HHS’s “Critical Condition” Report on Cybersecurity: Offering a Path Forward? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

HHS’s “Critical Condition” Report on Cybersecurity: Offering a Path Forward?

June 9, 2017
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A new report by a federal panel offers suggestions to help healthcare IT leaders move forward on cybersecurity

The conclusions in the report that the Health Care Industry Cybersecurity Task Force of the Department of Health and Human Services (HHS) released to Congress on June 2 were a bit like the conceptual equivalent of a slow-moving hurricane—devastating, but long predicted. Stating that “healthcare cybersecurity is in critical condition,” the report’s authors cited a severe lack of security talent, legacy equipment that runs on old, unsupported and vulnerable operating systems, vulnerabilities that impact patient care and an epidemic of known vulnerabilities. The report, developed by Task Force members comprised of government and private industry leaders, also cited “premature and over-connectivity” as an issue contributing to the critical state of cybersecurity. “Meaningful Use requirements drove hyper-connectivity without secure design and implementation,” the report’s authors wrote.

The report, entitled “Report on Improving Cybersecurity in the Health Care Industry,” is very much worth reading, in any case. As its authors note, “Now more than ever, all health care delivery organizations… have a greater responsibility to secure their systems, medical devices, and patient data. Most health care organizations face significant resource constraints as operating margins can be below one percent. Many organizations cannot afford to retain in-house information security personnel, or designate an information technology (IT) staff member with cybersecurity as a collateral duty. These organizations often lack the infrastructure to identify and track threats, the capacity to analyze and translate the threat data they receive into actionable information, and the capability to act on that information.” Importantly, they note that “Many organizations also have not crossed the digital divide in not having the technology resources and expertise to address current and emerging cybersecurity threats. These organizations may not know that they have experienced an attack until long after it has occurred. Additionally, both large and small health care delivery organizations struggle with numerous unsupported legacy systems that cannot easily be replaced (hardware, software and operating systems) with large numbers of vulnerabilities and few modern countermeasures. Industry will need to dramatically reduce the use of less defensible legacy and unsupported products, and more effectively reduce risk in future products through robust development and support strategies.”

Also importantly, the report’s authors note that,” With the exception of IT security personnel, many providers and other health care workers often assume that the IT network and the devices they support function efficiently and that their level of cybersecurity vulnerability is low. Recent high-profile incidents, such as ransomware attacks and large-scale privacy breaches, have shown this vulnerability assumption to be false and provided an opportunity to increase education and awareness about the benefits of cybersecurity in the health care community. Moreover, recent ransomware incidents have also highlighted how patient care at health care delivery organizations can be interrupted due to a system compromise. Members of the health ecosystem reported that prior to these breaches many security professionals had difficulty demonstrating the importance of cyber protections to organizational leadership, including how risk mitigation can save money and protect against reputational damage in the long-term. Making the decision to prioritize cybersecurity within the health care industry requires culture shifts and increased communication to and from leadership, as well as changes in the way providers perform their duties in the clinical environment. Thus, health care cybersecurity is a key public health concern that needs immediate and aggressive attention.”

On a practical level, the Task Force’s report sets out six imperatives for action. They are:

1. Define and streamline leadership, governance, and expectations for health care industry


2. Increase the security and resilience of medical devices and health IT.

3. Develop the health care workforce capacity necessary to prioritize and ensure

cybersecurity awareness and technical capabilities.

4. Increase health care industry readiness through improved cybersecurity awareness and


5. Identify mechanisms to protect research and development efforts and intellectual property

from attacks or exposure.

6. Improve information sharing of industry threats, weaknesses, and mitigations

On one level, these are all very obvious, and are all elements that every CIO of every patient care organization should already know and understand. But on a deeper level, they actually aren’t that obvious, at least not in their execution.

Here’s the thing: the proportion of patient care organizations across the U.S. that are truly cybersecurity-prepared remains very small overall. Of course, organizations all over the place across a spectrum. But certainly, far less than a majority are prepared for any but the most elementary kinds of attacks, and very, very few are prepared in the areas of medical device connectivity, workforce readiness, or heavy-duty hacker threats.

As Section III of the report, “Risks across the healthcare industry,” points out, “The attack surface of the health information system expands when interconnected devices, such as mobile devices, medical devices, and applications, are permitted to connect to EHRs. Further complicating the health information system and EHR integration is the mobile device/application component. For simplicity, the EHR is the hub and connected medical devices are spokes. The modern EHR is the central exchange of the information super-highway that provides key clinical information and analytics to providers giving quality data, billing information, etc. Most deployed EHR solutions across the U.S. are built on more than one vendor’s software solution. They are a complex mix of applications, programs, and interfaces from a variety of vendors. Implementing a patch, update, or significant data flow change requires massive support and a significant governance structure, which can destabilize the intricate and sometimes fragile connections to the “spokes”. Conversely, medical device system changes and updates typically come from a manufacturer, which makes their software easier to change compared with changing EHR software. The National Cybersecurity and Communications Integration Center (NCIC) addressed this attack surface in their 2012 bulletin.22 Though EHRs have some unique risks, the risk to this technology is similar to medical devices as far as user and device authentication, timely updates, user access rights, risk of malware, and denial of service.”

The report’s authors also note that “Cybersecurity threats and vulnerabilities can impact the confidentiality, availability, and integrity of IT networks and the medical devices and other systems connected to these networks. However, medical devices and the IT networks they connect to are unique. In addition to data security and privacy impacts, patients may be physically affected (i.e., illness, injury, death) by cybersecurity threats and vulnerabilities of medical devices. This harm may stem from the performance of the device itself, impeded hospital operations, or the inability to deliver care. As a result, addressing the patient safety risks posed by cyber threats are of paramount importance.”

With regard to that portion of the report, the reality is that, right now, only a tiny percentage of hospitals and large medical groups have worked out a feasible set of process and technological mechanisms to address threats coming in via medical devices, and that is one of the most glaring gap areas, and one that it’s good that the report has addressed.

Beyond that, though, healthcare IT leaders in patient care organizations need to move forward very quickly in several key areas, including behavioral monitoring, network segmentation, advanced backup and auditing procedures, and the use of external resources, particularly SOCs (security operations centers).

As many industry experts have told us editors at Healthcare Informatics in interviews, and as numerous speakers and discussion panelists have stated at our Health IT Summits, the time has come for healthcare IT leaders to embrace these more advanced strategies, methods, processes, and technologies. A simple focus on perimeter management absolutely no longer cuts it.

Take for example the issue of network segmentation: as data breaches become more common by the day, it is becoming clearer than ever that failing to segment means, in very stark terms, leaving the entirety of an organization’s broad IT network vulnerable to any breach, without appropriate containment. Meanwhile, while virtually every patient care organization runs regular data backups, particular of EHRs, how often are those backups audited? Leading industry experts have emphasized the need for regular (and of course, the definition of what is “regular” still varies quite wildly among healthcare IT professionals, depending on with whom one speaks) audits of backups. After all, most ransomware breaches are not discovered for eight or nine months or even longer; and on a very basic level, if one has been doing nine months of backups and one’s data has been infected for nine months, that makes for nine months of corrupted or unavailable data.

Meanwhile, behavioral monitoring is emerging as yet another critical process to engage in. Consultants working in healthcare cybersecurity are saying it over and over: behavioral monitoring works. It proactively can identify behavioral anomalies very early on; and is being used successfully to intervene very early in any endangering process.

As a panel of industry leaders discussed much of this on May 12 in Chicago, during the Healthcare Informatics Health IT Summit in Chicago. During that discussion, UC Irvine Health CIO Chuck Podesta noted that “There are ways to map out your processes; you can use rules to create spreadsheets that show behavioral patterns. You can utilize those tools—and as you avert these breaches, you can create educational programs around what you’ve found out. You don’t use employees’ names, but use circumstances. These frontline employees are absolutely essential to educate,” in order to minimize the chances of breaches, Podesta emphasized. “Of course, there are bad actors out there. But it’s so easy for breaches to occur because of mistakes made by your frontline employees. So no matter what you do on the outside, there’s always a way in. But what you can do on the inside, you can really protect against internal threats.”

And there is of course one other huge area of challenge, which is around human resources, expertise, and so on. And the reality in that context is that patient care organizations in the U.S. are hideously behind in acquiring the key personnel and resources needed to meet the cresting challenges. Not only are patient care organizations struggling to acquire chief information security officers (CISOs); many of those being named CISOs are not at the level needed to adequately manage the challenges now cresting towards them. What’s more, CISOs need entire teams of information security professionals; and the funding resources needed to adequately move forward.

So, all in all, this new report marks an important step in how the current set of cybersecurity challenges ramping up against patient care organizations in the U.S. Let’s hope that the leaders of patient care organizations in this country take this report seriously, and find its recommendations useful to the mountain of efforts they’ll need to harness going forward. The security of all the information systems—and the patient data—in this country depends on it.




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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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