Two British Doctors’ Searing Testimony on WannaCry’s Devastating Impact on the U.K.'s NHS | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Two British Doctors’ Searing Testimony on WannaCry’s Devastating Impact on the U.K.'s NHS

August 7, 2017
| Reprints
It was fascinating to read a NEJM op-ed by two NHS MDs, about how devastating the WannaCry attack was, for their daily medical practice

It was fascinating to read a Perspectives article in The New England Journal of Medicine, written by two physicians who practice inside the National Health Service (NHS) in the United Kingdom

It was fascinating to read a Perspectives article in The New England Journal of Medicine, written by two physicians who practice inside the National Health Service (NHS) in the United Kingdom. This was no ordinary op-ed: it was something akin to a whistleblower essay.

This op-ed, written by Rachel Clark, M.D. and Taryn Youngstein, M.D., and published online on August 3, under the headline, “Cyberattack on Britain’s National Health Service—a Wake-up Call for Modern Medicine,” was riveting.

Drs. Clark and Youngstein begin, “As you would expect in a pandemic, the headlines were alarmist: we were reportedly locked in a race against time to protect millions of patients from a new virus of unprecedented virulence that had crippled the United Kingdom’s National Health Service (NHS) and was spreading rapidly across the country. Except in this case, the virus was not organic but digital. On May 12, 2017,” they continue, “computer hackers attempted to hold the NHS hostage by exploiting a weakness in Microsoft operating systems. When NHS staff opened an apparently innocuous e-mail attachment, a ransomware worm known as ‘WannaCry’ infiltrated their computers, encrypting data and locking out users. Throughout the United Kingdom, NHS doctors and nurses found themselves helplessly staring at screens that ordered them to pay a Bitcoin ransom to unlock their computers.”

Here’s the thing: as Drs. Clark and Youngstein write, “Long before the headlines broke, those of us at work in the NHS that Friday sensed that something was amiss. Before official hospital alerts kicked in, we received messages from colleagues asking if we, too, had had our computers frozen. Rumors swiftly circulated: elective surgeries were being canceled, clinics rearranged, managers summoned to private meetings. A sense of unease began to build on the shop floor. As in every unfolding real-time crisis, confusion, bewilderment, and rumor were rife. Eventually, official news of the cyberattack broke. Whole hospital and primary care networks were suspended, and the NHS went into electronic lockdown.”

The doctors go on to write, “With lurid headlines lighting up our smartphones it would have been easy for staff and patients to panic. Information technology (IT) has become the linchpin of everything we do, with most NHS hospitals and general practices now using electronic notes, imaging systems, and drug-prescribing systems. We can just about survive without a stethoscope — once the symbol of our craft — but without our computer log-ins, modern medicine grinds to a halt. In fact, in many places, the chaos was to some degree preemptive. In a slick and effective attempt to protect themselves from harm, even hospitals unaffected by WannaCry were self-imposing electronic quarantine, avoiding infection by shutting down entire networks.”

Now, here’s the real kicker. “Certainly,” Drs. Clarke and Youngstein write, “for frontline doctors like us who are used to wrestling with clunky NHS IT systems, the biggest surprise of the malware attack was not that it happened but why it had taken so long. It is an irony lost on no NHS doctor that though we can transplant faces, build bionic limbs, even operate on fetuses still in the womb, a working, functional NHS computer can seem rarer and more precious than gold dust. But the NHS’s cyberattack experience has more nuanced and generalizable implications. First, it exposed the fact that although much has been written about cyberattacks potentially breaching confidential patient information, health care providers have not truly considered the physical harm that could befall our patients should an external party with malicious intent take over health service computers.4 This realization raises urgent questions about the necessity of equipping hospitals with fit-for-purpose IT. Digital security simply hadn’t been an NHS priority until WannaCry’s infection became the biggest cyberattack on critical infrastructure in U.K. history.” Further, the doctors describe the attack as “stressful, grueling, and exhausting — not least for the legions of NHS IT workers who toiled all night to update and then patch thousands of health service systems. For doctors,” they write, “it was a wake-up call.”

And, with regard to the infamous funding issues that have been bedeviling the NHS for decades, the authors write, “Underfunding ultimately left us horribly exposed to a predictable attack that threatened not just privacy but patient safety. If the WannaCry saga appears depressing, however — a realization of the perils of poorly funded health care — that was not the lesson we ultimately took from the experience. Facing adversity, with their backs against the wall, NHS staff quietly and resolutely got on with the job at hand.”

And that’s why I should not have been shocked—and yet was—to learn that the NHS’s information system was still operating on Windows XP. That’s right, Windows XP. Indeed, as Aatif Sulleyman wrote in The Independent of London on May 12, “Up to 90 per cent of NHS computers still run Windows XP, according to a report published in the BMJ [British Medical Journal] earlier this week. The operating system was released in 2001, and Microsoft cut support for it in 2014. People can continue to use the software, but doing so comes with enormous risks,” he wrote, quoting David Emm, the principal security researcher at international IT security firm Kaspersky, as saying that "Using XP is particularly bad because it’s no longer supported and there’s no way to patch it.” “Microsoft no longer builds or distributes security updates for XP, leaving it extremely vulnerable to viruses and cybercriminals. The company is extremely clear about how important it is to stop using XP,” Sulleyman noted.

So—yes—really—the leaders of the NHS had persisted in operating off Windows XP, despite repeated warnings. Indeed, as Jon Ungoed-Thomas and Dipesh Gadher reported on May 14 in The Sunday Times of London, NHS Digital, the IT organization behind the NHS, has been operating without a permanent chief executive, while they reported additionally that Jeremy Hunt, the U.K.’s health secretary had been “warned by watchdogs last July that NHS systems needed to be strengthened ‘as a matter of urgency.’ Dame Fiona Caldicott, the national data guardian, and the Care Quality Commission informed Hunt in an eight-page letter that there was a risk of ‘serious, large-scale data losses’ from a cyber-attack unless action was taken,” the Sunday Times reporters noted.

So… ohmygosh. This truly was IT operational malpractice at a very high level. And, I am grateful for Drs. Clarke and Youngstein for sharing with The New England Journal of Medicine’s readers what this looked like as a lived experience from the inside, on the part of frontline physicians.

Now, let’s be clear: there isn’t a precise equivalent to this situation in the United States. For one thing, we don’t have a single unified national healthcare delivery system. What’s more, while the U.S. healthcare system certainly has its funding issues, there simply is no equivalent to the entire U.S. healthcare delivery system running off Windows XP.

But before we “Yanks” (as the British like to call us) get complacent about this, we should consider how deeply relevant this episode is to U.S. healthcare and healthcare it, broadly speaking. The WannaCry explosion ricocheted across the globe in a matter of minutes—yes, we really all are connected now, these days—and it affected the operations of the Spanish telephone company, the French national railway system, and banks in Russia and Ukraine, among other entities. What’s more, given how quickly patient care organizations in the U.S. are being connected, via health information exchange and other mechanisms, it is absolutely imaginable that we could face analogous calamities in the future.

So, what lessons should we take from all of this? First of all, an incredibly basic one: at this point in the evolution of U.S. healthcare, probably more than 90 percent of patient encounters are facilitated by some level of automation, either via the EHR directly, or via some other clinical information system. These systems simply can no longer go down. Second, keeping all information systems in hospitals, medical groups, and health systems up to date in terms of IT security, is no longer a “good to have” kind of thing—it is essential to keeping patient care operating and moving forward. This is no longer optional. And third, healthcare and healthcare IT leaders are not managing data and IT security in a vacuum; the opposite, really. The threats are growing and accelerating literally every day now. And in the United States, the majority of patient care organizations are not ready for what’s coming at them. Consider the simple fact that many medical devices that are connected through automation to EHRs, are still running on XP and other insecure platforms. And that’s in the U.S.

So while we can cluck over the utter disaster that the WannaCry attack wreaked on the U.K.’s NHS, the reality is that literally, every healthcare system in the world is vulnerable to the attacks coming from increasingly sophisticated hackers who are operating from every possible corner of the world. And, in the end, what Drs. Clark and Youngstein had to say in this NEJM op-ed piece should serve as a warning—or at least, friendly advice from the already-burned—to patient care leaders in the U.S. Because, really, the NHS scenario, though it played out in a different context, is honestly not unimaginable over here. Trust their testimony.



2018 Raleigh Health IT Summit

Renowned leaders in U.S. and North American healthcare gather throughout the year to present important information and share insights at the Healthcare Informatics Health IT Summits.

September 27 - 28, 2018 | Raleigh


Healthcare’s “RegTech” Opportunity: Avoiding a 2008-Style Crisis

September 21, 2018
by Robert Lord, Industry Voice, Co-Founder and President of Protenus
| Reprints

In the financial crisis of 2007 to 2009, the financial industry suffered a crisis of trust. A decade later, banks and other financial institutions are still working to regain the confidence of consumers and regulators alike. In 2008 and 2009, while working at one of the world’s top hedge funds, I had a front-row seat to the damage that occurred to our economy, watching as storied corporate institutions fell or were gravely damaged. Today, as co-founder of a health technology company, I see healthcare is approaching a similarly dangerous situation. We must get ahead of the curve to avoid disaster.

Like finance, healthcare is a highly-regulated industry where non-compliance can result in severe financial and reputational consequences for healthcare companies, and severe impact on people’s lives. We deal with HIPAA, MACRA, HITECH, and hundreds of other foreboding acronyms on a daily basis. A lot of attention goes to the terrific and important work of clinical decision support, wellness apps, and other patient care technologies, but problems in the back office of hospitals must be addressed as well. One of these problems is the amount and complexity of healthcare regulation, and our healthcare system’s inability to keep up.

In finance, where I spent the early part of my career, the adoption of what is termed “RegTech” (regulatory technology) was driven by the increasing complexity of financial technology and infrastructure sophistication.  As trades moved faster, and as algorithms, processes and organizations became more complex, the technologies needed to ensure regulatory compliance had to move in tandem.  The crisis we experienced in 2008 was partially the result of the inability of the industry’s regulatory capabilities to keep up with the pace of technological change.  In many ways, the industry is still playing a catch-up game.

As healthcare professionals, looking to the lessons learned by our colleagues in finance can help us predict patterns and stay ahead of the curve. Right now, I’m seeing alarming parallels to challenges faced in finance a decade ago.


How to Assess IT Risk in a Healthcare Environment

In this webinar, Community Health System’s CISO Scott Breece and Lockpath's Sam Abadir will discuss the unique IT landscape of the healthcare industry and the challenges this presents for IT risk...

Robert Lord

The burden of regulation across our industry is simply staggering.  Thirty-nine billion dollars of regulatory burden is associated with healthcare annually, which is about $1,200 per patient, per year. Despite this high cost, we still have $1 trillion of fraud, waste and abuse in our healthcare system. With so much regulation, why are we seeing so little yield from that burden? In many cases, it’s because we’re merely checking boxes and not addressing core risks؅. Like finance, there was a great deal of effort on compliance with regulations, but not enough attention on addressing important systemic risks.

This is not to say I am against good regulation; in fact, many regulations serve to protect patients and improve care. The problem is that there are so many demands on healthcare systems, that compliance and regulation is often reduced to checking boxes to ensure that minimum defensible processes are built, and occasionally spot-checking that things look reasonable. We currently have nowhere near 100 percent review of activities and transactions that are occurring in our health systems every day, though our patients deserve nothing less. However, unless overburdened and under-resourced healthcare providers and compliance professionals can achieve leverage and true risk reduction, we’ll never be able to sustainably bend our compliance cost curve.

Systemic problems are often not discovered until something goes horribly wrong (e.g., Wall Street every decade or so, the Anthem data breach, etc.). Today In the financial industry, RegTech provides continual, dynamic views of compliance or non-compliance and allows management, compliance professionals and regulators to check compliance in real-time. They can view every record, understand every detail, and automate investigations and processes that would otherwise go undetected or involve lengthy and labor-intensive reviews.

The real promise of these new capabilities is to allow compliance professionals and regulators to perform the truest form of their jobs, which is to keep patient data secure, ensuring the best treatment for patients, and creating sustainable financial models for healthcare delivery. RegTech will open up lines of communication and help create conversations that could never have been had before—conversations about what’s not just feasible for a person to do, but what’s right to do for the people whom regulation seeks to protect.

No longer bound by limited resources that lead to “box-checking,” compliance officers can use new and powerful tools to ensure that the data entrusted to them is protected. At the same time, healthcare management executives can be confident that the enterprises they manage will be well served by risk reducing technological innovation.  Patients, the ultimate beneficiaries of healthcare RegTech, deserve as much.

Robert Lord is the co-founder and president of Protenus, a compliance analytics platform that detects anomalous behavior in health systems.  He also serves as a Cybersecurity Policy Fellow at New America.


More From Healthcare Informatics


HIPAA Settlements: Three Boston Hospitals Pay $1M in Fines for “Boston Trauma” Filming

September 20, 2018
by Heather Landi, Associate Editor
| Reprints

Three Boston hospitals that allowed film crews to film an ABC documentary on premises have settled with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) over potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

According to OCR, the three hospitals—Boston Medical Center (BMC), Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital (MGH)—compromised the privacy of patients’ protected health information (PHI) by inviting film crews on premises to film "Save My Life: Boston Trauma," an ABC television network documentary series, without first obtaining authorization from patients.

OCR reached separate settlements with the three hospitals, and, collectively, the three entities paid OCR $999,000 to settle potential HIPAA violations due to the unauthorized disclosure of patients’ PHI.

“Patients in hospitals expect to encounter doctors and nurses when getting treatment, not film crews recording them at their most private and vulnerable moments,” Roger Severino, OCR director, said in a statement. “Hospitals must get authorization from patients before allowing strangers to have access to patients and their medical information.”

Of the total fines, BMC paid OCR $100,000, BWH paid $384,000, and MGH paid $515,000. Each entity will provide workforce training as part of a corrective action plan that will include OCR’s guidance on disclosures to film and media, according to OCR. Boston Medical Center's resolution agreement can be accessed here; Brigham and Women’s Hospital's resolution agreement can be found here; and Massachusetts General Hospital's agreement can be found here.

This is actually the second time a hospital has been fined by OCR as the result of allowing a film crew on premise to film a TV series, with the first HIPAA fine also involving the filming of an ABC medical documentary television series. As reported by Healthcare Informatics, In April 2016, New York Presbyterian Hospital (NYP) agreed to pay $2.2 million to settle potential HIPAA violations in association with the filming of “NY Med.”

According to OCR announcement about the settlement with NYP, the hospital, based in Manhattan, violated HIPAA rules for the “egregious disclosure of two patients’ PHI to film crews and staff during the filming of 'NY Med,' an ABC television series.” OCR also stated the NYP did not first obtain authorization from the patients. “In particular, OCR found that NYP allowed the ABC crew to film someone who was dying and another person in significant distress, even after a medical professional urged the crew to stop.”

The OCR director at the time, Jocelyn Samuels, said in a statement, “This case sends an important message that OCR will not permit covered entities to compromise their patients’ privacy by allowing news or television crews to film the patients without their authorization. We take seriously all complaints filed by individuals, and will seek the necessary remedies to ensure that patients’ privacy is fully protected.” 

OCR’s guidance on disclosures to film and media can be found here.

Related Insights For: Cybersecurity


Independence Blue Cross Notifies 17K Patients of Breach

September 19, 2018
by Rajiv Leventhal, Managing Editor
| Reprints

The Philadelphia-based health insurer Independence Blue Cross is notifying about 17,000 of its members that some of their protected health information (PHI) has been exposed online and has potentially been accessed by unauthorized individuals.

According to an article in HIPAA Journal, Independence Blue Cross said that its privacy office was informed about the exposed information on July 19 and then immediately launched an investigation.

The insurer said that an employee had uploaded a file containing plan members’ protected health information to a public-facing website on April 23. The file remained accessible until July 20 when it was removed from the website.

According to the report, the information contained in the file was limited, and no financial information or Social Security numbers were exposed. Affected plan members only had their name, diagnosis codes, provider information, date of birth, and information used for processing claims exposed, HIPAA Journal reported.

The investigators were not able to determine whether any unauthorized individuals accessed the file during the time it was on the website, and no reports have been received to date to suggest any protected health information has been misused.

A statement from the health insurer noted that the breach affects certain Independence Blue Cross members and members of its subsidiaries AmeriHealth HMO and AmeriHealth Insurance Co. of New Jersey. Fewer than 1 percent of total plan members were affected by the breach.

See more on Cybersecurity