With So Much Investment in EHRs and Data, Why Has Data Security Lagged So Far Behind? | Heather Landi | Healthcare Blogs Skip to content Skip to navigation

With So Much Investment in EHRs and Data, Why Has Data Security Lagged So Far Behind?

August 2, 2016
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In the past several years, billions of dollars have been invested in health IT and digital health, including dollars spent by healthcare organizations investing in electronic health record (EHR) systems, taxpayer dollars from government incentives and private investments by venture capital firms into digital health technologies. And all of this investment in health IT and digital health comes down to one thing—healthcare data.

As most healthcare organizations and providers are now adopting EHRs and other health IT tools, the main goal is to digitize health data, taking it from the traditional pen and paper to electronic files, to bring healthcare into the digital world. And by digitizing health data, healthcare organizations can then more efficiently collect it, store it, share it across organizations and analyze it to drive more efficiency and better outcomes.

However, according to seed fund and startup accelerator Rock Health in its digital health funding report for 2015, the top six digital health categories, accounting for 50 percent of all funding, did not include data security or cybersecurity. The top six categories were healthcare consumer engagement, wearables and biosensing, personal health tools and tracking, payer administration, telemedicine and care coordination, Rock Health reported.

These issues came up during a recent round-table discussion and press event I attended that was focused on cybersecurity and healthcare. During the discussion, executive leaders at healthcare delivery organizations and in the digital health space discussed the cyber threats facing the healthcare industry, and the need for digital health companies and healthcare organizations to step up their focus and investment in data security. 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, with the aim of giving a market perspective about cybersecurity in the healthcare space.

Joel Krikston, managing director of Merck GHI, provided what I found to be very insightful food for thought about the ongoing digitization of healthcare, and the very real risks and potential business impacts of cyber threats and data breaches.

According to Krikston, in the past two and a half years, VC firms have invested $15 billion in digital health. “I’ve been in digital health panels with Verizon, Samsung, Honeywell, Lockheed Martin, so the list of people who are in healthcare all the sudden has grown dramatically. And what’s happened is there is an excitement and palpable belief, as least on behalf of private markets, that the time has finally come for the convergence of mobile technologies, digitization of healthcare and activated consumers. And, these macro trends have formed this perfect storm that there is a future state of healthcare that everyone is playing for and the foundational asset is data,” he said.

“So data has existed in healthcare, that’s not new, it has existed on paper, in file cabinets, where it has not been accessible or shareable,” Krikston noted. “The big dream going forward, whether its population health or patient engagement, or buzzwords like care coordination, is that we’re going to be able to take that data and share it with each other, running analytics on it and we’re going to make it appear in real-time at physicians’ and nurses’ workstations and the point of care. We’re going to get patients to self-report data that they’ve never self-reported before, and we’re going to be able to glean all of these insights into what is happening in healthcare delivery. We’re going to get clinicians to follow evidence-based protocol, get patients to take their drugs, and all because we have the data to inform decisions.”

However, Krikston asserted that the market has significantly underinvested in security as well as in workflow solutions to enable security technology to integrate with providers’ workflow.

“My fear is that we’ve just seen the tip of the iceberg when it comes to healthcare security breaches,” he said, also noting that even bigger healthcare security breaches could cause “a ripple effect throughout the healthcare market.”

“All of the [Centers for Medicare & Medicaid Services} initiatives, government reform, MACRA, and the other buzzwords to drive quality improvement, all of that could stop in its tracks, until CIOs and CEOs of hospital systems figure out what healthcare data security actually is,” he said.

And speaking from a venture capital perspective, Krikston says his organization is more closely scrutinizing digital health startups’ efforts with regard to security, compliance and controls. “I think due diligence for most investors on HIPAA issues is that they will ask companies, ‘Are you HIPAA compliant?’ and if the company says yes, then they move on the next thing on the diligence check list. We’re not doing that anymore.”

And, with $15 billion going into the digital health market in the past two and a half years, Krikston referred to healthcare data security as the “elephant in the room that nobody is talking about.” “So that’s why we’re getting together here to share ideas and talk about it,” he said, referring to the round-table discussion, which included people on the “front lines” of healthcare security, such as health IT executives at large health systems and a CIO of a small Kansas-based health system.

John Gobron, CEO of Aventura, agreed during the discussion that the healthcare industry is coming to the game late with regard to data security.

“It’s important to look at where we’ve come. It’s not just $15 billion of private investment, but also $20 billion of public investment, and all mostly into one thing, the electronic medical record (EMR) itself. We’re digitizing data which used to live in a chart and now it lives in the EMR. Here we are in 2016 with massive growth in EMR use, but almost no investment in the security of the data,” Gobron said.

In fact, Krikston estimated that the healthcare industry spends about 12 to 13 percent of IT dollars on security, where most other verticals spend north of 20 percent of their IT budgets on data security. The problem, he said, is that security became a compliance requirement issue in the healthcare industry as opposed to an investment in “best-in-class practices.”

And, it was pointed out during the discussions that, somewhat ironically, the digitizing of healthcare records has actually made healthcare data more valuable to cybercriminals. Gobron noted that the data security threat has evolved from the problem of losing laptops—and, often, software encryption can solve that problem by encrypting the data—to advanced persistent threats, such as malware.

“Five years ago, the data wasn’t that valuable, as it didn’t live in one place. You had a billing system, you had sub-specialty systems, and hackers weren’t attracted to it. Through Meaningful Use, the data is there, it’s real and every single hospital has it. There was so much effort and thought and investment into EHRs and EMRs, but the security has lagged behind,” he said.

According to many security experts, ransomware is one of the oldest forms of malware. “It’s almost like smallpox, its back,” Gobron said. “There is software to prevent it and there are ways, but it takes some investments and preparation. The speed in which the industry has implemented EMRs at the expense of other things, there might not be much money left for these kinds of security investments in proportion to the other investments. Rather than look at how ransomware works, it’s interesting to look at the why it works, which is that the data now lives in one place, so its super valuable.”

When asked about what the federal government’s role should be in helping healthcare organization’s combat cybersecurity threats, Gobron voiced frustration about the lack of focus on data security in the Meaningful Use measures.

“Meaningful Use Stage 1 had 50 measures, one of which was security and it was a risk assessment, so that’s what we got, we had a very small percentage of investment that went into it. And, unfortunately, all you need is one crack. I think the industry is starting to realize this,” he said.

For me, one of the more interesting insights shared during the discussions was the impact of healthcare data security breaches not only to individual organizations, but to the health IT world at large, and even, more significantly, to the overall healthcare industry as providers increasingly adopt technology in the ongoing evolution from a fee-for-service model to a value-based care model.

Krikston noted, “Beyond the impact to an individual, step back and remember that 70 percent of reimbursement will supposedly will be tied to some sort of quality measure soon, and that’s completely dependent on data. With Medicare creating last year a complex chronic care management program, a $17 billion market for physicians to interact with complex Medicare patients, at least 20 minutes a month, which is designed to proactively suck waste and cost out to the system, and that is completely dependent on data.”

He continued, “I think the big risk to me is if all these initiatives aimed at saving the American medical industry, which is unsustainable in its current state, is dependent on data, and that trust goes away, and adoption goes away, that’s a trillion-dollar impact on government initiatives and budget initiatives.”

Speaking from an investor perspective, Krikston said the fear for an investor forecasting the digital health market is “if something happens broadly in this market or in healthcare data security and you either lose patients, clinicians, hospitals or nurses as adopters of these tools, then I think all bets are off. And, we think about it a lot, much more than we used to it.”

For me, this was a startling idea, that if CIOs and health IT leaders and clinicians, and even consumers, cannot trust that health IT tools will keep data secure, that adoption could start to fall off. And, what would be the potential impact of that on the ongoing digitization of healthcare? What would that mean for ongoing health system-driven initiatives using digital health tools, such as patient engagement, remote monitoring and telehealth?

While these discussions may paint a dire picture, it raises many issues worth considering, and not just for health IT leaders at provider organizations, but also vendors and government leaders as well. It also serves as a reminder that data breaches or ransomware attacks are not “one-off” situations that only impact that particular organization, but is part of an evolving industry-wide threat. And, the issues raised also highlight how critical it is for hospitals and health systems to share best practices around data security to try to close that gap.

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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.

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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