Healthcare Cybersecurity

University of Maryland Medical System Discovers 250-Device Malware Attack

In the early hours of Sunday, December 9, 2018, the University of Maryland Medical System discovered an unauthorized individual had succeeded in installing malware on its network. Prompt action was taken to isolate the infected computers to contain the attack.

According to a statement issued by UMMS senior VP and chief information officer, Jon P. Burns, most of the devices that were infected with the malware were desktop computers. The prompt action taken by IT staff allowed the infected computers to be quarantined quickly. No files were encrypted and there was no impact on medical services.

UMMS should be commended for its rapid response. The attack was detected at 4.30am and by 7am, its networks and devices had been taken offline and affected devices had been quarantined. The majority of its systems were back online and fully functional by Monday morning.

The incident highlights just how important it is for healthcare organizations to have an effective incident response plan that can be immediately implemented in the event of a malware attack.

UMMS runs medical facilities in more than 150 locations and uses more than 27,000 computers. If a breach response plan had not been in place, the malware attack could have been far more serious and could have had a major impact on patients.

“The measures we took to identify the initial threat, isolate it to prevent intrusion, and to counter and combat the attack before it could infiltrate and infect our network worked as designed,” explained Burns.

At this stage, UMMS does not believe that any medical records or other patient data have been compromised. The investigation into the attack is continuing to determine how the malware was introduced. UMMS has enlisted help from computer forensics experts in this regard and the security breach has been reported to law enforcement.

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DHS/FBI Issue Fresh Alert About SamSam Ransomware

In late November, the Department of Justice indicted two Iranians over the use of SamSam ransomware, but there is unlikely to be any let up in attacks.

Due to the high risk of continued SamSam ransomware attacks in the United States, the Department of Homeland Security (DHS) and FBI have issued a fresh alert to critical infrastructure organizations about SamSam ransomware.

To date, there have been more than 200 SamSam ransomware attacks, most of which have been on organizations and businesses in the United States. The threat actors behind SamSam ransomware have received approximately $6 million in ransom payments and the attacks have resulted in more than $30 million in financial losses from computer system downtime.

The main methods of attack have been the use of the JexBoss Exploit Kit on vulnerable systems, and more recently, the use of Remote Desktop Protocol (RDP) to gain persistent access to systems. Access through RDP is achieved through the purchase of stolen credentials or brute force attacks.

Once access is gained, privileges are escalated to gain administrator rights. The threat actors then explore the network and deploy and execute the ransomware on as many devices as possible to maximize the disruption caused. A ransom demand is then placed on the desktop. Ransoms of between $5,000 and $50,000 are usually demanded, depending on the extent of encryption.

The FBI has analyzed the systems of many SamSam ransomware victims and has determined in many cases there has been previous unauthorized network activity unrelated to the SamSam ransomware attacks. This suggests the SamSam ransomware threat actors have purchased stolen credentials that have previously been used by other threat actors.

“Detecting RDP intrusions can be challenging because the malware enters through an approved access point,” explained DHS/FBI in the report, but there are steps that can be taken to make systems more secure.

Summary of DHS/FBI Advice to Improve Network Security

  • Audit the network for systems that use Remote Desktop Protocol for communications and disable RDP, if possible
  • Close open RDP ports on cloud-based virtual machine instances with public IPs, especially port 3389, unless there is a valid reason for keeping ports open
  • Adhere to cloud providers’ best practices for remote access to cloud-based VMs
  • Locate all systems with open RDP ports behind firewalls and ensure VPNs are used to access those systems remotely
  • Ensure third parties that require RDP access adhere to internal remote access policies
  • Enforce the use of strong passwords
  • Use multi-factor authentication, where possible
  • Ensure software is kept up to date and patches are applied promptly
  • Ensure all data are backed up regularly
  • Implement logging mechanisms that captured RDP logins and retain logs for 90 days. Review logs regularly for attempted intrusions
  • Where possible, disable RDP on critical devices and minimize network exposure for all control system devices
  • Regulate and limit external-to-internal RDP connections
  • Restrict user permissions, especially related to the use of unauthorized/unwanted software applications
  • Use spam filtering technology to scan all email attachments and make sure the attachment extensions match file headers
  • Disable file and printer sharing services where possible. If those services are required, use strong Active Directory authentication.

Technical details of four SamSam (MSIL/Samas.A) ransomware variants have been released (Alert: AA18-337A) to help network defenders protect against attacks.

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First Hospital GDPR Violation Penalty Issued: Portuguese Hospital to Pay €400,000 GDPR Fine

The first hospital GDPR violation penalty has been issued in Portugal. The Portugal supervisory authority, Comissão Nacional de Protecção de Dados (CNPD), took action against the Barreiro Montijo hospital near Lisbon for failing to restrict access to patient data stored in its patient management system.

Concerns were raised about the lack of data access controls in April 2018. Medical workers in the southern zone discovered non-clinical staff were using medical profiles to access the patient management system.

CNPD conducted an audit of the hospital and discovered 985 hospital employees had access rights to sensitive patient health information when there were only 296 physicians employed by the hospital. Only medical doctors at the hospital should have been able to access that level of detailed information about patients. CNPD also discovered a test profile had been set up with full, unrestricted administrator-level access to patient data and nine social workers had been granted access to confidential patient data.

The failure to implement appropriate access controls is a violation of the EU’s General Data Protection Regulation (GDPR) which came into force on May 25, 2018.

The hospital has been fined €400,000 ($455,050) for the GDPR violations – €300,000 for the failure to limit access to patient data and €100,000 for the failure to ensure the confidentiality, integrity, and availability of treatment systems and services. The hospital is taking legal action over the GDPR penalty.

This is the first GDPR violation fine to be issued in Portugal and one of the first fines since GDPR started to be enforced in May 2018. The financial penalty is well below the maximum fine that can be issued for a GDPR violation, which is up to €20 million ($22.74 million) or 4% of global annual turnover, whichever is greater.

In November, the supervisory authority in Germany, Baden-Württemberg Data Protection Authority, issued a financial penalty to the chat platform for the failure to secure the personal information of EU residents. suffered a data breach that exposed the email addresses of 808,000 users and 1.8 million usernames and passwords. The investigation revealed sensitive information such as passwords were stored in plain text. was fined €20,000 ($22,750). The relatively low fine was due to the level of transparency over the breach, exemplary cooperation with the data protection authority, and the speed at which security upgrades were applied.

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ONC Announces Winners of Easy EHR Issues Reporting Challenge

The Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) has announced the winners of its Easy EHR Issues Reporting Challenge.

Currently, reporting EHR safety concerns is cumbersome and causes disruption to clinical workflows. A more efficient and user-friendly mechanism is required to allow EHR users to quickly identify, document, and report issues to their IT teams.

Fast reporting of potential safety issues will allow the root causes of problems to be found more quickly and for feedback to be provided to EHR developers rapidly to ensure problems are resolved in the shortest possible timeframe.

The aim of the challenge was to encourage software developers to create solutions that would help clinicians report EHR usability and safety issues more quickly and efficiently in alignment with their usual clinical workflows and make the reporting of EHR safety issues less burdensome.

After assessing all submissions, ONC chose three winners:

1st Place and $45,000 was awarded to James Madison Advisory Group, which developed a unique solution for documenting and reporting potential EHR safety issues. The tool can be launched using a system tray icon or hotkey without exiting the EHR workflow. The solution works on Windows 8 systems and above and all EHR platforms. The software tool exports data in the HHS Agency for Healthcare Research and Quality (AHRQ) Common Formats XML and PDF, can capture screenshots, and simplifies report delivery.

2nd Place and $25,000 was awarded to Pegwin which developed a software platform that clinicians can use to create and send safety and usability reports with three clicks of a mouse. The solution has an intuitive design, uses contextual menus, and automates Common Formats reporting as far as possible.

3rd Place and $10,000 was awarded to Jared Schwartz and his team for developing a Google Chrome plug-in that integrates with IT ticketing systems. The plug-in allows more consistent capturing of EHR safety issues.

Improving the safety of health IT remains an important priority,” said Andy Gettinger, M.D., ONC chief clinical officer. “We believe that making it easier for end users to report will help in that goal.”

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OIG Identified Serious Security Failures at Arizona Managed Care Organizations

The Department of Health and Human Services’ Office of Inspector General (OIG) has issued a report on the findings of security audits at two managed care organizations (MCOs) in Arizona. OIG discovered serious security flaws in information systems that could place the confidentiality, integrity, and availability of Medicaid data and systems used to process Medicaid managed care claims at risk.

OIG conducted the audits to determine whether the Arizona Medicaid MCOs were adequately protecting their information systems and Medicaid data, and whether they were in compliance with Health Insurance Portability and Accountability Act (HIPAA) security requirements.

OIG discovered 19 security vulnerabilities in access controls and configuration management spanning 9 security control areas.

5 vulnerabilities were identified in the access controls category and 14 vulnerabilities were identified in the configuration management category. They included vulnerabilities in access controls, administrative controls, patch management, antivirus management, database management, server management, website security, and the configuration of network devices. The vulnerabilities were collectively and, in some cases, individually significant, although OIG did not uncover any evidence to suggest the vulnerabilities had been exploited.

Examples of vulnerabilities in the access control category include the failure to disable user accounts for terminated employees in a timely manner and the lack of two-factor authentication for remote network access.

Examples of vulnerabilities in the configuration management category include the misconfiguration of firewall Secure Shell (SSH) session timeouts. While the default timeout was 5 minutes, at one of the MCOs it had been changed to 30 minutes. Such a long timeframe would allow an attacker to access the system using an authenticated administrator session that had not been terminated.

The MCOs failed to apply patches on workstations promptly. If vulnerabilities persist, they can be exploited to gain access to data as the May 2017 WannaCry attacks on the UK’s National Health Service (NHS) clearly demonstrated.

Antivirus software was not updated at one of the MCOs. Around half of its servers had out of date antivirus definitions, which could have allowed malware to be installed undetected. Unsupported software was still in use on three production servers used by one MCO and there was no encryption used on the claims processing database.

The auditors found that in three security control areas, which accounted for 10 of the 19 vulnerabilities identified, similar vulnerabilities were present at both audited MCOs.

The discovery of similar security vulnerabilities at both MCO’s strongly suggests that other MCOs in the state, and potentially nationwide, could have the same vulnerabilities. OIG also notes that federal regulations covering the security of Medicaid data differ depending on who holds the data. The different application of security measures by state agencies and MCOs could affect state-MCO relationships nationwide and thus increase the risk of exposure of Medicaid data.

OIG recommended the CMS to conduct a documented risk assessment to determine how the disparate application of Federal security requirements creates cybersecurity risks for Medicaid data maintained by MCOs, and suggested the CMS identify actions that could be taken to address the security gaps.

OIG also recommended that the CMS should inform all state agencies of the findings of the audits to raise awareness of the vulnerabilities to enhance nationwide awareness of cybersecurity weaknesses.

The CMS did not concur with the OIG recommendation to conduct a documented risk assessment. “CMS stated that a risk assessment is already a requirement under the jurisdiction of the HHS Office for Civil Rights (OCR) and it would be duplicative of existing risk assessment efforts.”

OIG noted that since the issue concerns the Medicaid program and OCR is not responsible for the disparate application of Federal security requirements, the CMS is in the best position to ensure that security requirements are consistently applied to protect Medicaid data, regardless of who holds the data.  The CMS did concur with the the recommendation to notify state agencies about the cybersecurity vulnerabilities uncovered by the audits.

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DOJ Indicts Two Iranian Hackers for Role in SamSam Ransomware Attacks

The U.S. Department of Justice has announced significant progress has been made in the investigation of the threat actors behind the SamSam ransomware attacks that have plagued the healthcare industry over the past couple of years.

The DOJ, assisted the Royal Canadian Mounted Police, Calgary Police Service, and the UK’s National Crime Agency and West Yorkshire Police, have identified two Iranians who are believed to be behind the SamSam ransomware attacks.

Both individuals – Faramarz Shahi Savandi and Mohammad Mehdi Shah Mansouri – have been operating out of Iran since 2016 and have been indicted on four charges:

  • Conspiracy to commit fraud and related computer activity
  • Conspiracy to commit wire fraud
  • Intentional damage to a protected computer
  • Transmitting a demand in relation to damaging a protected computer

The DOJ reports that this is the first ever U.S. indictment against criminals over a for-profit ransomware, hacking, and extortion scheme.

In contrast to many threat actors who use ransomware for extortion, the SamSam ransomware group conducts targeted, manual attacks on organizations. Most ransomware gangs use spam email and other mass distribution techniques to infect as many individuals as possible.

The SamSam ransomware group exploits vulnerabilities and conducts brute force RDP attacks to gain access to systems, then investigates networks and moves laterally before manually deploying ransomware on as many computers as possible.

This method of attack allows the threat actors to inflict maximum damage. With a large percentage of an organization’s computers and systems taken out of action, the gang can issue large ransom demands. The ransoms demanded are typically in the range of $5,000 to $50,000, with the amount based on the number of devices that have been encrypted.

In the two years that the gang has been deploying SamSam ransomware, approximately $6,000,000 in ransom payments have been collected from around 200 victims. Many victims chose not to pay the ransom demands but still incurred significant costs mitigating the attacks. The DOJ estimates that in addition to the ransom payments, additional losses from downtime due to the attacks has exceed $30 million.

The gang’s list of victims is long and includes the cities of Newark, New Jersey and Atlanta, the Colorado Department of Transportation, and the Port of San Diego. Healthcare industry victims include Hancock Health, Adams Memorial Hospital, Kansas Heart Hospital, Allied Physicians of Michiana, Cass Regional Medical Center, Nebraska Orthopedic Hospital, LabCorp of America, Allscripts, and MedStar Health.

Research by Sophos indicates 26% of attacks were on the healthcare organizations, 13% were on government agencies, 11% were on educational institutions, and 50% were on private companies. The attacks have primarily been conducted on organizations in the United States, with other victims spread across Canada, the UK, and the Middle East.

The DOJ said the SamSam ransomware gang “engaged in an extreme form of 21st-century digital blackmail, attacking and extorting vulnerable victims like hospitals and schools, victims they knew would be willing and able to pay.”

The DOJ will continue to work with international law enforcement agencies to gather evidence and bring those responsible to justice.

The DOJ has also taken the opportunity to spread the message that all industry sectors are at risk of being attacked. “This indictment highlight[s] the need for businesses, healthcare institutions, universities, and other entities to emphasize cyber security, increase threat awareness, and harden their computer networks,” wrote the DOJ in a press release announcing the indictment.

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2.65 Million Atrium Health Patients Impacted by Business Associate Data Breach

A data breach has been reported by AccuDoc Solutions Inc., a provider of healthcare billing services, that resulted in the exposure of the protected health information of 2,650,000 patients of Atrium Health.

Morrisville, NC-based AccuDoc Solutions prepares bills for patients and operates the online payment system used by Atrium Health, a network of 44 hospitals throughout North Carolina, South Carolina and Georgia.

On October 1, 2018, AccuDoc Solutions notified Atrium Health that some of its databases had been compromised. The breach investigation revealed hackers had gained access to AccuDoc Solutions databases between September 22 and September 29, 2018.

An extensive forensic investigation into the attack confirmed that patient information had been compromised, but the information stored in its databases could only be viewed. No PHI was downloaded by the attackers nor distributed via other channels.

AccuDoc Solutions reports that the breach was due to a security vulnerability at a third-party vendor. The business relationship with that vendor has now been terminated. AccuDoc Systems has locked out the hackers and has enhanced its security measures to prevent future attacks.

Atrium Health said the information compromised in the attack was limited to patients’ names, addresses, invoice numbers, account balances, service dates, and health insurance information. Approximately 700,000 Social Security numbers were also compromised; however, no sensitive financial information or medical records were affected.

“We are notifying the patients and guarantors who may have been impacted by this incident. We take cybersecurity very seriously, and we’ve worked very hard to determine exactly what happened, and how to prevent it from happening again,” said a spokesperson for Atrium Health. “The fact that even one record was accessed is one too many. Our patients expect us to keep all of their information private, which is why we took action so quickly.”

Atrium Health is now notifying all affected patients and has offered credit monitoring and identity theft protection services to patients impacted by the breach.

AccuDoc serves approximately 50 other healthcare providers; however only one other client was affected by the breach: Baylor Medical Center in Frisco, TX. Approximately 40,000 Baylor Medical Center patients were affected.

Based on the estimated number of individuals affected, this is the largest healthcare data breach since the 3,466,120-record breach at Newkirk Products Inc., that was reported to OCR in September 2016. It is the eleventh largest healthcare data breach reported since OCR started publishing breach summaries in 2009.

Largest Ever Healthcare Data Breaches

Rank Entity Entity Type Individuals Affected Breach Type Date
1 Anthem Inc. Health Plan 78,800,000 Hacking/IT Incident Feb-15
2 Premera Blue Cross Health Plan 11,000,000 Hacking/IT Incident Mar-15
3 Excellus Health Plan, Inc. Health Plan 10,000,000 Hacking/IT Incident Sep-15
4 Science Applications International Corporation Business Associate 4,900,000 Loss Nov-11
5 University of California, Los Angeles Health Healthcare Provider 4,500,000 Hacking/IT Incident Jul-15
6 Community Health Systems Professional Services Corporation Business Associate 4,500,000 Hacking/IT Incident Aug-14
7 Advocate Health and Hospitals Corporation, dba Advocate Medical Group Healthcare Provider 4,029,530 Theft Aug-13
8 Medical Informatics Engineering Business Associate 3,900,000 Hacking/IT Incident Jul-15
9 Banner Health Healthcare Provider 3,620,000 Hacking/IT Incident Aug-16
10 Newkirk Products, Inc. Business Associate 3,466,120 Hacking/IT Incident Aug-16
11 AccuDoc Solutions Inc. Business Associate 2,650,000 Hacking/IT Incident Nov-18
12 21st Century Oncology Healthcare Provider 2,213,597 Hacking/IT Incident Mar-16

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Ransomware Attack Results in Partial Closure of Emergency Rooms at Two Hospitals

Computer systems used by East Ohio Regional Hospital (EORH) in Martins Ferry, OH, and Ohio Valley Medical Center (OVMC) in Wheeling, WV, were taken out of action over the weekend as a result of a ransomware attack.

The ransomware started encrypting files on the evening of Friday, November 23. While the attackers succeeded in gaining access to certain systems by penetrating the first layer of security, the subsequent layer was not breached, and the protected health information of its patients was not compromised. Even so, the attack resulted in disruption to certain medical services at both hospitals.

Patients walking into the emergency room could still be processed and treated, but the hospitals were unable to accept patients from emergency squads. During the attack the hospitals switched to paper charts to ensure data protection and e-squad patients were diverted to other hospitals.

Several hospital systems were taken offline to protect the integrity of information and IT teams have been working around the clock to eradicate the ransomware, restore files, and bring systems back online. The hospitals chose not to pay the ransom demand and instead restored affected files from backups after rebuilding affected systems.

Initially it was hoped that systems would be restored by Sunday evening; however, e-squad patients were still being diverted to other hospitals on Monday evening while the IT staff restored affected systems. “We’ve made great progress, but we are not there yet,” explained Daniel Dunmyer, CEO of OVMC, “It’s taken hours for significant improvement, but it will take days for finalization.”

Until essential systems are restored, the emergency rooms will remain on yellow diversion and remain partially closed. On yellow diversion, “the EMS can call in to the ER and we can let them know if it’s a case we can taken,” explained Dunmyer. On Tuesday, the software used to read radiology and CT scans and make that information available to ER staff was still being rebuilt. Only when that system is restored will EORH/OVMC go off diversion in the ERs.

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NIST Releases Draft Paper on Telehealth and Remote Monitoring Device Cybersecurity

The National Institute of Standards and Technology’s National Cybersecurity Center of Excellence (NCCoE) has released a draft paper covering the privacy and security risks of telehealth and remote monitoring devices and best practices for securing the telehealth and remote monitoring ecosystem.

Patient monitoring systems have traditionally been deployed within healthcare facilities; however, there has been an increase in the use of remote patient monitoring systems in patients’ homes in recent years. While these systems are straightforward to secure in a controlled environment such as a hospital, the use of these systems in patients’ homes introduces new risks.

Managing the risks and ensuring the remote monitoring systems and devices have an equivalent level of security as in-house systems can be a major challenge.

The purpose of the paper is to create a reference architecture which addresses the security and privacy risks and provides practical steps that can be taken to improve the overall security of the remote patient monitoring environment.

The paper addresses cybersecurity concerns related to the use of the devices in patients’ homes, the use of home networks, and patient-owned devices and identifies cybersecurity measures that can be implemented by healthcare organizations with RPM and video telehealth capabilities.

“The project team will perform a risk assessment on a representative RPM ecosystem in the laboratory environment, apply the NIST Cybersecurity Framework and guidance based on medical device standards, and collaborate with industry and public partners,” explained NCCoE.

NCCoE has evaluated the following functions of the devices:

  • Connectivity of devices and applications deployed on patient-owned devices such as smartphones, tablets, laptops, and desktop computers
  • How applications transmit monitoring data to healthcare providers
  • The ability for patients to interact with their point of contact to initiate care
  • The ability for data to be analyzed by healthcare providers to identify trends and issue alerts to clinicians about issues with patients
  • The ability for data to be shared with electronic medical record systems
  • The ability for patients to initiate videoconference sessions through telehealth applications
  • The ability for application patches and updates to be installed
  • How a healthcare provider can establish a connection with a remote monitoring device to obtain patient telemetry data
  • How a healthcare provider can connect to a remote monitoring device to update the device configuration

The paper does not cover risks specific to third party telehealth platform providers nor does it evaluate device vulnerabilities and defects.

Stakeholders have been invited to comment on the draft paper. Comments will be accepted until December.

The guidance document can be downloaded on this link.

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