Could Cybercriminals Be on the Verge of Executing a New, Terrible Type of Attack on Healthcare? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Could Cybercriminals Be on the Verge of Executing a New, Terrible Type of Attack on Healthcare?

July 31, 2017
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A team of writers outlines the possibility of a terrifying new scenario for patient care organizations—the potential direct manipulation of patient data to cause harm

An excellent “Perspective” op-ed article published online earlier this month in The New England Journal of Medicine is bringing forward for industry leaders to consider, a very important and alarming new possibility around data breaches involving PHI (protected health information). Could criminal hackers actually tamper with critical clinical information contained within electronic health records (EHRs), to the potential devastation of patients? Yes, it’s possible—and we need to talk about it.

Under the headline “Threats to Information Security—Public Health Implications,” William J. Gordon, M.D., Adam Fairhall, A.L.M., and Adam Landman, M.D., M.I.S., M.H.S., write online in the July 12 New England Journal of Medicine about the accelerating threats to patient care being posed by hackers. Noting recent high-profile incidents, they write, “In health care, information security has classically been regarded as an administrative nuisance, a regulatory hurdle, or a simple privacy matter. But the recent ‘WannaCry’ and ‘Petya’ ransomware attacks have wreaked havoc by disabling organizations worldwide, including parts of England’s National Health Service (NHS) and the Heritage Valley Health System in Pennsylvania. These events are just two examples of a wave of cyberattacks forcing a new conversation about health care information security. With the delivery of health care increasingly dependent on information systems, disruptions to these systems result in disruptions in clinical care that can harm patients. Health care information security has emerged as a public health challenge.”

Further, the authors note, “Threats to information security plague many industries, but the threats against health care information systems in particular are growing. Data breaches, generally described as an impermissible use or disclosure of protected health information, are particularly prevalent. Nearly 90 percent of health care organizations surveyed by the Ponemon Institute (which does independent research on privacy, data protection, and information security policy) suffered a data breach in the past 2 years; meanwhile, 64 percent of organizations reported a successful attack targeting medical files in 2016—a 9 percent increase in just 1 year.1 Multiple causative factors are involved in the uptick in attacks against health care systems, but some reasons cited in that study include low organizational vigilance, inadequate staffing and funding for information technology security, insufficient technology investment, and the underlying value of health care data as compared with data from other industries.”

The authors go on to explain to their audience about how DoS (denial of service) and ransomware attacks work. “Although DoS and ransomware attacks disrupt systems and can significantly impair the ability to deliver efficient care, they do not necessarily expose patient information,” they note. And then they state that, “More worrisome are attacks that result in breaches of protected health information and personally identifiable information,” which can be black-marketed on the Dark Web, or “used for various fraudulent activities, including falsified claims, medical device purchasing (and reselling), and credit card identity theft.”

Now, here’s where the authors break ground in terms of the way in which they articulate a threat that until now has tended mostly only to be whispered about. They write that “The potential for manipulation of clinical systems and clinical data constitutes an additional threat. The effect of such threats on medical devices has been well described. In 2015, the Food and Drug Administration (FDA) and the U.S. Department of Homeland Security’s Industrial Control Systems Cyber Emergency Response Team (ICS-CERT) issued an alert regarding an infusion system that could allow an attacker to remotely control the device and alter therapy administration. In January 2017, the FDA issued a similar warning for St. Jude Medical’s radio-frequency–enabled implantable cardiac devices and transmitters. Fortunately, a software patch could be applied automatically to the affected transmitters,” they note. Further, they write, “Manipulation of patient data could be even more damaging. An attacker with access to a laboratory system could modify data—changing potassium values, for example. Unsuspecting health care providers could react to the falsified potassium values, providing treatment that could harm the patient. Radiology protocols, diagnostic reports, genetic data, progress notes, and electronic prescriptions—the list of possible targets goes on. Protecting our information systems and our health data is critical to ensuring the safe delivery of health care.”

Let’s think about that for a moment—the possibility that some evil or deranged individuals might consciously and purposely decide to manipulate data in order to harm and possibly even kill, patients. At first, such a prospect might sound like the stuff of science fiction or horror novels. But, really? At a time when individuals are engaged in every form of despicable terrorism and other acts of violence and desecration towards their fellow human beings, can we afford to be naïve and believe that something like this couldn’t happen? Because it could.

So the reality is that CIOs, CMIOs, CTOs, lab leaders, pharmacy leaders, and everyone else involved in clinical informatics and IT and clinical leadership in hospitals, medical groups, and health systems, needs to understand that we’ve entered a new phase in the history of the healthcare system in which the unthinkable is possible—and everyone needs to prepare for the unthinkable.

How to do so? There are governance, management, process, and technological aspects of this. To begin with, representatives of all the stakeholder groups involved and potentially involved—IT, clinical informatics, medicine, nursing, pharmacy, laboratory, general administration, and even risk management, legal, and human resources—in hospitals, large medical groups, and health systems, will need to gather around a very big, round table in their patient care organizations, and begin to do scenario planning. They will need to look at what protocols and guardrails they have in place, and will very likely need to bring in IT security consultants in order to map out a plan—and will then need to test out their plan and set in place the protocols and processes to manage an actual attack that manipulates patient data. How will patient care organization leaders even know that such an attack has taken place…? Right now, very, very few organizations would be in a position to know, until after the attackers involved had wreaked tremendous damage.

Sadly—tragically—in our contemporary society, there are bad actors out there who absolutely would be motivated, for whatever reason, or perhaps most chillingly, no reason at all—to try to wreak havoc on patient care organizations in the U.S. and elsewhere. And, given the globalization of technology and our increasing connectivity, the potential for such a doomsday-type of attack is real. I salute authors Gordon, Fairhall, and Landman, for articulating so well the threats facing patient care organizations in the U.S., and beyond, and for prompting patient care leaders to take action—proactively—before the next terrible thing happens to a U.S.—or any—patient care organization.

 

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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

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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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