Are Data Security Measures Getting in the Way of Efficient Workflow? Healthcare Providers in the Trenches Share their Stories | Heather Landi | Healthcare Blogs Skip to content Skip to navigation

Are Data Security Measures Getting in the Way of Efficient Workflow? Healthcare Providers in the Trenches Share their Stories

August 9, 2016
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While high-level discussions about data security strategies and technologies to protect patient data are important at every healthcare delivery organization, it’s important to keep in mind how security measures are impacting the clinicians and physicians who work in the trenches every day to provide patient care.

Healthcare professionals at hospitals, health systems and medical practices are using electronic health records (EHRs) and other health IT applications every day to access patient data in order to provide patient care and are often navigating security measures and log-ons for multiple applications. For those working on the frontlines, a critical issue is how data security measures, such as frequent log-ons and password authentication, impact workflow.

According to Scott Raymond, R.N., who serves as executive director of strategic innovation and information technology at the Fountain Valley, Calif.-based MemorialCare Health System, hospitals have to strike a tenuous balance between using technology to secure health data without impeding clinicians’ workflow. “Generally, when you put security in place, it’s putting in fences and doors that you have to go through, or hurdles to go over, and that is typically going to slow down workflow. From a healthcare IT perspective, we are responsible for that data and securing that data, but we’re trying to balance our environment—we want to secure our data, but also enable clinicians to use the systems easily, so the patient gets the best care and most efficient care and we can get the patient into the system and out as quickly as possible.”

These issues came up during a press event I attended that was focused on cybersecurity and healthcare. During the discussion, executive leaders at healthcare delivery organizations and digital health companies discussed the cyber threats facing the healthcare industry, and drilled down into the everyday issues around data security and workflow that impact clinicians on the frontlines of patient care. The round-table discussion took place in San Francisco and was sponsored by Merck Global Health Innovation, Merck’s venture capital group, Aventura, a situational awareness technology vendor and ClearData, a cloud computing vendor.

The healthcare IT leaders present at the event, including Raymond with MemorialCare and Ed Stiner, director of information technology at Republic County Hospital, Belleville, Kansas, provided in-the-trenches insights about hospital data security from the perspectives of both large and small healthcare organizations. MemorialCare Health System is an integrated delivery system with six hospitals based in Orange County and Los Angeles, while Republic is a 25-bed critical access hospital in north Kansas.

According to Chris Bowen, founder and chief privacy and security officer at ClearData, security risk assessments performed at healthcare organizations have exposed many common weaknesses, such as doctors writing down passwords and posting them next to computer stations. And, John Gobron, CEO of Aventura, noted that if security measures impede doctors and nurses getting to patient data quickly, they will simply find workarounds to the security or write down or share passwords.

“With a lot of applications at the point of care, it’s really about speed. You have patients on the ward and you’ve got 50 to 60 log-ons throughout the day, and you do this times three or four different applications, you’re going to go crazy or you’re not going to use the system,” Gobron said.

This ties into a study I wrote about last month that found medical workers, nurses and physicians frequently workaround cyber security controls in healthcare settings. The study’s researchers found that “workarounds to cybersecurity are the norm, rather than the exception,” and the fact that such workarounds go unnoticed or, in some cases, even tolerated, “allows healthcare organizations to continue to deploy security that doesn’t work.”

At Republic County Hospital, hospital staff were frequently frustrated with the time-consuming process of getting in and out of health IT systems, Stiner said. The hospital, like many organizations, runs several different applications with each requiring users to enter a separate log-on and password. Physicians and nurses would often forget their credentials so administrators would have to perform a reset. And, because nurses and physicians move around the hospital, they frequently had to log on and off computers, which became time-consuming and the burden led to many physicians no longer using the system, Stiner said. The hospital implemented a single sign-on platform from Aventura and staff have since reported improved workflows and hours saved throughout the day, Stiner said.

Raymond agreed that workflow issues related to health IT, and the security around it, are everyday issues at hospitals. “It’s a struggle to get doctors to keep using the system. You have to give them some sort of benefit, an open road, to using it, but not so open that anybody can get to the data, so that’s where that balance comes in.”

Many healthcare organizations are moving to two-factor authentication, so a user name and password combined with a token or badge tap-in. “You can set that balance by how often you want users to re-authenticate. My feeling is that once I’ve authenticated you and you are on your shift and working in your unit, then I’m going to let you go about your business and be as efficient as possible. If you go out on break or go out for lunch, then I’m going to require you, based on the timeframe, to re-authenticate,” Raymond said.

While there have been innovations with regard to data security moving beyond just passwords and two-factor authentication, the challenge, according to those involved in the discussions, is that the healthcare industry, by nature, moves slowly.

“There’s excitement around Bluetooth low energy beacons, but there’s a balance in terms of how fast the industry can go,” Gobron said. “The technology exists in other places, that’s nothing new, but it’s just a question of getting healthcare to go at a faster speed, and there’s a lot at stake. You can’t put unproven technology in front of a group of nurses. You can’t take the newest Silicon Valley-based technology and stick it into a hospital and then wonder what’s going to happen.”

“Healthcare moves a little slower because you have only one shot at adoption,” Raymond added. When MemorialCare implemented its EHR system, Raymond led an enterprise-wide physician integration and physician informatics effort to help with physician adoption. “I would hear things like, ‘I’m not a work clerk. I didn’t go into medicine to type things out.’ To get doctors to use the EMR, you have to create ways that they can get to the information easily and you have to show them the benefit. And if you put a lot of roadblocks in front of them, they’re not going to use it.”

And, with regard to implementing new security tools, he said, “Physicians, especially, if you put a system in front of them that doesn’t work, they’ll try it a few times, and then they’ll say, ‘I’m out.’ To try to get them to come back around on that again is very difficult.”

With the rise in ransomware attacks on healthcare organizations, the discussion also turned to protecting IT systems should a hacker access the systems. Having layered security is critical, so hackers can’t traverse the network in a straight line, and segmenting the data is an effective defensive strategy as well, many health IT leaders said.

“The most important thing is to have good, secure and fast backups,” Raymond said. “Eventually, they are going to get in some way; they’re very sophisticated on sending out phishing emails and eventually someone will click on one. We do a lot of work to educate our users and to send out our own phishing campaigns to reduce that percentage, but it’s going to happen, so it’s all defensive.”

Raymond pointed to the ransomware attack at Hollywood Presbyterian, located in Southern California, as an example. As previously reported by Healthcare Informatics, back in February, Hollywood Presbyterian’s computer system were knocked offline for more than a week following a ransomware attack.

“They didn’t have fast enough backup, the way I look at it,” Raymond said. “They couldn’t restore their system fast enough, they went five days and still couldn’t get to their data, so they negotiated and paid the ransom and got their data back.” Using flash storage, a hospital hit with a ransomware attack could potentially back up their systems in less than an hour, he said.

Everyone involved in the discussions agreed that physician and staff engagement is critical when implementing security IT solutions. And, within the healthcare environment, a strong, effective security strategy goes hand-in-hand efficient workflow, the healthcare IT leaders present at the round-table discussion all agreed.

“From a hospital perspective, it’s all about throughput,” Raymond said. “You want to get the patient to the ER, get them diagnosed, get the medicine they need, and then get them discharged or admitted as an inpatient. And, at the same time, for healthcare organizations, reimbursement is going down, so our efficiency has to go up, and the only way efficiency can go up is throughput. If you put things in the way of that, you’re going to have a hard time.”

For healthcare IT leaders implementing security strategies, as well as cybersecurity solutions providers designing security tools, these are critical issues worth considering as the healthcare industry continues to combat evolving cyber threats.


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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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