Healthcare Cybersecurity

AJMC Study Reveals Common Characteristics of Hospital Data Breaches

Posted by HIPAA Journal

The American Journal of Managed Care has published a study of hospital data breaches in the United States. The aim of the study was to identify common characteristics of hospital data breaches, what the biggest problem areas are, the main causes of security incidents and the types of information most at risk.

The study revealed hospitals are the most commonly breached type of healthcare provider, accounting for approximately 30% of all large healthcare security incidents reported to the Department of Health and Human Services’ Office for Civil Rights by providers between 2009 and 2016.

Over that 7-year time period there were 215 breaches reported by 185 nonfederal acute care hospitals and 30 hospitals experienced multiple breaches of 500 or more healthcare records. One hospital experienced 4 separate breaches in the past 7 years, five hospitals had 3 breaches, and 24 hospitals experienced 2 breaches. In addition to hospitals experiencing the highest percentage of security breaches, those breaches also resulted in the theft/exposure of the highest number of health records.

While hacks were commonly experienced, it was not electronic healthcare data that was the biggest problem area. Paper and film were the most common locations of breached protected health information. 65 hospitals reported paper/film data breaches over the time period that was studied; however, while those breaches were the most common, they typically affected a relatively small number of patients.

Recently, there has been an increase in hacks and malware and ransomware attacks on network servers, although between 2009 and 2016 – for hospitals at least – network servers were the least common location of breached PHI. While the least common, they were the most severe. Network server breaches resulted in the highest number of stolen records.

The second most common location of breaches was PHI stored in locations other than paper/film, laptops, email, desktops, EHRs, or network servers. Those breaches had been reported by 56 hospitals. In third place was laptop breaches, reported by 51 hospitals.

The types of data breaches most commonly experienced were theft incidents, which had been reported by 112 hospitals. Unauthorized access/disclosures were in second place with incidents reported by 54 hospitals. Hacking/IT incidents was third and was behind 27 hospital data breaches.

Multivariate logistic regression analyses were performed to explore factors associated with hospital data breaches. The researchers found significant differences between hospitals that had experienced a data breach and those that had not.

Teaching hospitals and pediatric hospitals were found to be the most susceptible to data breaches. 18% of teaching hospitals had experienced at least one data breach, compared to 3% without a breach. Six percent of pediatric hospitals had experienced a breach compared to 2% that had not.

Larger hospitals were also more prone to data breaches than smaller facilities. 26% of large hospitals had experienced a data breach, compared to 10% that had no breaches. Investor-owned hospitals had reported fewer breaches than not-for profit hospitals.

There were no significant differences based on the level of IT sophistication, health system membership, biometric security use, hospital region, or area characteristics.

The researchers suggest that while hospitals have invested in technology and have digitized health data to meet Meaningful Use requirements, security has not been a major focus and investment in data security has been lacking. Hospitals are typically only spending 5% of their IT budgets on security and that needs to improve if hospital data breaches are to be prevented. Security measures also need to be improved for paper/films to reduce the opportunity for unauthorized access and theft.

The researchers suggest hospitals should be conducting regular audits to determine who is accessing PHI, while audits of data security protections will help hospitals identify vulnerabilities before they are exploited.

The use of biometric identifiers can limit the potential for unauthorized access of ePHI and 2-Factor authentication should be implemented on all user accounts.

The researchers also suggest access to PHI should be limited to the minimum necessary amount to allow employees to complete their work duties. By restricting access, the severity of data breaches will be reduced.

The methodology, full results, and conclusions can be found on this link.

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What Covered Entities Should Know About Cloud Computing and HIPAA Compliance

Posted by HIPAA Journal

Healthcare organizations can benefit greatly from transitioning to the cloud, but it is essential to understand the requirements for cloud computing to ensure HIPAA compliance.

In this post we explain some important considerations for healthcare organizations looking to take advantage of the cloud, HIPAA compliance considerations when using cloud services for storing, processing, and sharing ePHI, and we will dispel some of the myths about cloud computing and HIPAA compliance.

Myths About Cloud Computing and HIPAA Compliance

There are many common misconceptions about the cloud and HIPAA compliance, which in some cases prevent healthcare organizations from taking full advantage of the cloud, and in others could result in violations of HIPAA Rules.

Some of the common myths about cloud computing and HIPAA compliance are detailed below:

Use of a ‘HIPAA compliant’ cloud service provider will ensure HIPAA Rules are not violated

False: A cloud service provider can incorporate all the necessary safeguards to ensure the service or platform can be used in a HIPAA compliant manner, but it is the responsibility of the covered entity or business associate using the service to ensure that HIPAA Rules are followed. CSPs will not accept liability for misuse of their service/platform or misconfigurations by healthcare employees.

Cloud service providers are classed as conduits and a BAA is not required

False: Cloud services providers are considered business associates (see below) even if they do not – or cannot access stored data. The failure to enter into a business associate agreement prior to using the platform or service in connection with ePHI is a serious violation of HIPAA Rules.

A business associate agreement is required before de-identified PHI can be stored in the cloud

False: There are no HIPAA Privacy Rule restrictions covering the use or storage of de-identified PHI. De-identified PHI is not considered to be protected health information.

Physicians cannot use mobile devices to access ePHI stored in the cloud

False. There is nothing in HIPAA Rules that prevents the use of mobile devices for accessing data stored in the cloud, provided administrative, technical, and physical safeguards are in place to ensure the confidentiality, integrity, and availability of PHI for any data stored in the cloud or downloaded to a mobile device.  However, some healthcare organizations may have internal policies prohibiting the use of mobile devices with cloud services.

Cloud service providers must retain PHI for 6 years

False: HIPAA-covered entities must retain PHI for 6 years, but that rule does not apply to cloud service providers. If a HIPAA covered entity stops using a cloud service, all stored data must be returned to the covered entity or should be permanently deleted. If the CPS is required to retain stored data to meet the requirements of other laws, the information must be returned or deleted when that time period has elapsed.

A cloud service provider cannot be used if data is stored outside of the United States

False: A cloud service provider can store data on servers located in any country. There are no geographical restrictions. However, HIPAA covered entities should assess the risks – by means of a risk analysis – before using such a cloud service, as data stored on servers overseas may not be subject to the same level of protection as data stored on U.S-based servers.

Cloud Service Providers and Business Associate Agreements

While cloud service providers have long been known to be HIPAA business associates, the introduction of the HIPAA Omnibus Rule in 2013 made this clearer. “A data storage company that has access to protected health information (whether digital or hard copy) qualifies as a business associate, even if the entity does not view the information or only does so on a random or infrequent basis.”

The HIPAA conduit exception rule does not apply to cloud service providers. Companies are only considered ‘conduits’ if they offer a transmission only communication services when access to communications is only transient in nature. Cloud service providers are not considered to be conduits, even if the service provider encrypts all data and does not hold the keys to unlock the encryption.

Consequently, a business associate agreement must be entered into with the cloud platform or service provider before the platform or service is used for storing, processing, or transmitting ePHI.

If the cloud service is only ever used for sharing or storing de-identified PHI, a BAA is not required. De-identified PHI is no longer PHI, provided all identifiers have been stripped from the data. (See deidentification of PHI for further information.)

Cloud Computing and HIPAA Compliance

Cloud computing and HIPAA compliance are not at odds. It is possible to take advantage of the cloud and even improve security, but there are important considerations for any healthcare organizations considering using cloud services for storing, sharing, processing, or backing up ePHI

Risk Analysis and Risk Management

Prior to the use of any cloud service it should be subjected to a risk assessment. HIPAA-covered entities and their business associates must conduct their own risk analysis and establish risk management policies.

Business Associate Agreements

Before any cloud platform or service is used in connection with ePHI, the service provider and covered entity must enter into a HIPAA-compliant business associate agreement. The use of a cloud service without a BAA in place is a violation of HIPAA Rules.

Service Level Agreements (SLA)

In addition to a BAA, covered entities should consider a service level agreement (SLA) covering more technical aspects of the service, which may or may not address HIPAA concerns. The service level agreement can cover system uptime, reliability, data backups, disaster recovery times, customer service response times, and data return or deletion when the BAA is terminated. The SLA should also include the penalties should performance fall short of what has been agreed.

Encryption

Any data shared via the cloud should be protected by end-to-end encryption, and any data stored in the cloud should be encrypted at rest. Full considerations should be given to the level of encryption used by the CSP, which should meet NIST standards. While encryption is important, it will not satisfy all Security Rule requirements and will not maintain the integrity of ePHI nor ensure its availability.

Access Controls

Covered entities must ensure that access controls are carefully configured to ensure that only authorized individuals are able to access ePHI stored in the cloud. Prior to the use of any cloud platform or service, the administrative and physical controls implemented by the cloud service provider should be carefully evaluated.

Data Storage Locations

Covered entities should determine the locations where data is stored and risks associated with those locations should be evaluated during the risk analysis. Cloud service providers often store data in multiple locations to ensure fast access and rapid data recovery in the event of disaster. Data protection laws in foreign countries may differ considerable from those in the U.S.

Maintaining an Audit Trail

Healthcare organizations must have visibility into how cloud services are used, who is accessing cloud data, failed attempts to view cloud resources, and files that have been shared, uploaded, or downloaded. An audit trail must be maintained and logs should be reviewed regularly.

Cloud Benefits for Healthcare Organizations

Some of the key benefits for healthcare organizations from transitioning to the cloud are detailed below:

  • Linking a public cloud with data centers allows healthcare organizations to increase capacity without having to invest in additional hardware
  • The cloud is highly scalable – Capacity can be easily increased to meet business demands
  • Healthcare organizations can improve security by avoiding transporting ePHI on portable devices such as zip drives, portable hard drives, and laptop computers. The loss and theft of portable devices is a major cause of HIPAA data breaches
  • The cloud makes sharing ePHI with partners, patients, and researchers easier and faster
  • An unlimited number of data backups can be stored in the cloud. Data can be recovered quickly in the event of disaster
  • The cloud can help healthcare organizations decommission legacy infrastructure and improve security
  • The cloud allows healthcare organizations to reduce their data center footprints
  • Healthcare data can be securely accessed by authorized individuals in any location
  • The cloud allows healthcare organizations to offer and improve their telehealth services
  • The cloud supports the creation of an edge computing system to reduce latency and speed up data access

Choosing a Cloud Partner

While there are many cloud service providers that are willing to work with healthcare organizations, not all are prepared to accept liability for data breaches or violations of HIPAA Rules. Any CSP that will not sign a BAA should be avoided; however, not all cloud companies offer the same level of protection for stored and transmitted data. Willingness to sign a BAA is no guarantee of the quality of the service.

It is essential for a HIPAA covered entity to carefully assess any cloud service, even if the company claims it supports HIPAA compliance.

HIPAA-Compliant Cloud Platforms and Cloud Services

Over the coming weeks we will be assessing the services of a wide variety of cloud service providers to determine whether their platforms support HIPAA compliance.

For further information on specific vendors and to find out if they offer platforms that support HIPAA compliance, visit the links below:

Cloud Platforms

Cloud-Based Services

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Healthcare Industry Scores Poorly on Employee Security Awareness

Posted by HIPAA Journal

A recent report published by security awareness training company MediaPro has revealed there is still a lack of preparedness to deal with common cyberattack scenarios and privacy and security threats are still not fully understood by healthcare professionals.

For MediaPro’s 2017 State of Privacy and Security Awareness Report, the firm surveyed 1,009 US healthcare industry employees to assess their level of security awareness. Respondents were asked questions about common privacy and security threats and were asked to provide answers on several different threat scenarios to determine how they would respond to real world threats.

Based on the responses, MediaPro assigned respondents to one of three categories. Heroes were individuals who scored highly and displayed a thorough understanding of privacy and security threats by answering 93.5%-100% of questions correctly. Novices showed a reasonable understanding of threats, answering between 77.4% and 90.3% of answers correctly. The lowest category of ‘Risks’ was assigned to individuals with poor security awareness, who scored 74.2% or lower on the tests. Those individuals were deemed to pose a significant risk to their organization and the privacy of sensitive data.

Overall, 78% of healthcare employees were classified as risks or novices. The percentage of individuals rated in these two categories across all industry sectors was 70%, showing the healthcare industry still lags behind other industry sectors on security awareness and privacy and security best practices.

The survey revealed physicians’ understanding of privacy and security threats was particularly poor. Half of physicians who took part in the study were classified as risks, meaning their actions were a serious security threat to their organization. Awareness of the common identifiers of phishing emails was particularly poor, with 24% of physicians displaying a lack of understanding of phishing, compared with 8% of office workers and non-provider counterparts.

One of the main areas where security awareness was lacking was the identification of the common signs of a malware infection. 24% of healthcare employees had difficulty identifying the signs of a malware infection compared to 12% of the general population.

Healthcare employees scored worse than the general population in eight areas assessed by MediaPro: Incident reporting, identifying personal information, physical security, identifying phishing attempts, identifying the signs of malware infections, working remotely, cloud computing, and acceptable use of social media.

MediaPro points out that the 2017 Data Breach Investigations Report from Verizon showed human error accounted for more than 80% of healthcare data breaches last year, emphasizing the need for improved security awareness training for healthcare employees. Further, cybercriminals have been increasing their efforts to gain access to healthcare networks and sensitive patient information.

“The results of our survey show that more work needs to be done,” MediaPro explains in the report. “HIPAA courses often do not include information on how to stay cyber-secure in an increasingly interconnected world. Keeping within HIPAA regulations, while vital, does not educate users on how to spot a phishing attack, for example.”

If the security awareness of healthcare employees is not improved, the healthcare industry is likely to continue to be plagued by data breaches, irrespective of the level of maturity of their security defenses.

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How Many HIPAA Violations in 2017 Resulted in Financial Penalties?

Posted by HIPAA Journal

We are often asked about healthcare data breaches and HIPAA violations and two of the most recent questions are how many HIPAA violations in 2017 resulted in data breaches and how many HIPAA violations occurred in 2017.

How Many HIPAA Violations Occurred in 2017?

The problem with determining how many HIPAA violations occurred in 2017 is many violations are not reported, and out of those that are, it is only the HIPAA breaches that impact more than 500 individuals that are published by the Department of Health and Human Services’ Office for Civil Rights on its breach portal – often incorrectly referred to as the “Wall of Shame”.

To call it a ‘Wall of Shame’ is not fair on healthcare organizations because the breach reports show organizations that have experienced data breaches, NOT organizations that have violated HIPAA Rules. Even organizations with multi-million-dollar cybersecurity budgets, mature security defenses, and advanced employee security awareness training programs can experience data breaches. All it takes if for a patch not to be applied immediately or an employee to accidently click on a phishing link for a data breach to occur. The breach reports are therefore not an accurate guide to the number of HIPAA violations that have occurred.

Some attorneys general publish details of data breaches, and many of those breaches are the result of HIPAA violations; however, only a small number of states publish that data breach summaries and as with OCR’s breach portal, there are many breaches that have occurred at organizations that are fully compliant with HIPAA Rules. It is also not possible to say how many of those breaches were the result of HIPAA violations. That can only be determined with a detailed investigation.

Complaints about potential HIPAA violations are frequently submitted to OCR. These tend to be smaller incidents involving relatively few individuals, such as a patient who believes HIPAA Rules have been violated or employees who believe colleagues have violated HIPAA Rules. OCR occasionally releases figures on the number of complaints that it receives, but many of those complaints turn out to be unfounded and, in many cases, OCR cannot prove beyond reasonable doubt that a HIPAA violation has occurred.

It is also not possible to gauge the level of serious HIPAA violations that have occurred based on settlements and civil monetary penalties. Even when there is evidence to suggest HIPAA Rules have been violated, financial settlements are typically only pursued when a case against a HIPAA-covered entity is particularly strong and likely to be won.

It is therefore not possible to determine how many HIPAA violations in 2017 resulted in data breaches nor how many violations occurred last year.

How Many HIPAA Violations in 2017 Resulted in Financial Settlements?

It is also not possible to determine how many HIPAA violations in 2017 have resulted in financial penalties being issued, at least not yet. OCR and state attorneys general open investigations when data breaches are experienced or complaints are received about potential HIPAA violations. However, it takes time to conduct investigations and gather evidence. Even when there is evidence of HIPAA violations, cases can take years before settlements are reached or civil monetary penalties are issued.

The latest HIPAA settlement is a good example. Fresenius Medical Care North America settled its case with OCR for $3,500,000 in 2018, yet the data breaches that triggered the investigation occurred in 2012. The list below shows the settlements and civil monetary penalties issued in 2017 and the years in which the violations occurred.

So unfortunately, it is not possible to say how many HIPAA violations in 2017 resulted in financial penalties, as that will not be known for many years to come

HIPAA Settlements and Civil Monetary Penalties in 2017

 

Covered Entity Penalty Amount Penalty Type Reason for Penalty Date of Violation(s)
21st Century Oncology $2,300,000 Settlement Multiple HIPAA Violations 2015
Memorial Hermann Health System $2,400,000 Settlement Careless Handling of PHI 2015
St. Luke’s-Roosevelt Hospital Center Inc. $387,000 Settlement Unauthorized Disclosure of PHI 2014
The Center for Children’s Digestive Health $31,000 Settlement Lack of a Business Associate Agreement 2003-2015
Cardionet $2,500,000 Settlement Impermissible Disclosure of PHI 2011
Metro Community Provider Network $400,000 Settlement Lack of Security Management Process 2011
Memorial Healthcare System $5,500,000 Settlement Insufficient ePHI Access Controls 2007-2012
Children’s Medical Center of Dallas $3,200,000 Civil Monetary Penalty Impermissible Disclosure of ePHI 2006-2013
MAPFRE Life Insurance Company of Puerto Rico $2,200,000 Settlement Impermissible Disclosure of ePHI 2011
Presense Health $475,000 Settlement Delayed Breach Notifications 2013

 

What we can say is HIPAA violations have occurred at most healthcare organizations, although oftentimes the violations are minor and inconsequential. We can go further and say that a majority of healthcare organizations have failed to follow HIPAA Rules to the letter all of the time.

The evidence comes from the second round of HIPAA compliance audits conducted by OCR in late 2016 and 2017. A final report on the findings of the audits has yet to be published, but last September preliminary results were released. They showed that healthcare organizations are still not getting to grips with HIPAA Rules and noncompliance is commonplace.

Findings of the 2017 HIPAA Compliance Audits

Listed below are the preliminary findings of the second round of HIPAA compliance audits. The audits consisted of ‘Desk Audits’ conducted on 166 covered entities on the HIPAA Privacy, Security, and Breach Notification Rules and 41 business associates of HIPAA covered entities on the Security and Breach Notification Rules.

OCR gave each audited entity a rating from 1-5 based on the level of compliance. A rating of 1 means the organization was in compliance with the goals and objectives of the audited standards and implementation specifications. A rating of 5 was given to entities that did not provide OCR with evidence to show that a serious attempt had been made to comply with HIPAA Rules.

HIPAA Rule Aspect of HIPAA Rule 1 Rating 2 Rating 3 Rating 4 Rating 5 Rating N/A
Breach Notification Rule Timeliness of Notification 65% 6% 2% 9% 11% 7%
Breach Notification Rule Content of Notification 14% 14% 23% 37% 7% 5%
Privacy Rule Patient Right to Access 1% 10% 27% 54% 11% N/A
Privacy Rule Notice of Privacy Practices 2% 33% 39% 11% 15% 2%
Privacy Rule Provision of eNotice 57% 15% 4% 6% 15% 3%
Security Rule Risk Analysis 0% 2% 19% 23% 13% N/A
Security Rule Risk Management 1% 3% 13% 29% 17% N/A

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VA OIG Discovers Security Vulnerabilities Introduced at Orlando VA Medical Center

Posted by HIPAA Journal

The VA Office of Inspector General has discovered a Wi-Fi network was set up at a Florida VA medical center without being coordinated with the VA’s Office of Information & Technology (OI&T). As a result, vulnerabilities were introduced that could have been exploited to gain unauthorized access to VA systems.

The VA Office of Inspector General conducted an audit of the Orlando Veterans Affairs Medical Center (VAMC) at Lake Nona, FL after receiving a complaint that the Veterans Services Adaptable Network (VSAN) was being developed without coordination with the Office of Information & Technology (OI&T), and that appropriate funding for the project had not been obtained through proper channels.

While evidence of funding irregularities was not uncovered, the VA OIG did confirm that a WiFi network for patients had been set up without coordination with OI&T, and that the network did not have the appropriate security controls applied in accordance with VA policies.

After the network had been set up, a risk assessment was not performed and there was no segregation between the VSAN and VA network. The VA OIG explained in its report that the lack of oversight by local OI&T staff resulted in unnecessary risks being introduced that could have resulted in other VA systems being compromised. No evidence was uncovered to suggest any vulnerabilities had been exploited.

The VA OIG reports that staff did not ensure security controls were applied in accordance with the VA’s security requirements due to competing priorities and resources. A security risk assessment was not performed because management did not allocate the necessary resources to the task.

The VA OIG has recommended the executive in charge for the Office of the Under Secretary for Health and the executive in charge for the Office of Information and Technology ensure that all guest Internet networks, industrial control systems, and external air-gapped networks are properly segregated and meet VA security requirements.

The report highlights a common problem: The installation of software or use of hardware that has not been authorized by IT departments. Referred to as shadow IT, the unauthorized hardware and software can introduce vulnerabilities that may not be discovered and corrected by IT departments.

Without the oversight of the IT department, software may not be kept up to date and vulnerabilities could easily be exploited to gain access to healthcare networks.

Health IT departments can implement controls that prevent the installation of software by employees and employees should be instructed, in no uncertain terms, that the installation of software or use of devices without first having obtained authorization from the IT department is strictly prohibited.

IT departments should also consider conducting scans of the network to identify rogue devices that have been connected, although that means that IT departments must also maintain an accurate inventory of all authorized devices.

Network access tools can also be deployed to further protect healthcare networks. These tools restrict network access to authorized devices that have the appropriate security controls, AV software, and latest versions of software installed.

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How Can Healthcare Organizations Protect Against Cyber Extortion

Posted by HIPAA Journal

In its January 2018 Cybersecurity Newsletter, the Department of Health and Human Services’ Office for Civil Rights drew attention to the rise in extortion attempts on healthcare organizations and offered advice on how healthcare organizations can protect against cyber extortion

Ransomware Attacks Have Risen Significantly

Ransomware attacks on healthcare organizations have increased significantly over the past two years. Healthcare providers are heavily reliant on access to electronic data and any attack that prevents access is likely to have a major impact on patients. The inevitable disruption to services – and the cost of that disruption – makes it more likely that a ransom will be paid.

The relatively high probability of a ransom being paid, coupled with the ease of attacking healthcare organizations, has made the industry an attractive target for cybercriminals.

It may be more cost effective and better for patients if a ransom to be paid instead of recovering data from backups. That was certainly the view of Hancock Health. A ransom payment of 4 Bitcoin was paid to minimize disruption when data could have been recovered from backups.

Paying a ransom may seem preferable, but there is no guarantee that data will be recoverable. This year has seen wiper malware used that mimics ransomware. In such cases, there are no keys to unlock encrypted data. There have also cases of ransoms being paid, only for further demands to be sent, such as the 2016 ransomware attack on Kansas Heart Hospital.

Data Theft and Threats of Data Dumps

There have been numerous cases of data theft by hackers followed by threats to dump the data online if a ransom payment is not made – The modus operandi of the hacking group, TheDarkOverlord. The hacking group was responsible for many cyber extortion attacks on healthcare providers over the past 2 years.

Typically, this type of attack sees vulnerabilities exploited to gain access to data. Brute force attacks allow weak passwords to be guessed, and the past year saw several healthcare organizations have data stolen as a result of misconfigurations of databases and unsecured Amazon S3 buckets. Several attacks saw data deleted from healthcare organizations’ databases after data had been exfiltrated, adding an extra incentive to pay the ransom demand.

As with ransomware attacks, there is no guarantee that the attacker will return data, make good on a promise not to publish data or delete any copies of stolen PHI.

DoS and DDoS Attacks

Not all cyber extortion attempts involve the theft of data or use of encryption to prevent PHI access. Denial of Service (DoS) and Distributed Denial of Service (DDoS) attacks direct large volumes of traffic to computers and servers rendering them inaccessible. Demands for payment are often issued to stop the attacks, or threats of attacks are made unless payment is made.

How Can Healthcare Organizations Reduce Cyber Extortion Risk?

There are several ways that healthcare organization can reduce the risk of cyber extortion attacks, most of which are general cybersecurity best practices which should already have been adopted. Others are requirements of HIPAA Rules.

The most important measure, and one which so many healthcare organizations fail at,  is to perform a comprehensive, organization-wide risk analysis covering all systems and devices containing ePHI and systems/devices that can be used to access PHI. A risk management program must also be implemented that addresses all identified vulnerabilities and reduces them to an acceptable level.

Since so many cyber extortion attacks take advantage of unplugged vulnerabilities, healthcare organizations need to ensure all software and operating systems are kept up to date and patches are applied promptly. Robust inventory and vulnerability identification processes are necessary to ensure the accuracy and completeness of risk analyses.

Healthcare organizations should consider signing up with information Sharing and Analysis Organizations (ISAO) and other providers of threat intelligence to discover new threats and vulnerabilities in time to block attacks.

Ransomware attacks often occur as a result of healthcare employees responding to malicious emails. Unless a security awareness training program is implemented, employees will be a major weak point in security defenses. Technologies should also be implemented to block malicious emails and prevent them from reaching end users’ inboxes.

While anti-malware, anti-virus, and other signature-based malware defenses are not as effective as they once were, they are still an essential part of security defenses for healthcare organizations. Firewalls and other perimeter and network defenses should also be deployed, while internal defenses should be hardened to slow down attacks and prevent lateral movement within a network. Network segmentation is strongly recommended.

Just as encryption can prevent breaches when portable devices are lost or stolen, encryption can also prevent attackers from gaining access to sensitive data if the network is breached. Regular backups should also be created to ensure data recovery is possible without paying a ransom. A good backup strategy is the 3-2-1 approach. At least three copies of data, on two different media, with one copy stored securely off-site.

Backups are only of use if data recovery is possible. Backups should therefore be tested to make sure data has not been corrupted and can be recovered in the event of a cyberattack.

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$3.5 Million Settlement to Resolve HIPAA Violations That Contributed to Five Data Breaches

Posted by HIPAA Journal

The first HIPAA settlement of 2018 has been announced by the Department of Health and Human Services’ Office for Civil Rights (OCR). Fresenius Medical Care North America (FMCNA) has agreed to pay OCR $3.5 million to resolve multiple potential HIPAA violations that contributed to five separate data breaches in 2012.

The breaches were experienced at five separate covered entities, each of which was owned by FMCNA. Those breached entities were:

  • Bio-Medical Applications of Florida, Inc. d/b/a Fresenius Medical Care Duval Facility in Jacksonville, Florida (FMC Duval)
  • Bio-Medical Applications of Alabama, Inc. d/b/a Fresenius Medical Care Magnolia Grove in Semmes, Alabama (FMC Magnolia Grove)
  • Renal Dimensions, LLC d/b/a Fresenius Medical Care Ak-Chin in Maricopa, Arizona (FMC Ak-Chin)
  • Fresenius Vascular Care Augusta, LLC (FVC Augusta)
  • WSKC Dialysis Services, Inc. d/b/a Fresenius Medical Care Blue Island Dialysis (FMC Blue Island)

Breaches Experienced by FMCNA HIPAA Covered Entities

The five security breaches were experienced by the FMCNA covered entities over a period of four months between February 23, 2012 and July 18, 2012:

  • The theft of two desktop computers from FMC Duval during a February 23, 2012 break-in. The computers contained the ePHI – including Social Security numbers – of 200 individuals
  • The theft of an unencrypted USB drive from FMC Magnolia Grove on April 3, 2012. The device contained the PHI – including insurance account numbers – of 245 individuals
  • On April 6, 2012 FMC Ak-Chin discovered a hard drive was missing. The hard drive had been removed from a computer that had been taken out of service and the drive could not be located. The hard drive contained the PHI – including Social Security numbers – of 35 individuals
  • An unencrypted laptop computer containing the ePHI of 10 patients – including insurance details – was stolen from the vehicle of an employee on June 16, 2012. The laptop had been left in the vehicle overnight. The bag containing the laptop also contained the employee’s list of passwords
  • Three desktop computers and one encrypted laptop were stolen from FMC Blue Island on or around June 17-18, 2012. One of the computers contained the PHI – including Social Security numbers – of 35 patients

Multiple HIPAA Failures Identified

OCR launched an investigation into the breaches to establish whether they were the result of failures to comply with HIPAA Rules. The investigation revealed a catalogue of HIPAA failures.

OCR established that the FMCNA covered entities had failed to conduct a comprehensive and accurate risk analysis to identify all potential risks to the confidentiality, integrity, and availability of ePHI: One of the most common areas of non-compliance with HIPAA Rules. If an accurate risk assessment is not performed, risks are likely to be missed and will therefore not be managed and reduced to an acceptable level.

OCR also discovered the FMCNA covered entities had impermissibly disclosed the ePHI of many of its patients by providing access to PHI that is prohibited under the HIPAA Privacy Rule.

Several other potential HIPAA violations were discovered at some of the FMCNA covered entities.

FMC Magnolia Grove did not implement policies and procedures governing the receipt and removal of computer hardware and electronic storage devices containing ePHI from its facility, and neither the movement of those devices within its facility.

FMC Magnolia Grove and FVC Augusta had not implemented encryption, or an equivalent, alternative control in its place, when such a measure was reasonable and appropriate given the risk of exposure of ePHI.

FMC Duval and FMC Blue were discovered not to have sufficiently safeguarded their facilities and computers, which could potentially lead to unauthorized access, tampering, or theft of equipment.

FMC Ak-Chin had no policies and procedures in place to address security breaches.

Financial Penalty Reflects the Seriousness and Extent of HIPAA Violations

The $3.5 million settlement is one of the largest issued to date by OCR to resolve violations of HIPAA Rules. In addition to paying the sizeable financial penalty, FMCNA has agreed to adopt a robust corrective actin plan to address all HIPAA failures and bring its policies and procedures up to the standard demanded by HIPAA.

The FMCNA covered entities must conduct comprehensive, organization wide risk analyses to identify all risks to the confidentiality, integrity, and availability of PHI and develop a risk management plan to address all identified risks and reduce them to a reasonable and acceptable level.

Policies and procedures must also be developed and implemented covering device, media, and access controls and all staff must receive training on current and new HIPAA policies and procedures.

“The number of breaches, involving a variety of locations and vulnerabilities, highlights why there is no substitute for an enterprise-wide risk analysis for a covered entity,” said OCR Director Roger Severino. “Covered entities must take a thorough look at their internal policies and procedures to ensure they are protecting their patients’ health information in accordance with the law.”

Settlement Shows it is Not the Size of the Breach that Matters

All of the five breaches resulted in the exposure of relatively few patients’ PHI. No breach involved more than 235 records, and three of the breaches exposed fewer than 50 records.

The settlement shows that while the scale of the breach is considered when deciding on an appropriate financial penalty, it is the severity and the extent of non-compliance that is likely to see financial penalties pursued.

The settlement also clearly shows that OCR does investigate smaller breaches and will do so when breaches suggest HIPAA Rules have been violated.

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2017 Worst Year Ever for Cybersecurity Incidents According to Online Trust Alliance

Posted by HIPAA Journal

According to the Online Trust Alliance´s “Cyber Incident & Breach Trends Report”, 2017 was the “worst year ever” for cybersecurity incidents. The organization estimates that, based on the number of reported breaches, there were nearly double the number of cybersecurity incidents than in 2016.  

The Online Trust Alliance´s “Cyber Incident & Breach Trends Report” is more than a review of the previous year´s cybersecurity incidents. The organization investigates how the incidents occurred in order to identify trends, and what could have been done to prevent the incidents so that businesses can implement appropriate measures to defend against future incidents.

The organization admits that the report´s headline figure of 159,700 cybersecurity incidents is a guesstimate based on the number of incidents reported during the third quarter of 2017. As the report states, many incidents are not reported, and the true figure could be much higher. However, using the same criteria, the organization guesstimated the number of cybersecurity incidents in 2016 at 82,000 – implying that there were nearly double in 2017.

Trends in Cybersecurity Incidents

The trends in cybersecurity incidents identified by the Online Trust Alliance will not surprise frequent visitors to HIPAA Journal. Ransomware attacks saw the biggest increase in numbers, but another type of ransom-based attack – the Ransom Denial-of-Service (RDoS) attack – was also identified as becoming more popular among cybercriminals. In this form of attack, cybercriminals threaten a Dedicated Denial-of-Service (DDoS) attack unless a ransom is paid in advance.

The organization also commented on the new risk threats generated by the growth in IoT devices, and an 85% increase in malicious email. The increase in malicious mail included a 90% increase in business-targeted ransomware and a rise in the number of BEC attacks. It was calculated there had been a four-fold increase in the number of records breached in 2017 and an estimated loss to US companies of $1.6 billion due to BEC attacks reported to the FBI (since 2015).

Key Avoidable Causes of Incidents

The report´s authors claim that 93% of breaches could have been avoided with proper preparedness and due diligence. The key avoidable causes of incidents were the failure to regularly patch software vulnerabilities and implement appropriate controls to prevent insider theft or the accidental exposure of confidential data. As the majority of successful ransomware attacks are initiated by malicious emails, the report suggests not enough is being done to block spam and train users to recognize phishing attacks.

Other areas identified as being avoidable causes of cybersecurity incidents included:

  • The lack of a thorough risk assessment to include internal and external partners, and third-party or cloud-based services.
  • Misconfigured servers and devices, and out-of-date operating systems and applications that were no longer supported.
  • The failure to encrypt data and safely manage encryption keys. The lack of encryption led to a loss of data when devices and drives are lost, stolen or hacked.

Conclusions from the Cyber Incident and Breach Trends Report

The “Cyber Incident & Breach Trends Report” does not include much information that most healthcare IT experts are not already aware of. However it does act as a good summary of best practices businesses should adopt to mitigate the risk of cybersecurity incidents. One particularly valid point made in the report is that “security and privacy are not absolute and must evolve”. Businesses are recommended to regularly review their procedures for creating, maintaining and transmitting data, especially in light of evolving threats, changing technologies and new regulations.

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Lightning Likely to Strike Twice for Victims of Ransomware Attacks

Posted by HIPAA Journal

A new report commissioned by online security company Sophos has revealed that victims of ransomware attacks are likely to experience further attacks within a year. The report confirms the healthcare industry is at the greatest risk of suffering multiple ransomware attacks.

In order to compile the report – “The State of Endpoint Security Today” – the research company Vanson Bourne surveyed 2,700 IT managers in organizations of 100 to 5,000 users across the US, Canada, Mexico, France, Germany, UK, Australia, Japan, India, and South Africa. The results of the survey make unpleasant reading:

  • 54% of the surveyed organizations were victims of one or more ransomware attacks in the last year.
  • Of the organizations that were victims of ransomware attacks, there was an average of two attacks per organization.
  • The median financial impact per affected organization amounted to $133,000 (including ransom paid, downtime, rectification costs, etc.).
  • The financial impact for the top 3% of organizations suffering a successful ransomware attack was between $6.6 million and $13.3 million.
  • The healthcare industry was the top target for ransomware attacks (76% of respondents), followed by energy (65%), professional services (59%), and retail (58%).
  • 77% of attacked organizations were running up-to-date endpoint security at the time of the attack, however 54% of organizations have not implemented specific anti-ransomware technology.

Why Healthcare Organizations are more often Victims of Ransomware Attacks

Despite being among the top spenders on online security, healthcare organizations are more often victims of ransomware attacks. The authors of the report believe this is because healthcare is perceived as a soft target by cybercriminals due to having an aging IT infrastructure and restricted resources for improving IT security. Healthcare organizations are also considered to be more likely to pay a ransom.

This would imply that healthcare organizations are spending their IT budgets on the wrong kind of security defenses, and the results of the survey appear to confirm that implication. 60% of respondents said their current cyber defenses are insufficient to contend with the growing complexity of ransomware attacks, although only 31% of respondents expect to be victims of a ransomware attack in the future.

Dan Schiappa – the senior vice president and general manager of products at Sophos – said: “Ransomware is not a lightning strike – it can happen again and again to the same organization. Cybercriminals are deploying multiple attack methods to succeed, whether using a mix of ransomware in a single campaign, taking advantage of a remote access opportunity, infecting a server, or disabling security software.

As cybercriminals are finding entry points other than those protected by endpoint security, healthcare organizations should review all their IT infrastructure to identify potential vulnerabilities. In addition to implementing software security solutions where required, special attention should be given to users connecting with healthcare networks in order to ensure they are aware of the threat from ransomware.

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