An audit of a large Southeastern hospital by the Department of Health and Human Services Office of Inspector General (HHS-OIG) identified security weaknesses in internet-facing applications, which could potentially be exploited by threat actors for initial access. Similar security weaknesses are likely to exist at many U.S. hospitals. The aim of the audit was to assess whether the hospital had implemented adequate cybersecurity controls to prevent and detect cyberattacks, if processes were in place to ensure the continuity of care in the event of a cyberattack, and whether sufficient measures had been implemented to protect Medicare enrollee data.

The audited hospital had more than 300 beds and was part of a network of providers who share patients’ protected health information for treatment, payment, and healthcare operations. The hospital had adopted the HITRUST Common Security Framework (CSF) version 9.4 as its main cybersecurity framework, used that framework for regulatory compliance and risk management, and had implemented physical, technical, and administrative safeguards as required by the HIPAA Rules.

HHS-OIG reviewed the hospital’s policies and procedures to assess its cybersecurity practices concerning data protection, data loss prevention, network management, and incident response, and interviewed appropriate staff members to gain further cybersecurity and risk mitigation insights. HHS-OIG conducted penetration tests and external vulnerability assessments on four of the hospital’s internet-facing applications.

The hospital had implemented cybersecurity controls to protect Medicare enrollee data and ensure the continuity of care in the event of a cyberattack, and the cybersecurity controls detected most of HHS-OIG’s simulated cyberattacks; however, weaknesses were found that allowed the HHS-OIG to capture login credentials and use them to access the account management web application, and a security weakness in its input validation controls allowed manipulation of the application.

HHS-OIG sent 2,171 phishing emails, but only the last 500 were blocked. A total of 108 users clicked the link in the email (6% click rate), and one user entered their login credentials in the HHS-OIG phishing website. The captured login credentials allowed HHS-OIG to access the account, although it did not appear to contain patient information. Once the web application was accessed, HHS-OIG was able to view the user’s devices associated with the account, as well as a list with options to deactivate multifactor authentication and add/remove devices from the account. If it were a real cyberattack, a threat actor could use the access for a more extensive compromise. HHS-OIG said strong user identification and authentication (UIA) controls for the account management web application had not been implemented; however, the click rate and login rate were relatively low, therefore, no recommendations were made regarding its anti-phishing controls.

Another internet-facing application was found to lack strong input validation controls, which made the application vulnerable to an injection attack. An attacker could inject malicious code into weak input fields, alter commands sent to the website, and access sensitive data or manipulate the system. While the hospital had conducted vulnerability scans and third-party penetration tests, the vulnerability failed to be identified. Further, the web application did not have a web application firewall for filtering, monitoring, and blocking malicious web traffic, such as injection attacks.

HHS-OIG made four recommendations: Implement strong user identification and authentication controls for the account management web application; periodically assess and update user identification and authentication controls across all systems; assess all web applications to determine if an automated technical solution, such as a web application firewall, is required; and utilize a wider array of testing tools for identifying vulnerabilities in applications, such as dynamic application testing tools, static application testing tools, and manual, interactive testing.

HHS-OIG did not name the audited hospital due to the risk that it could be targeted by threat actors. Further audits of this nature will be conducted on other healthcare providers to determine whether similar security issues exist and if there are any opportunities for the HHS to improve guidance and outreach to help hospitals improve their security controls.

“This report highlights the need for healthcare organizations to adapt their security programs to reflect a fundamental shift: sensitive data now resides not just in on-prem, internal apps, but also in web-based SaaS applications,” Russell Spitler, CEO of Nudge Security, told the HIPAA Journal. “Traditional network-focused security controls cannot adequately protect cloud applications where data flows across organizational boundaries. This makes identity security controls—particularly MFA and SSO—essential for protecting this dynamic attack surface.”

Spitler suggests “healthcare organizations should take a systematic approach that prioritizes comprehensive visibility and strong authentication controls across their entire application ecosystem.” Key steps recommended by Spitler include:

• Conducting a comprehensive inventory of all SaaS and web applications to understand the full picture of the organization’s attack surface
• Prioritizing MFA implementation for applications with privileged access or sensitive data, starting with internet-facing systems
• Deploying SSO solutions that can enforce MFA centrally while improving user experience and reducing password-related security risks
• Using conditional access policies that require MFA for any access from outside the corporate network or from unmanaged devices
• Regularly testing authentication controls through penetration testing and phishing simulations, as HHS OIG did in this audit

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