrating data centers housed in individual hospitals to “sophisticated, advanced co-location facili­ties” and the new data centers provide increased secu­rity controls and protections.

“Throughout the whole year, our focus has been on transforming our data center, and that includes improv­ing the availability and integrity of data and overall per­formance. It also includes the security controls within the data centers, from the physical controls to environmen­tal controls, to improving the general security and tech­nologies within the data centers themselves. And that’s been a ton of heavy lifting this year,” Mehring says.

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Mehring and his team also have focused on what he refers to as “blocking and tackling improvements,” ranging from multi-factor authentication enhancements to process improvements around vulnerability identi­fication and remediation activities. “We spent a lot of time trying to improve our assessment processes to get a little bit more detailed on the way that we identify risk and the way that we articulate risk to our stakeholders in the enterprise. We focused on general improvements in those areas, but most of our efforts have really fo­cused on our data center transformation, and some of the things that orbit around that.”

And, he adds, “That’s so important for our organization as we proceed to transform ourselves as a healthcare de­livery system. It’s really setting up the playing field; setting up the infrastructure and security services to support all those future business initiatives and clinical operations.”

The Current State of Healthcare Cybersecurity

When looking at the current state of cybersecurity in the healthcare industry, current data breach reports and news reports about malware incidents paint a trou­bling picture. Cybersecurity software company Protenus, which publishes a “Breach Barometer” report ev­ery month, reported 233 total breaches in the first six months of 2017; in all of 2016, about 450 breaches were reported. The company also reports that the trend first noted in 2016 has continued, with an average of one health data breach per day. Protenus tracks breach inci­dents either disclosed to the U.S. Department of Health and Human Services (HHS) or to the media.

However, there are indications that healthcare provider orga­nizations have boosted their cybersecurity efforts and are responding more quickly and strategically to cyber threats. In October, FirstHealth of the Car­olinas reported that it had shut down its computer networks af­ter a threat from a new version of the WannaCry malware virus was detected. The health sys­tem reported at the time that its information system team immediately identified the threat and implemented security protocols. The health system reported that because of the quick response by the infor­mation security team, the virus did not reach any patient information, operational information or databases.

In a 2017 Healthcare Information and Management Systems Society (HIMSS) Cybersecurity Survey, more than half of respondents (60 percent) reported their organizations em­ploy a senior information security leader, such as a CISO. What’s more, the survey results indicated that organiza­tions that employ a CISO or other senior information se­curity leader have adopted holistic cybersecurity practices.

Gauging the current state of healthcare cybersecurity, Mehring says, “Looking at it from a posture and a protec­tion perspective and when I talk to my peers, it feels to me that the water line is overall rising together. Five years ago, I think, in healthcare, what we saw is the ‘haves’ and ‘have nots’ at very dramatic levels. We had healthcare delivery systems and providers with differing levels of security, where a lot of the blocking and tackling secu­rity controls weren’t in place. There was this huge dispa­rate ecosystem, and that’s important because, especially when you get local, we all have to share; in a metroplex, all of our systems talk to each other. It’s important that we all understand that we all have to improve together.”

Mehring also says he is seeing more information shar­ing among healthcare security leaders, noting both infor­mal, local efforts as well as national efforts through cyber threat-sharing groups, such as the National Health Information Sharing and Analysis Center (NH-ISAC) and the HITRUST Alliance. In the Dallas area, one local hos­pital hosts regular summits bringing together local CISOs and security staff. Mehring says, “We share information with each other and give best practices, which is great, as when you get into the healthcare delivery ecosystem, local really matters. National is important, but when we are delivering care and sharing information, a lot of that is happening at a very local level, between health systems.”

Evolving External Threats

It’s widely known that healthcare is a prime target for hackers and cybercrime, with malware and ransomware attacks a constant concern for healthcare security lead­ers. In May, the WannaCry ransomware virus plagued the National Health Service in the United Kingdom and the NotPetya malware caused massive disruptions to multinational companies in 65 countries back in June, including health IT company Nuance Communications, which had to shut down its network.

Like many other healthcare security leaders, Mehring sees ransomware as a major threat to many industries, including healthcare, and one that will not go away any­time soon. As one silver lining, though, he also notes that security vendors are providing more robust infra­structures in response to the malware threats.

“I think a lot of people learned their lessons very quickly around ransomware and how to handle it. That includes, number one, putting the right protections in place on the front end, and if it gets in, having the right response and recovery strategy in place. We see many organizations being able to recover quickly from those types of destructive events. I think what you see is a lot of lessons learned being applied, so the impacts have gone down. But, do I think that threat exists? Absolute­ly, and it will continue to evolve.”

One way cyber threats have evolved, Mehring points out, is that hackers are starting to attack what he refers to as the "underbelly,” or the technical supply chain. In the NotPetya malware attack in June, for instance, cybersecurity experts believe that a software update mechanism of a Ukrainian tax preparation program had been compromised to spread the malware.

“When they attacked the Ukrainian application, which was associated to some U.S. companies as well as other companies, they attacked that trust that had been built with that company’s application, and they attacked, es­sentially, the update service associated with that appli­cation. When a malware gets in, with the right level of permission and the right level of access to the environ­ment, it’s going to do a little bit of harm, and depending on how it’s set up, it could do lots of harm.

He continues, “This is something that we really need to pay attention to; the vendors or software services that are integrated tightly into our healthcare delivery sys­tems. It’s probably the next attack vector in, and, unfor­tunately, it’s a great vector into an enterprise, because of the trust that we lay into those types of services.”

The speed of malware attacks is increasing as well, Mehring notes, and that puts more pressure on health­care organizations to have the right tools, techniques and processes in place to respond and recovery quickly. “The organizations that are not able to start to apply automation and orchestration into their infrastructure and services will probably see in the future how the lack of that becomes the real problem and can really impact their infrastructure.”

At Texas Health Resources, Mehring says the organi­zation’s cybersecurity strategy evolves to address these threats, with an increased focus on the security postures of its vendor partners. “You have got to ask really good questions of your vendors and how their services integrate into your environment. You need to ensure they are doing all the things that they should be doing to protect their environment, and yours, in the delivery of that service.”

He adds, ‘If you are integrating a software service into your environment, that’s managed externally by a vendor, you need to ensure you’re putting the appropriate con­trols in place so that any harm caused on their side does not impact the rest of the environment. And we do that through a lot of different ways, through appropriate pro­visioning of accessing and identity, appropriate provision­ing of network services and isolation and segmentation.”

Insiders Remain a Constant Threat

Specialist insurer Beazley reports that in the first nine months of 2017, unintended disclosures accounted for 41 percent of healthcare data breach incidents. The high level of unintended disclosure incidents remains more than dou­ble that of the second most frequent cause of loss—hack or malware (19 percent), according to the Beazley report.

At Texas Health Resources, Mehring says security leaders utilize sophisticated IT monitoring systems, such as behavioral analytics, to detect anomalous behavior as well as continuous auditing and monitoring of protected health information (PHI) within the electronic health re­cord (EHR) and data loss prevention technologies.

There are also non-technical processes and programs that should be used, Mehring points out, such as a hot­line that employees can use to report anomalous behav­ior. “You need a good hotline that allows the reporting of things, and from that hotline, you need to make sure the information is acted upon and communicated to the right department, whether its HR or it’s the legal or se­curity team,” he says.

At a high level, Mehring says it’s critical that the CISO have strong relationships with human resources and compliance leaders within the organization to de­velop processes and policies to identify and address insider threat actions. “From a policy perspective, it’s about who is going to own the policy for that type of data and who sets the rules?” A transparent sanction­ing program also is key so employees are aware that activities are being monitored. “Employees need to know that there is a process in place for accountability when something is inappropriately accessed or inap­propriately shared,” he says.

Medical IoT and Cybersecurity

For many hospital and health system CISOs, the gover­nance of medical device programs is the next frontier in IT security. Healthcare provider organizations are now managing an increasing number of digitally connected devices, and, as more devices come online, the cyberse­curity risk increases and intensifies in complexity.

“I think most of us are still coming to terms with how we characterize IoT. Is a medical device an IoT, is a re­frigerator that stores blood an IoT? Is a monitor that is displaying our marketing information in our hospital, is that IoT? If somebody gets a wearable, is that an IoT? And the answer to that is probably, yes, to all of that in some way,” Mehring says.

A critical, foundational step to managing medical de­vices is developing a comprehensive inventory and asset identification of all digitally connected devices within an organization, he notes. “Then you have to start develop­ing at least some internal rules of how we characterize those types of IoT things and make sure we can differen­tiate between those different asset types because they are going to get different protection profiles. A medical device is going to get a different protection profile than a monitor on the wall in a hospital passageway that’s providing branding information,” he notes.

Understanding how various medical devices communi­cate, both inside and outside the hospital environment, also is a vital step in maintaining and protecting devices. “Developing good data flow mapping and understand­ing the way that devices communicate is very important. That allows you to put in better protection mechanisms once you understand how things communicate with each other. You can ensure that the appropriate communica­tion security strategy is put in place around those devic­es,” Mehring says.

At THR, health system C-suite leaders have long been aware that cybersecurity is not just an IT problem, but a corporate-wide risk management issue, and one that requires an evolving, strategic approach to address the changing threat environment.

 


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Assessing the New Cybersecurity Practices Publication: Why Small and Medium-Sized Care Organizations Have Reason to Rejoice

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A new set of voluntary cybersecurity practices just released by HHS offers practical advice and conceptual supports that fill information gaps
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How helpful will the new set of voluntary cybersecurity practices that the Department of Health and Human Services (HHS) released in late December, be, to the leaders of patient care organizations? Only time will tell, as part of the value of the release will only be made manifest as the leaders of patient care organizations move forward to implement some of those practices, and the potential success of such implementations is in some way measured and benchmarked.

But the release is a first start, at least. As Healthcare Informatics Associate Editor Heather Landi reported on January 2, HHS released the set of practices in the form of a publication “that marks the culmination of a two-year effort that brought together over 150 cybersecurity and healthcare experts from industry and the government under the Healthcare and Public Health (HPH) Sector Critical Infrastructure Security and Resilience Public-Private Partnership.”

“Cybersecurity is everyone’s responsibility. It is the responsibility of every organization working in healthcare and public health.  In all of our efforts, we must recognize and leverage the value of partnerships among government and industry stakeholders to tackle the shared problems collaboratively,” Janet Vogel, HHS Acting Chief Information Security Officer (CISO), said in a statement published with the release of the new publication.

Health Industry Cybersecurity Practices: Managing Threats and Protecting Patients (HICP), the primary publication of the Cybersecurity Act of 2015, Section 405(d) Task Group, aims to raise awareness, provide vetted cybersecurity practices, and move organizations towards consistency in mitigating the current most pertinent cybersecurity threats to the sector,” HHS officials stated. “It seeks to aid healthcare and public health organizations to develop meaningful cybersecurity objectives and outcomes. The publication includes a main document, two technical volumes, and resources and templates.”

The overall publication consists of several sections, the first being the HICP, which “examines cybersecurity threats and vulnerabilities that affect the healthcare industry. It explores five current threats and presents 10 practices to mitigate those threats; “Technical Volume 1: Cybersecurity Practices for Small Health Care Organizations,” which offers cybersecurity practices for small healthcare organizations; “Technical Volume 2: Cybersecurity Practices for Medium and Large Health Care Organizations”; the “Resources and Templates” portion, which “includes a variety of cybersecurity resources and templates for end users to reference”; and a Cybersecurity Practices Assessments Toolkit, which “helps organizations prioritize their cyber threats and develop their own action plans using the assessment methodology outlined in the Resources and Templates volume”—that last section being still under development as of Jan. 2.

As Landi reported, “The HICP publication aims to provide cybersecurity practices for this vast, diverse, and open sector to ultimately improve the security and safety of patients. The main document of the publication explores the five most relevant and current threats to the industry. It also recommends 10 cybersecurity practices to help mitigate these threats.”

What’s more, she wrote, “The main document presents real-life events and statistics that demonstrate the financial and patient care impacts of cyber incidents.  It also lays out a call to action for all industry stakeholders, from C-suite executives and healthcare practitioners to IT security professionals, that protective and preventive measures must be taken now. The publication also includes two technical volumes geared for IT and IT security professionals, one focusing on cybersecurity practices for small healthcare organizations, and one focused on practices for medium and large healthcare organizations.”

Among the salient statistics reported in the HICP:

  • Fifty-eight percent of malware attack victims are small businesses.
  • In 2017, cyber-attacks cost small and medium-sized businesses an average of $2.2 million.
  • Sixty of small businesses go out of business within six months of an attack.
  • And, 90 percent of small businesses do not use any data protection at all for company and customer information.

How does that translate into impacts on smaller healthcare organizations? Among other incidents, the HICP notes that:

  • A popular orthopedic practice announced that its computer system was hacked via breach of a software vendor’s log-in credentials. This breach put just under a half-million people at risk of identity theft. Of those, 500 patient profiles appeared for sale on the dark web. The information for sale included names, addresses, social security numbers, and other personally identifiable information (PII). Although not posted for sale, pertinent PHI such as X-ray results and medical diagnoses were also stolen.

 

  • A rural hospital had to replace its entire computer network after a ransomware cyber-attack froze the hospital’s electronic health record (EHR) system. Doctors were unable to review their patients’ medical histories or transmit laboratory and pharmacy orders. Officials were unable to restore essential services and could not pay the ransom for the return of their system. After consultations with the Federal Bureau of Investigation and cybersecurity experts, hospital officials made the difficult decision to replace the entire system.
  •  

Of particular practicality is some of the very basic advice given to the leaders of smaller healthcare organizations. To wit: “Doctors and nurses know that hand sanitizing is critical to prevent the spread of germs. That does not mean health care workers wash up as often as they should. Similarly, we know that cybersecurity practices reduce the risk of cyber-attacks and data breaches. Just as we are able to protect our patients from infection, we should all work towards protecting patient data to allow physicians and caregivers to trust the data and systems that enable quality health care. Just as health care professionals must wash their hands before caring for patients, health care organizations must practice good ‘cyber hygiene’ in today’s digital world, including it as a part of daily universal precautions,” the HICP notes. “Like the simple act of hand-washing, a culture of cyber-awareness does not have to be complicated or expensive for a small organization. It must simply be effective at enabling organization members to protect information that is critical to the organization’s patients and operations. Your organization’s vigilance against cyber-attacks will increase concurrently with your and your workforce’s knowledge of cybersecurity. This knowledge will enable you to advance to the next series of cybersecurity Practices, expanding your organization’s awareness of and ability to thwart cyber threats.”

Meanwhile, both smaller and larger patient care organizations will benefit from the technical supports, including a Security Risk Assessment Tool, a set of recommendations on medical devices and cybersecurity, and an incident response risk management handbook.

What this set of resources does is to fill a gap between theory and technical practice in a key area. Will it shift the entire landscape of cybersecurity for patient care organizations? No, that would be a far-too-ambitious goal. But the healthcare IT leaders of smaller and medium-sized patient care organizations in particular, will welcome practice advice and supports, as they move forward in their journeys around cybersecurity. Any such journey is inherently challenging, and federal publications and resources like these will be of real value in moving patient care organization HIT leaders forward.

 

 

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HHS Releases Voluntary Healthcare Cybersecurity Practices

January 2, 2019
by Heather Landi, Associate Editor
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In late December, the Department of Health and Human Services (HHS) released voluntary cybersecurity practices to the healthcare industry with the aim of providing practice guidelines to cost-effectively reduce cybersecurity risks.

The “Health Industry Cybersecurity Practices (HICP): Managing Threats and Protecting Patients” publication aims to provide guidance to healthcare organizations of all types and sizes, ranging from local clinics to large hospital systems.

The industry-led effort was in response to a mandate set forth by the Cybersecurity Act of 2015 Section 405(d), to develop practical cybersecurity guidelines to cost-effectively reduce cybersecurity risks for the healthcare industry.

According to HHS, the publication marks the culmination of a two-year effort that brought together over 150 cybersecurity and healthcare experts from industry and the government under the Healthcare and Public Health (HPH) Sector Critical Infrastructure Security and Resilience Public-Private Partnership.

“Cybersecurity is everyone’s responsibility. It is the responsibility of every organization working in healthcare and public health.  In all of our efforts, we must recognize and leverage the value of partnerships among government and industry stakeholders to tackle the shared problems collaboratively,” Janet Vogel, HHS Acting Chief Information Security Officer (CISO), said in a statement.

While technologies are vital to the healthcare industry and help provide life-saving treatments and improve patient care, these same technologies are vulnerable to myriad attacks from adversaries, ranging from criminals and hacktivists to nation-states, according to HHS. These technologies can be exploited to gain access to personal patient data or render entire hospital systems inoperable. Recent cyber-attacks against the nation’s healthcare industry continue to highlight the importance of ensuring these technologies are safe and secure.

“The healthcare industry is truly a varied digital ecosystem. We heard loud and clear through this process that providers need actionable and practical advice, tailored to their needs, to manage modern cyber threats. That is exactly what this resource delivers; recommendations stratified by the size of the organization, written for both the clinician as well as the IT subject matter expert,” Erik Decker, industry co-lead and Chief Information Security and Privacy Officer for the University of Chicago Medicine, said in a statement.

The HICP publication aims to provide cybersecurity practices for this vast, diverse, and open sector to ultimately improve the security and safety of patients. The main document of the publication explores the five most relevant and current threats to the industry. It also recommends 10 cybersecurity practices to help mitigate these threats.

The main document presents real-life events and statistics that demonstrate the financial and patient care impacts of cyber incidents.  It also lays out a call to action for all industry stakeholders, from C-suite executives and healthcare practitioners to IT security professionals, that protective and preventive measures must be taken now. The publication also includes two technical volumes geared for IT and IT security professionals, one focusing on cybersecurity practices for small healthcare organizations, and one focused on practices for medium and large healthcare organizations.

 

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CynergisTek, Protenus Partner on Privacy Monitoring Programs

December 26, 2018
by Heather Landi, Associate Editor
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CynergisTek, Inc., an Austin, Texas-based healthcare cybersecurity firm, is partnering with Protenus, a healthcare compliance analytics company, to combine the companies’ technology tools and services with a focus on patient privacy monitoring programs.

The partnership will grant health systems access to Protenus’ analytics platform that leverages artificial intelligence to gather data related to potential patient privacy risks, along with CynergisTek’s patient privacy monitoring services.

According to the Protenus research, insider incidents accounted for 23 percent of all breaches that occurred at health systems in Q3 2018. This figure will only continue increasing, indicating that now more than ever, health systems need a cost-effective solution to meet the daily challenges of managing patient privacy.

To address this need, CynergisTek and Protenus formed a preferred partnership to combine CynergisTek’s healthcare consulting experience and privacy programs with Protenus’ healthcare analytics technology to offer health systems both the people, processes, and technology components of a strong patient privacy monitoring program, according to the companies.

“As health systems face mounting challenges in creating and maintaining robust patient privacy monitoring programs, we identified a need to partner with a company offering complementary services so that health systems can act on the insights uncovered by our analytics,” Nick Culbertson, CEO and co-founder of Protenus, said in a statement.

 “Data privacy is evolving as a dominate theme in conversations, both in healthcare and other industries, and health systems need to take an end-to-end approach to patient privacy to truly address this complex and mission-critical challenge,” Mac McMillan, CEO and president of CynergisTek, said in a statement.

 

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