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Will the “Good Guys” Ever Catch Up to the “Bad Guys” When It Comes to Cybercrime in Healthcare?

February 7, 2017
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A new cybersecurity/cybercrime survey shows how global and trans-vertical the issues really are

Can the “good guys” ever catch up to the “bad guys” when it comes to data and IT security in healthcare? That most basic of questions seemed to hang over the results of a recent new report on data and IT security that spanned all industries and was international in scope.

As Assistant Editor Heather Landi reported in an article last week, “Eighty-one percent of senior IT security executives at healthcare organizations anticipate IT security spending increases in the next 12 months, yet, at the same time, successful data breaches are also up significantly. These were the findings of a recent survey conducted by Thales, a data security and information systems solutions provider, and in conjunction with 451 Research, which point to an ongoing disconnect between the security solutions organizations spend money on and the ability of those solutions to protect sensitive data.”

As Landi noted, “The report findings present a glass half-full or half-empty dilemma. The projected increase in IT security spending could potentially be good news for healthcare IT leaders dealing with budget constraints, however, the findings seem to indicate that organizations continue to focus their spending on strategies and tools that are not effectively preventing data breaches.”

Across all industries, the report found, 88 percent of business organizations feel vulnerable to data and IT security threats; 68 percent have experienced a data breach; and 73 percent have increased their spending in order to fight the scourge of breaches and hacking.

In addition, the Thales 2017 Data Threat Report, issued in conjunction with analyst firm 451 Research, found that, across all industries, business organizations are still prioritizing network and endpoint solutions over encryption despite the rise in data breaches. While 30 percent of respondents classify their organizations as “very vulnerable” or “extremely vulnerable” to data attacks (and the number of breaches continues to rise), the two top spending priorities are network (62 percent) and endpoint (56 percent) protection solutions. In contrast, spending on data-at-rest solutions (46 percent) comes last.

The press release announcing the report and the survey results on which it was based, included a statement from Garrett Bekker, senior analyst, information security, at 451 Research, and author of the report. “One possible explanation for this troubling state? Organizations keep spending on the same solutions that worked for them in the past but aren’t necessarily the most effective at stopping modern breaches,” Bekker said. “Data protection tactics need to evolve to match today’s threats. It stands to reason that if security strategies aren’t equally as dynamic in this fast-changing threat environment, the rate of breaches will continue to increase.”

What’s more, as Landi’s report last week noted, “Overall, 68 percent of survey respondents, across all industries, have experienced a breach with 26 percent experiencing a breach in the last year – both numbers that rose from last year. According to Andy Kicklighter, director of product strategy at Thales e-Security, within the healthcare segment, the number of organizations that reported having a breach in the past year increased from 18 percent to 20 percent. ‘So, that’s one in five who said they had been breached just in the last year,’ he said.”

Kicklighter also noted that the cybersecurity threat landscape continues to evolve and is becoming more sophisticated with the prevalence of spear phishing attacks combined with the availability of malware for use by cybercriminals. “Zero-day malware is not detectable with anti-virus, and you can buy it on a black market website for $4,000 or $5,000. So, if you are really determined, you are going to find a way to get credentials and get inside. If you don’t put in place technology that enables you to safeguard and control access to the sensitive data inside your organization, that’s a problem,” he noted.

A number of points are worth making here. Of course, it comes as no surprise that business organizations not only in the United States, but around the world, are being hit by malware and every other kind of cyberattack now. And the same is true in terms of these threats hitting all industries, not just healthcare. What’s more, organizations in many industries remain behind the curve, because the threats are indeed becoming more and more sophisticated, and in some cases simply different or new, every day, as Thales’s Andy Kicklighter has noted.

But healthcare remains particularly vulnerable in two very distinct contexts. First, it is still catching up to other industries such as the financial services, retailing, and transportation industries, in terms of building core data and IT security infrastructure, as well as in terms of core spending on, and staffing up for, data and IT security. So there’s that.

Second, because of the near-universalization of electronic health records (EHRs) that has occurred just in the past few years in U.S. healthcare, U.S. patient care organizations are now under unprecedented threat in terms of being potential and actual targets of malware, including ransomware, of every type. As has been noted frequently in recent months, the value of an individual’s credit card on the black market or on the street is probably only about $1.00 at this point, given that credit card companies and banks have put in very robust systems and processes to immediately shut off spending capability, and given that consumers have gotten very good at immediately notifying their banks and credit card companies of the theft or compromise of their bank and credit cards. But in healthcare, the situation is far more complex and compromised. For one thing, experts are finding that the average gap between the moment when ransomware enters a patient care organization, most often through a staff member’s opening a phishing-infected e-mail or clicking on a link, to when a clinical information system is completely encrypted and someone receives the ransom note, is around eight months. And a tremendous amount of damage can occur during that time.

What’s more, as experts are telling us, the value of a patient’s record in the U.S. averages at least $75.00, compared to the $1.00 value of a consumer’s credit card. That mostly has to do with the tremendous amount of demographic information embedded in a patient’s electronic record. Hacking someone’s EHR allows the hacker the opportunity to potentially construct a new, false identity, with all that demographic and other personal information. So is it any wonder that hospitals, medical groups, and health systems in the U.S. are collectively an enormously alluring target for data hackers from all over the world?

I remember just five or six years ago, when people were still worried about needing to shred the credit card offers they received in their junk mail loads in their home mailboxes (not that one shouldn’t still rip up those mailings into little pieces upon receipt, as a small precaution). That almost seems like a period of innocence now, relatively speaking.

In any case, back to the bigger picture: while on one level, it might perhaps be heartening to see that U.S. healthcare organizations are far from alone in their vulnerability to the cresting wave of data and IT security threats hitting them like a gigantic tsunami—this really is a global and all-industry phenomenon—on the other hand, the fact that U.S. healthcare leaders are coming to this from a position of having to rapidly catch up, is disconcerting, to say the least.

And, two more important points: first, as I mentioned above, healthcare is a uniquely alluring target to the hackers and cybercriminals, because of the monetary value of the data in EHRs and other clinical information systems, to the criminals. And second, and this is important: while there have been spectacular breaches in the past couple of years of health insurance companies, some of them involving millions of insureds, those large health insurers also have access to financial and organizational resources, simply because of their size and scope, that hospitals, medical groups, and health systems do not have. Even the largest patient care organizations in the U.S. are very small organizations compared to large (or even medium-sized) health plans. So there is a size differential there that works tremendously to the disadvantage of the healthcare IT leaders at patient care organizations, that simply can’t be discounted.

As Mac McMillan, CEO of the Austin, Texas-based CynergisTek consulting firm, emphasizes in all of his speeches and presentations, the stark reality is that CISOs, CIOs, and everyone else in healthcare IT will always be playing catch-up to some extent around these issues, because the moment that they, the good guys, begin to get a handle on an emerging or new threat, the bad guys, the cybercriminals, are already a few steps ahead of them.

So the short answer to the question I posed at the beginning of this blog—whether the “good guys” can ever catch up to the “bad guys”—is, put very simply and bluntly, no. That simply won’t be possible. But what will be possible, and must be attempted, is for healthcare IT leaders at patient care organizations to continue to build the processes, systems, and teams needed to be as up-to-date as humanly possible, going forward. That includes engaging in leading-edge data and IT security strategies, such as behavioral monitoring; advanced network segmentation and securitization processes; advanced backup and auditing processes; and, in many cases, the engagement of outside consulting firms, particularly of security operations centers (SOCs), to provide round-the-clock services at advanced levels of proficiency and capability.

I’ll be addressing these questions on Thursday, March 23, when I moderate a panel on the subject of “A Deeper Dive: Understanding the Next Generation of Cybersecurity Threats,” at our Health IT Summit in Cleveland, which will be held at the Ritz-Carlton in that city (the full agenda for our Cleveland Health IT Summit can be found here). I’ll have the honor and privilege to be surrounded by industry experts for that discussion, including FBI supervisory special agent Bryan P. Smith of the FBI’s Cleveland office; Pamela Banchy, CIO and vice president of clinical information at the Western Reserve Health System; Matthew Junod, CISO at the Unviersity of Toledo; and Karen Martinko, IT security manager at MetroHealthSystems. Those industry leaders will help our assembled Summit participants think through what the leading-edge strategies and options are in this area, and which ones healthcare IT leaders should be pursuing in their organizations.

So the reality is that this cybersecurity battle is going to be an unending war, going into the future. But the good news is that patient care organizations in the U.S. are beginning to catch up in terms of putting in the core foundations—in terms of funding, staffing, governance, and above all, strategy—in this area of essential importance to everyone. And that is significant—and worth noting.


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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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