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Washington Debrief: Call for Feds to Have Greater Transparency on Cybersecurity; CMS Announces MACRA Flexibility

September 12, 2016
by Leslie Kriegstein, Vice President of Congressional Affairs, CHIME
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CHIME & AEHIS Call on Feds to Have Greater Transparency on Cybersecurity

Key Takeaway: CHIME and AEHIS last week submitted comments to National Institutes of Standards and Technology (NIST) on a Request for Information (RFI) on cybersecurity.

Why it Matters:  NIST in August issued a RFI -- “Information on Current and Future States of Cybersecurity in the Digital Economy” – with goal of gathering input for its upcoming recommendations for strengthening cybersecurity. CHIME and AEHIS made nine overarching recommendations on the challenges and barriers to improving the current state of healthcare, including:

  1. The need for federal agencies to improve transparency of known threats in order for the healthcare industry to better implement risk mitigation strategies.
  2. The need for more actionable and plain English guidance about current threats.
  3. Since a growing number of medical devices are now connected to the internet and hospital networks, cybersecurity needs to be seen as a business issue related to patient safety, not just an Information Technology problem.

We also called for changes affecting the way compliance enforcement is handled, need for under-resourced providers, greater attention to maximizing protections afforded by Business Associate Agreements, patient safety, and the need to prioritize healthcare as a critical infrastructure.


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FTC Hearing on Ransomware

Key Takeaway: Federal Trade Commission (FTC) tackles ransomware.

Why it Matters: In a signal that cybersecurity remains a growing concern for policymakers, the FTC last week hosted a special symposium on ransomware.  A recording of the webinar can be found here. The commission explored a number of topics, including:

  • How do ransomware extortionists gain access to consumer and business computers?
  • What role can consumer and business education play in preventing ransomware infections?
  • Are there steps consumers and businesses should be taking to reduce the risk of ransomware or to decrease its impact?
  • Are there technological measures that computer operating system and web browser designers can take to prevent ransomware?
  • Are there browser plug-ins or other tools that consumers and businesses can employ that will warn if their data is about to be encrypted?
  • What can be learned from criminal law enforcement’s efforts to combat ransomware?
  • If you fall prey to ransomware, should you pay the ransom?
  • If you pay the ransom, how likely are you to receive the decryption key and be able to view your files?
  • What happens if you don’t pay the ransom? Are your files lost forever?

The FTC is accepting comments on these topics through October 7. 

Meaningful Use

CHIME Comments on OPPS Rule, Applaud 90-day Reporting, MU changes

Key Takeaway: CHIME submited comments on the Centers for Medicare and Medicaid Services (CMS) proposed hospital outpatient prospective payment system rule (OPPS).

Why it Matters: CMS’ proposed rule called for numerous changes to the Meaningful Use program for hospitals providing some much needed relief for both 2016 and later years. CHIME strongly supports the changes CMS has called for, while also highlighting additional areas that we feel warrant changes. We called on CMS to:

  1. Finalize the proposal for a 90-day reporting period for 2016 as quickly as possible and adopt a likeminded policy for future years as well;
  2. Reconsider the full-year reporting for electronic clinical quality measures (eCQMs) for hospitals and adopt a quarter reporting period instead;
  3. Align regulatory requirements for clinicians and hospitals in the Medicare and Medicaid programs as closely as possible in order to maximize the greatest degree of flexibility;
  4. Develop education tools for providers to help them navigate different sets of rules (i.e. Merit-based Incentive Program (MIPS) and Medicare versus Medicaid);
  5. Only require provider use of new technologies when:
    1. They have become widely available and their functionality has been proven to improve patient care (i.e. application programming interfaces (APIs) and patient-generated data (PGD)); and
    2. Assuming new technologies are found to be effective, do not require a full-year reporting for any new Meaningful Use measures in order to give both vendors and providers time to adapt to the new criteria.
  6. Reduce thresholds for hospitals for ePrescribing; the timeframe upon which information must be made available to patients upon discharge; secure messaging; patient-generated data (PGD); and public health and clinical data registry reporting; and
  7. Any mandates for using registries must be preceded by proven, common data standards that are broadly available in the EHRs and implemented by the registries.

CMS Announces More Flexibility under MACRA

Key Takeaway: CMS posted a blog outlining more flexible options under the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), teeing up forthcoming changes in the final rule.

Why it Matters: In advance of the publication of the final rule on MACRA and the Merit-Based Incentive Payment System (MIPS), CMS Administrator Andy Slavitt posted a blog last week outlining four different ways clinicians will be able to maximize flexibility under the new Quality Payment Program:

  • Option 1: Test the Quality Payment Program. Requires submission of some data starting January 1, 2017, to avoid penalties and is designed to help clinicians acclimate to the new system.
  • Option 2: Participate for part of the calendar year. Allows clinicians to participate after January 1.  Data must be submitted but would not be for the entire year while allowing clinicians to quality for a small incentive payment.
  • Option 3: Participate for the full calendar year. Clinicians who are ready to participate in the program and start submitting data can qualify for a modest incentive payment
  • Option 4: Participate in an Advanced Alternative Payment Model (APMs) in 2017. Those clinicians who receive enough Medicare payments or see enough Medicare patients through APMs could qualify for a 5 percent incentive payment in 2019.

Congressional Leaders Weigh-In on Forthcoming MACRA Rules

Key Takeaway: Leaders of the House Ways & Means and Energy & Commerce committees penned a letter to HHS Secretary Sylvia Burwell urging for adoption of final MACRA rules that create greater flexibility for physicians as they adapt to new reimbursement models.

Why It Matters: Stakeholders expect that the first performance year for the new Medicare physician reimbursement models is 2017. Congress, along with the provider community, are concerned that the Centers for Medicare and Medicaid Services (CMS) will not allow enough flexibility for Medicare physicians as they transition into the new reimbursement programs given the expedited timeline that accompanies the 2017 start date.


CHIME Joins Letter to CMS to Improve Reimbursement for Telehealth Services

Key Takeaway: CHIME signed a comment letter to the CMS promoting telehealth reimbursement expansion.

Why it Matters: CHIME joined 24 other organizations in responding to CMS’ physician fee schedule proposed rule where we called for reimbursement policies that are more supportive of telehealth and other connected health technologies. Medicare telehealth reimbursement policies have trailed other payers’.  The letter urged CMS to consider how these technologies, if reimbursement is expanded, can better facilitate coordinated care and savings.  The letter noted, for instance:


Despite the proven benefits of connected health technology to the American healthcare system, these solutions are largely ignored by the current Medicare system in their rule making. For example, according to the CMS, traditional fee-for-service Medicare “telehealth” reimbursement totaled a mere $13.9 million in calendar year 2014, largely an effect of CMS’ continued use of a now 16-year-old definition and its refusal to waive the backwards and outdated restrictions in Section 1834(m) on “telehealth.” Furthermore, remote monitoring technologies, which are dependent on technologies excluded from telehealth services, are unreasonably restrained by CMS’ decision to bundle monitoring with other codes, resulting in a lack of reimbursement for remote monitoring solutions.


Patient Identification/Precision Medicine Announcements

Key Takeaway: The Obama administration made two announcements on precision medicine last week. Successfully matching patients to their records remains critical to advancing this effort forward.

Why it Matters: Precision medicine remains a top priority for the White House and they recognize that data interoperability is a cornerstone to its success. CHIME continues to assert that the ability to uniquely identify a patient is pivotal to addresses a fundamental challenge to interoperability and thus to the success of precision medicine efforts. Last week the White House:

  • Published a 72-page report on their Cancer Moonshot Initiative which strives to accelerate work to advance cancer research work that typically would have taken ten years, in five. A blue ribbon panel made numerous recommendations including several aimed at data.
  • A Frontiers conference that will be hosted on October 13th in Pittsburgh that will be attended by the President and co-hosted by the University of Pittsburgh and Carnegie Mellon University.  The conference will focus on the future of innovation including advances in precision medicine and healthcare innovation.


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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.

Related Insights For: Cybersecurity


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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