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United States Federal CIO at CHIME16: Time to Change the Cybersecurity Paradigm

November 3, 2016
by Rajiv Leventhal
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CIOs need to be at the forefront of the digitization that will transform healthcare, says Tony Scott

At the CHIME16 CIO Fall Forum, Tony Scott, CIO, U.S. Office of Management & Budget (OMB), urged healthcare CIO attendees to change the conversation around cybersecurity from one of traditional organizational approaches to one centered on quality and digitization.

Scott, the third CIO of the United States, appointed by President Obama on Feb. 5, 2015, and formerly of VMware Inc., gave the closing keynote on the first day of the College of Healthcare Information Management Executives (CHIME) CIO Fall Forum at the JW Marriott Phoenix Desert Ridge Resort in Phoenix, Ariz. Scott said that at the White House, his team is sharply focused on digitization and the effect it has on every enterprise around the world, no matter the industry.

But, he said, it’s important to remember that digitization is different than automation. “Much of the money we have spent on technology over the last 30 to 40 years has essentially been on automating manual processes. Computers sped it up, but the workflow didn’t change much,” Scott said. However, in an era with mobile devices, sensors and the like, work shouldn’t be done the way it was done before, he attested. “We have a chance to re-invent how things get done. We have seen it take place in the media and entertainment industry, in banking, and in transportation. Digitization affects everything, including government,” Scott said.

But Scott said that there is a clear missing link with digitization right now: an institution’s organizational charts are a challenge, as they get in the way of sectors and people realizing their full potential. “If you look at the technical architecture, the apps, the infrastructure, and how work gets done in any institution, and if that’s a 1:1 match for your organizational chart, you’re in trouble,” Scott stated. “If that’s the case, you’re probably not thinking digital through the use of modern technology.”

He added, “What’s better is if every design you do starts with the customer viewpoint, so the outside in. How does the customer want to get information and use it? That’s real digitization.” This approach, Scott continued, sounds simple, but the way things are run and operated on in most organizations are too tightly bound to the organizational charts. “The lesson learned is that digitization will blow that paradigm up, one way or the other. Economics, information flow and customer demand drive you to a completely different place,” he said, adding “CIOs have to be at the forefront of that.”


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Scott noted that the federal government spends $80 billion per year on information technology, making it the single largest purchaser of information technology in the world. “We have great buying power, but spend most of it just ‘keeping the lights on’ pretty old stuff. Some [technology systems] we have are 20, 30, and 40 years old, and those things can’t serve the needs of our modern enterprise and also can’t be protected well,” he said.

In healthcare, Scott said he sees many of the same problems he saw when he was chief technology officer at General Motors. At that time, the common thought was that American cars simply couldn’t keep up to speed with Japanese car manufacturers. “People said the American car industry was on its death bed. No one wanted to buy one,” Scott recalled. But then he said, the conversation started to change to one about quality; the Baldrige Award was created (the Malcolm Baldrige National Quality Award is presented annually by the president of the U.S. to organizations that demonstrate quality and performance excellence), and the discussion became about what can be done together, what can be learned, and what processes can be put in place to evolve. “So in this industry, American car manufacturing became [better] across the board as a result,” he said.

Scott said it’s the same idea in healthcare. “You’re taking some of those same techniques, methods and tools, and applying them in a different space,” he said. For cybersecurity specifically, he continued, every time there is an incident, breach, or failure, “I think we should think of it is a quality issue. It’s a defect in the design, implementation, and operation of information systems. You can take those processes, techniques and tools and apply them in this critical space. But you need to go back to the design to have an impact,” Scott said.

As such, the hope is that work with the National Institute of Standards and Technology (NIST) and the Baldrige program will help to change the conversation, Scott said. “Rather than say, ‘hey this is bad or did you hear about this breach,’ you can instead say, ‘what lessons did we learn, how can we apply this type of quality to this space, and how can we measure the impact of the work we have done? Changing that conversation is important in the digitization journey and the cybersecurity journey. That’s when you can see dramatic results,” he said.

Scott gave an example of this working in the federal sector. Ten years ago, a standard was passed for two-factor authentication: PIV (personal identity verification) cards. Every federal agency CIO was told that they must implement PIV cards for two-factor authentication for all users across the federal government, Scott explained. “We got to about 40 percent implementation across the government when I got there, which means only 40 percent in 10 years [or so] time,” he said.

A few years later, a major breach at OMB happened. Scott and his team analyzed it and saw how the attack materialized; indeed, it was privileged users being compromised, which could have been prevented by this two-factor authentication implementation, he said. “So I said at the time, in the next six weeks, not six years, we will make big progress. And in six weeks, we got up to over 80 percent implementation, and 100 percent implementation for privileged users. How? Well, we said that it’s a priority, we said we will have a public score card, report results every week, and I challenged CIOs to measure it and have a public display. I asked them if they wanted to be at the top or the bottom of the list. And yes, we did other things as well, such as patching vulnerabilities and reducing the number of system administrators, but it shows you what a focused effort looks like,” Scott said.

That strategy inspired Scott’s team to embark on a cybersecurity national action plan, he said. “Whatever time I have left in this administration, one of the things that’s so important for us to do is leave with a different message,” he concluded. “Not only is cybersecurity important, but there is something we all can do about it—when we recognize good work, share it across the community.”

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OCR Fines Providers for HIPAA Violations, Failure to Follow “Basic Security Requirements”

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) for a number of 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, OCR also fined a Colorado-based hospital, Pagosa Springs Medical Center, $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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