Healthcare Cybersecurity

Cyberattacks on Hospitals Cause Significant Disruption at Neighboring Healthcare Facilities

A recent study has confirmed that healthcare cyberattacks not only cause disruption at the organization that experiences an attack but also at emergency departments at neighboring hospitals, where patients face longer wait times due to increased patient numbers which place a strain on resources.

The study involved a retroactive analysis of two academic emergency departments operated by a healthcare delivery organization (HDO) in San Diego, which were in the vicinity of an unrelated HDO that experienced a ransomware attack. The researchers looked at adult and pediatric patient volume, emergency medical services diversion data, and emergency department stroke care metrics for four weeks prior to the attack, during the attack, and four weeks after the attack.

The ransomware attack in question occurred on May 1, 2021, and affected an HDO with 4 acute care hospitals, 19 outpatient facilities, and more than 1,300 combined acute inpatient beds. The attack prevented access to electronic medical records and imaging systems and affected the HDO’s telehealth capabilities. Staff were forced to use pen and paper to record patient information and emergency traffic was redirected to unaffected facilities. The attack caused disruption for 4 weeks, and around 150,000 patient records were compromised.

An attack on one hospital will often see patient numbers increase at neighboring hospitals, and the increased volume of patients and resource constraints impact time-sensitive care for health conditions such as acute stroke. The researchers found there were significant disruptions to services at the neighboring healthcare facilities, even though they were not targeted or directly affected by the ransomware attack. Compared to the period before the attack, there was a 15.1% increase in the daily mean emergency department census, a 35.2% increase in mean ambulance arrivals, a 6.7% increase in mean admissions, a 127.8% increase in patients leaving without being seen, a 50.4% increase in visits where patients left against medical advice, and a 47.6% increase in median waiting room times.

The researchers chose acute stroke care as an example of a time-sensitive, resource-intensive, technologically dependent, and potentially lifesaving set of complex actions and decisions, that required a readily available multidisciplinary team working in close coordination. The researchers observed a 74.6% increase in stroke code activations and a 113.6% increase in confirmed strokes compared to the pre-attack phase.

Since a ransomware attack on one hospital impacts other non-targeted healthcare facilities, the researchers suggest that ransomware and other cyberattacks should be classed as regional disasters. The researchers report no significant difference in door–to–CT scan or acute stroke treatment times, but suggest the disruptions due to ransomware attacks could easily lead to negative patient outcomes. “These findings support the need for coordinated regional cyber disaster planning, further study on the potential patient care effects of cyberattacks, and continued work to build technical health care systems resilient to cyberattacks such as ransomware,” wrong the researchers, who also suggest this should be made a national priority given the increase in cyberattacks on healthcare organizations in recent years.

The study – Ransomware Attack Associated With Disruptions at Adjacent Emergency Departments in the US – was conducted by Christian Dameff, MD, MS, Jeffrey Tully, MD, and Theodore C. Chan MD, and was published in JAMA Open Network.

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CommonSpirit Health Says Ransomware Attack Likely to Cost $160 Million

CommonSpirit Health has provided an updated estimate on the cost of its October 2022 ransomware attack, which is expected to increase to $160 million. The ransomware attack was detected by CommonSpirit Health on October 2, 2022, forcing systems to be taken offline. The attack affected over 100 current and former CommonSpirit facilities in 13 states. The forensic investigation determined hackers first gained access to its network on September 16, 2022, and were ejected on October 3, 2022. The attackers stole data from two file servers, although they did not gain access to its medical record system. The stolen files contained the protected health information of almost 624,000 patients.

CommonSpirit Health operates 143 hospitals and around 2,300 other healthcare facilities in 22 states and is the second-largest non-profit health system in the United States. CommonSpirt’s first quarter results show total revenues from the 3 months to March 31, 2023, of $8.3 billion, and $25.6 billion for the 9 months to March 31. In the first quarter of 2023, CommonSpirit reported $648 million in operating losses and $1.1 million in losses for the 9 months to March 31. Net losses of $231 million and $445 million were reported for the 3- and 9-month periods due to improved investment returns. CommonSpirit said the ransomware attack did not have any impact on the current quarter’s operating results.

The ransomware attack was initially estimated to cost around $150 million, but a further $10 million in costs has been added to that figure. The increased cost factors in lost revenues due to business interruption, costs incurred remediating the ransomware attack, and other business-related expenses. In a call with investors, CommonSpirit explained that most of the $160 million is expected to be recovered from underwriters, although recovery of the costs is expected to take some time. CommonSpirit also confirmed in its quarterly report that it is facing a class action lawsuit over the ransomware attack and data breach. The lawsuit was filed in December 2022 in the U.S. District Court for the Northern District of Illinois and alleges negligence due to the failure to implement reasonable and appropriate security measures to protect patient data. The lawsuit seeks damages for the plaintiff and class exceeding $5 million, injunctive relief, and legal costs.

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April 2023 Healthcare Data Breach Report

There was a 17.5% month-over-month fall in the number of reported healthcare data breaches with 52 breaches of 500 or more records reported to the HHS’ Office for Civil Rights (OCR) – less than the 12-month average of 58 breaches per month, and one less than in April 2022.

April 2023 Healthcare Data Breaches

One of the largest healthcare data breaches of the year was reported in April, but there was still a significant month-over-month reduction in breached records, which fell by 30.7% to 4,425,891 records. The total is less than the 12-month average of 4.9 million records a month, although more than twice the number of records that were breached in April 2022.

Healthcare records breached in the last 12 months - April 2023

Largest Healthcare Data Breaches Reported in April 2023

As previously mentioned, April saw a major data breach reported that affected 3,037,303 individuals – The third largest breach to be reported by a single HIPAA-covered entity so far this year, and the 19th largest breach to be reported by a single HIPAA-regulated entity to date.  The breach occurred at the HIPAA business associate, NationsBenefits Holdings, and was a data theft and extortion attack by the Clop ransomware group involving the Fortra GoAnywhere MFT solution.  8 of the month’s 21 breaches of 10,000 or more records were due to these Clop attacks, including the top 5 breaches in April. Brightline Inc. was also hit hard by those attacks, which were reported separately for each covered entity client (9 reports). Together, the attacks on Brightline involved the PHI of more than 964,000 individuals.

18 of the 21 breaches of 10,000 or more records were hacking incidents. The remaining three breaches were unauthorized disclosures of protected health information, one due to tracking technologies and the other two due to mailing errors. While ransomware and data theft/extortion attacks dominated the breach reports, phishing, business email compromise, and other email account breaches are common, with 5 of the top 21 breaches involving hacked email accounts. End-user security awareness training is recommended to reduce susceptibility to these attacks and multifactor authentication should be implemented on all email accounts, ideally using phishing-resistant multifactor authentication.

Name of Covered Entity State Covered Entity Type Individuals Affected Location of Breached Information Breach Cause
NationsBenefits Holdings, LLC FL Business Associate 3,037,303 Network Server Hacking and extortion (Fortra GoAnywhere MFT)
Brightline, Inc. CA Business Associate 462,241 Network Server Hacking and extortion (Fortra GoAnywhere MFT)
Brightline, Inc. CA Business Associate 199,000 Network Server Hacking and extortion (Fortra GoAnywhere MFT)
Brightline, Inc. CA Business Associate 180,694 Network Server, Other Hacking and extortion (Fortra GoAnywhere MFT)
California Physicians’ Services d/b/a Blue Shield of California CA Business Associate 61,790 Network Server Hacking and extortion (Fortra GoAnywhere MFT)
MiniMed Distribution Corp. CA Healthcare Provider 58,374 Network Server Unauthorized disclosure of PHI to Google and other third parties (Tracking code)
Brightline, Inc. CA Business Associate 49,968 Network Server, Other Hacking and extortion (Fortra GoAnywhere MFT)
United Steelworkers Local 286 PA Health Plan 37,965 Email Hacked email account
Retina & Vitreous of Texas, PLLC TX Healthcare Provider 35,766 Network Server Hacking incident
Brightline, Inc. CA Business Associate 31,440 Network Server Hacking and extortion (Fortra GoAnywhere MFT)
Brightline, Inc. CA Business Associate 21,830 Network Server Hacking and extortion (Fortra GoAnywhere MFT)
Iowa Department of Health and Human Services – Iowa Medicaid Enterprise (Iowa HHS-IME) IA Health Plan 20,815 Network Server Hacking incident at business associate (Independent Living Systems)_
Lake County Health Department and Community Health Center IL Healthcare Provider 17,000 Email Hacked email account
Southwest Healthcare Services ND Healthcare Provider 15,996 Network Server Hacking incident (data theft confirmed)
La Clínica de La Raza, Inc. CA Healthcare Provider 15,316 Email Hacked email accounts
St. Luke’s Health System, Ltd. ID Healthcare Provider 15,246 Paper/Films Mailing error
Two Rivers Public Health Department NE Healthcare Provider 15,168 Email Hacked email account
Robeson Health Care Corporation NC Healthcare Provider 15,045 Network Server Malware infection
Northeast Behavioral Health Care Consortium PA Health Plan 13,240 Email Hacked email account (Phishing)
Centers for Medicare & Medicaid Services MD Health Plan 10,011 Paper/Films Mailing error at business associate (Palmetto GBA)
Modern Cardiology Associates PR Healthcare Provider 10,000 Network Server Hacking incident

Causes of April 2023 Healthcare Data Breaches

Hacking and other IT incidents continue to dominate the breach reports, accounting for 36 of the month’s breaches (69.2%) and the vast majority of the breached records. Across those incidents, 4,077,019 healthcare records were exposed or stolen – 92.1% of the records that were breached in April. The average breach size was 119,914 records and the median breach size was 9,675 records.

April 2023 Healthcare data breach causes

Ransomware attacks continue to be conducted by there has been a notable shift in tactics, with many ransomware gangs opting for data theft and extortion without encrypting files, as was the case with the attacks conducted by the Clop ransomware group which exploited a zero-day vulnerability in the Fortra GoAnywhere MFT solution. The BianLian threat group has previously conducted attacks using ransomware, but this year has been primarily conducting extortion-only attacks, which are quieter and faster. 12 of the month’s breaches (40%) involved hacked email accounts, highlighting the importance of security awareness training and multifactor authentication.

There were 13 unauthorized access/disclosure incidents in April, including a 58K-record incident involving tracking technologies that transferred sensitive data to third parties such as Google, instances of paper records not being secured, and PHI that had been exposed over the Internet. Across those 13 breaches, 105,155 records were impermissibly disclosed. The average breach size was 8,089 records and the median breach size was 1,304 records.

There were two theft incidents involving 3,321 records in total and one improper disposal incident. The improper disposal incident was reported as involving 501 records – a placeholder commonly used to meet the Breach Notification Rule reporting deadline when the total number of individuals affected has yet to be determined.  As the chart below shows, the majority of incidents involved ePHI stored on network servers and in email accounts.

Location of PHI in April 2023 healthcare data breaches

Where Did the Breaches Occur?

The raw data on the OCR breach portal shows the reporting entity, which in some cases is a HIPAA-covered entity when the breach actually occurred at a business associate. The breach portal shows 31 data breaches were reported by healthcare providers, 8 by health plans, and 13 by business associates. The charts below are based on where the breach occurred, rather than the entity that reported the data breach, to better reflect the extent to which data breaches are occurring at business associates.

April 2023 healthcare data breaches by HIPAA-regulated entity type

While healthcare providers were the worst affected HIPAA-regulated entity, the majority of the month’s breached records were due to data breaches at business associates.

Records exposed or stolen in April 2023 healthcare data breaches by hipaa-regulated entity type

Geographical Distribution of April 2023 Healthcare Data Breaches

Data breaches of 500 or more records were reported by HIPAA-regulated entities in 25 states and Puerto Rico, with California the worst affected state with 16 breaches, 9 of which were the same incident that was reported separately for each client by Brightline Inc., which is why the breach count was so high for California this month.

State Breaches
California 16
Florida 4
New York & Pennsylvania 3
Illinois, Kentucky, Ohio, & Texas 2
Alabama, Arizona, Idaho, Iowa, Indiana, Maryland, Michigan, Minnesota, Nebraska, North Carolina, North Dakota, Oregon, Utah, Virginia, Washington, West Virginia, Wisconsin & Puerto Rico 1

HIPAA Enforcement Activity in April 2023

No HIPAA enforcement actions were announced by OCR or state attorneys general in April 2023 to resolve violations of HIPAA and state laws, and no Health Breach Notification Rule enforcement actions were announced by the Federal Trade Commission.

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Bipartisan Legislation Introduced to Address Rural Hospital Cybersecurity Skill Gaps

New bipartisan legislation has recently been introduced to help address the current shortage of cybersecurity skills at rural hospitals. The Rural Hospital Cybersecurity Enhancement Act was introduced by Sen. Gary Peters (D-MI), chair of the Senate Homeland Security and Governmental Affairs Committee, and Sen. Josh Hawley (R-MO), committee member.

Cyberattacks on healthcare organizations have increased significantly over the past few years. These attacks cause considerable disruption to patient care and can put lives at risk and while health systems have increased investment in cybersecurity, many small and rural hospitals lack the necessary resources and struggle to hire skilled cybersecurity professionals. At a recent Senate Homeland Security and Governmental Affairs Committee hearing, cybersecurity experts testified about the current healthcare cybersecurity challenges. Kate Pierce, former CIO and CISO at North County Hospital in Vermont and executive at Fortified Health Security said cybercriminals have shifted their focus and are now actively targeting small and rural hospitals. Large health systems have implemented advanced cybersecurity measures and employ large cybersecurity teams to manage their sophisticated defenses, but there is a large disparity in cybersecurity spending at small and rural hospitals, which tend to have much weaker defenses.

“A basic security measure like 24/7 monitoring of systems is “pie-in-the-sky” for these organizations,” explained Pierce at the hearing. “Despite all the guidance, recommendations and services provided over the past few years by HSCC, 405(d), H-ISAC, CISA, and other organizations, I have found that the vast majority of small and rural hospitals are unaware of these resources, and too overwhelmed to take advantage of these valuable tools.”

The Rural Hospital Cybersecurity Enhancement Act requires the Cybersecurity and Infrastructure Security Agency (CISA) to develop a comprehensive cybersecurity workforce development strategy for healthcare facilities that provide inpatient and outpatient care services in non-urbanized areas. The strategy should include public-private partnerships, the development of curricula and training resources, and policy recommendations. The bill requires the Director of CISA to create instructional materials for rural hospitals to train staff on fundamental cybersecurity measures, and for the Department of Homeland Security to report annually to congressional committees on updates to the strategy and any programs that have been implemented.

“Ransomware attacks against hospitals and health care systems that compromise sensitive medical information and disrupt patient care must be stopped. Unfortunately, small and rural hospitals often lack the resources to invest in cybersecurity defenses and staff to prevent these breaches,” said Senator Peters. “This bipartisan legislation will require the federal government to ensure our most vulnerable health care providers have the necessary tools to protect patient information and provide lifesaving care even as criminal hackers continue to target their networks.”

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FBI and CISA Issue Warning About BianLian Ransomware and Extortion Group

A joint cybersecurity alert has been issued by the Federal Bureau of Investigation (FBI), Cybersecurity and Infrastructure Security Agency (CISA), and Australian Cyber Security Centre (ACSC) about the BianLian ransomware and data extortion group.

The BianLian group has been conducting attacks in the United States since at least June 2022 and has actively targeted critical infrastructure organizations, including the healthcare and public health sector. The BianLian group is a ransomware actor that develops and uses ransomware in its attacks, typically engaging in double extortion tactics, where sensitive private data is exfiltrated from victims’ networks before files are encrypted. The group threatens to leak the stolen data if the ransom is not paid. This year, the group has largely switched to extortion-only attacks where files are not encrypted after exfiltration. These attacks have proven to be effective as the release of stolen data can cause significant damage to an organization’s reputation and legal complications.

The BianLian group primarily gains access to victims’ networks by using Remote Desktop Protocol (RDP) credentials, which may be obtained through brute force attacks to guess weak credentials, purchasing credentials from initial access brokers, or phishing attacks. Once credentials are obtained, the group deploys a custom backdoor specific to each victim, and commercially available remote access tools are downloaded such as TeamViewer, Atera Agent, SplashTop, and AnyDesk. The group uses command-line tools and scripts for network reconnaissance and harvesting more credentials. PowerShell and Windows Command Shell are used to disable antivirus software such as Windows Defender and Anti-Malware Scan Interface (AMSI), and the registry is modified to uninstall services such as Sophos SAVEnabled, SEDenabled, and SAVService services.

Tools typically downloaded onto victims’ networks include Advanced Port Scanner, SoftPerfect Network Scanner, SharpShares, and PingCastle to aid discovery, along with native Windows tools and Windows Command Shell, with PsExec and RDP with valid accounts used for lateral movement. Once sensitive data has been located, data exfiltration occurs via File Transfer Protocol (FTP), Rclone, or Mega. Once data exfiltration has occurred, threats are issued to publish the stolen data.

The best defense against attacks is to limit the use of RDP and other remote desktop services. Audits should be conducted of all remote access tools on the network to identify installed and currently used software. Any remote access tools that are not currently used should be removed or disabled, and RDP should be locked down. Security software should be used to detect instances of remote access software being loaded in the memory, and logs should be reviewed of remote access software to detect any abnormal use.

Authorized remote access solutions should only be used from within the network over approved remote access solutions, such as virtual private networks (VPNs) or virtual desktop interfaces (VDIs). Inbound and outbound connections on common remote access software ports and protocols should be blocked at the network perimeter. Organizations should also disable command-line services and scripting activities and restrict the use of PowerShell on critical systems, and enhanced PowerShell logging should be enabled. Regular audits of administrative accounts should be conducted, time-based access for accounts should be set at the admin level and higher, and the principle of least privilege should be applied.

The cybersecurity alert includes Indicators of Compromise (IOCs), details of the tactics, techniques, and procedures (TTPs) used by the group, and other recommended mitigations.

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Illumina Sequencing Instruments Affected by Maximum Severity Vulnerability

Healthcare providers and laboratory personnel have been warned about a maximum severity vulnerability in Illumina Universal Copy Service software used by its DNA sequencing instruments.

The vulnerability affects Illumina products with Illumina Universal Copy Service (UCS) v2.x installed:

  • iScan Controls Software (v4.0.0 and v4.0.5)
  • iSeq 100 (all versions)
  • MiniSeq Control Software (v2.0 and later)
  • MiSeq Control Software (v4.0 RUO Mode)
  • MiSeqDx Operating Software (v4.0.1 and later)
  • NextSeq 500/550 Control Software (v4.0)
  • NextSeq 550Dx Control Software (v4.0 RUO Mode)
  • NextSeq 550Dx Operating Software (v1.0.0 to 1.3.1)
  • NextSeq 550Dx Operating Software (v1.3.3 and later)
  • NextSeq 1000/2000 Control Software (v1.4.1 and prior)
  • NovaSeq 6000 Control Software (v1.7 and prior)
  • NovaSeq Control Software (v1.8)

Affected devices are vulnerable to two flaws, the most serious of which – CVE-2023-1699 – allows binding to an unrestricted IP address. If exploited, a malicious actor could use UCS to listen on all IP addresses, including those capable of accepting remove communications, remotely take control of the affected devices, change device settings, and alter or steal sensitive data. The flaw can be exploited remotely with low attack complexity and has been assigned a CVSS score of 10 out of 10.

The second flaw, tracked as CVE-2023-1966, affects UCS v1.x and v2.0 and is due to unnecessary privileges. A remote attacker could upload and execute code remotely at the operating system level, allowing changes to be made to settings and configurations and sensitive data to be accessed on the affected products. The vulnerability has been assigned a CVSS score of 7.4 out of 10.

The vulnerabilities were discovered by Illumina and were reported to the Cybersecurity and Infrastructure Agency (CISA). Illumina says it is unaware of any instances of actual or attempted exploitation of the flaws; however, due to the severity of the vulnerabilities and the ease of exploitation, immediate patching is recommended.

On April 5, 2023, Illumina notified customers about the flaw requesting they check for signs of exploitation. A patch has now been released along with a Vulnerability Instructions Guide to help users address the flaw based on the specific configurations of their devices. The U.S. Food and Drug Administration (FDA) recently issued a warning to healthcare providers and laboratory personnel that the vulnerabilities may present risks for patient results and customer networks. Until the patch can be applied, steps should be taken to reduce the risk of exploitation, including minimizing network exposure, ensuring the affected devices are not accessible over the Internet, locating control system networks and remote devices behind firewalls, and only using secure methods to remotely access the devices, such as a Virtual Private Network (VPN).

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Passwordless Authentication Adoption Increases but Poor Password Practices Persist

A recent survey of IT decision makers has provided insights on password management practices and has confirmed the increasing adoption of passwordless authentication. This is the third year that the password manager provider, Bitwarden, has conducted its Password Decisions Survey, which this year was conducted by Propeller Insights on 400 America IT decision makers and 2,000 Internet users and revealed their password habits, and attitudes to password security and passwordless authentication technologies.

The survey confirmed that little has changed over the past 12 months, with poor password practices proving difficult to eliminate. Password manager use declined slightly year-over-year, with 84% of IT decision makers saying they use password management software at work, down from 84% in 2022, but up from 77% in 2021. The slight decline may be in part due to a significant data breach at LastPass in 2022. While the password manager was not breached, hackers gained access to an encrypted backup copy of the password vaults of an unspecified number of users.

Despite this, password managers are still widely thought to improve password security and the survey indicates there is considerable demand from employees for password managers, with 79% of Internet users saying they would like their employer to provide one. While 84% of respondents said they use a password manager at work, poor password practices are still common, with 54% of respondents admitting to saving their passwords in a document on their computer (53% in 2022), 45% relying on memory for passwords (42% in 2022), and 29% writing their passwords down (unchanged). 22% of employees claim they have been reusing the same password for more than a decade.

While 66% of IT decision makers said they share passwords securely via a password manager, a significant percentage use less secure methods such as email (41%), shared online documents (38%), chat and messaging apps (30%), verbal disclosures (27%), and written notes (22%). Worryingly, 90% of IT decision makers admitted to reusing passwords in the workplace, down slightly from 92% in 2022. Out of the respondents that do reuse passwords, the extent to which passwords are reused is reducing. 11% reuse passwords on 15+ sites (15% in 2022), 24% use the same password on 10-15 sites (27% in 2022), 36% reuse passwords on 5-10 sites (33% in 2022), and 19% use the same password on 1-5 sites (16% in 2022).

2-factor authentication can significantly improve security and adoption is growing, with 92% of respondents saying they use it in the workplace, up from 88% in 2022. The most common reasons for not implementing 2-FA are believed to be a failure to understand the benefits, a belief that passwords alone provide good enough protection, account hacking is unlikely, and the negative effect the additional authentication on workflows.

Despite the risks of using unauthorized software and hardware (shadow IT), 32% of IT decision makers admitted to using unauthorized devices and software as did 49% of employees. The majority of people who admitted to using shadow IT (73%) said they did so because it helps them work more efficiently. 52% said they still used unauthorized software or hardware when they were unable to get authorization to use it, and 50% just went ahead because of the slow response times for authorization from the IT department.

The increasing cost of data breaches and the rate that they are occurring has prompted organizations to seek cyber insurance. 75% of surveyed IT decision makers said they have cyber insurance policies, but insurers are demanding proof of security measures before they agree to provide insurance policies. 65% of IT decision makers said they had to demonstrate they provided security awareness training to employees, had multifactor authentication (64%), used a password manager (61%), had an incident response plan (50%), had adequate data backup processes (48%), and demonstrate they were patching regularly (28%). Only 3% of organizations were not required to provide any proof that these measures were in place.

Concern about password security and the number of password-related data breaches are driving the adoption of passwordless technology such as biometrics, passkeys, and security keys. 41% of respondents believe passwordless authentication provides better security, 24% say it improves the user experience, 17% say it reduces the burden on the IT department, and 19% believe it improves productivity. 57% of U.S. respondents said they were excited about passwordless technology, with 49% saying they have either deployed the technology or are planning to, although out of those that have started to adopt passwordless authentication, 87% have yet to roll it out across the entire organization. Out of the organizations that have adopted the technology, 51% use biometrics, facial recognition, fingerprint, or voiceprints, and 31% use a physical item such as a security key or FIDO auth.

One of the major reasons for reluctance to use passwordless technology such as fingerprints, voice prints, and face IDs is fear that it would be used against them, which was a concern for 36% of respondents that have yet to adopt the technology. 55% of respondents said they prefer to rely on memory for passwords, even though people that rely on memory tend to create much weaker passwords. Remembering passwords also leads to productivity losses. 58% of respondents said they regularly have to reset their passwords because they have forgotten them, with 12% saying it is an everyday occurrence.

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HC3: Ransomware Groups are Exploiting GoAnywhere and PaperCut Vulnerabilities

The Health Sector Cybersecurity and Coordination Center (HC3) has issued a fresh ransomware warning to the healthcare and public health (HPH) sector following a spate of attacks on the HPH sector in April by the Clop and LockBit ransomware groups.

HC3 has issued multiple alerts about the Clop and LockBit ransomware-as-a-service groups which have conducted multiple attacks on the healthcare sector. Clop was behind the attacks on Fortra’s GoAnywhere MFT solution in January/February 2023 and the 2022 attacks on the Accellion File Transfer Application (FTA), both of which exploited zero-day vulnerabilities in those solutions. The latest alert about LockBit was issued in December 2022 following multiple attacks on HPH sector organizations.

The Clop group exploited the GoAnywhere MFT vulnerability (CVE-2023-0669) and stole data from around 130 organizations, and both groups have been observed exploiting two other recently disclosed vulnerabilities – CVE-2023-27350 and CVE-2023-27351 – which are authentication bypass vulnerabilities in the widely used print management software, PaperCut MF/NG. Those two vulnerabilities were disclosed by the developer on April 19, 2023, and were corrected in PaperCut versions 20.1.7, 21.2.11, and 22.0.9 and later.

On April 26, 2023, Microsoft announced that a threat actor known as Lace Tempest was exploiting the PaperCut flaws and that the activity overlapped with the FIN11 and TA505 threat groups,  both of which have ties to Clop. After exploiting the vulnerabilities, TrueBot malware was deployed, which is known to be used by the Clop ransomware operation. LockBit ransomware was deployed in some of the attacks.

Network defenders have been advised to promptly patch their servers by updating to the latest versions of PaperCut. If that is not possible, there is a recommended workaround, which involves blocking all traffic to the web management port (9191) from external IP addresses on edge devices and blocking all traffic to default port 9191 on the server’s firewall. Users of Fortra’s GoAnywhere MFT solution should rotate the Master Encryption Key, reset all credentials, review audit logs, and delete suspicious administrator and user accounts.

Further recommended mitigations against attacks by Clop, LockBit, and other cybercriminal groups are detailed in the HC3 alert.

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Organizations Face Increased Scrutiny of Health Data Breaches

Healthcare hacking incidents are increasing, there are new regulatory requirements and compliance initiatives due to Dobbs and Pixel use, and lawsuits against healthcare organizations over privacy violations are soaring. HIPAA-regulated entities and other organizations that operate in the healthcare space are now facing increased scrutiny of their data security practices and compliance programs, and the coming 12 months will likely see an increase in enforcement actions and lawsuits over privacy violations.

The recently published BakerHostetler Data Security Incident Response Report (DSIR) draws attention to these issues and provides insights into the threat landscape to help organizations determine how to prioritize their efforts and investments. The report, now in its 9th year, was based on 1,160 security incidents managed by BakerHostetler’s Digital Assets and Data Management Practice Group in 2022.

After a surge in ransomware attacks in 2021, 2022 saw a reduction in attacks; however, there was a surge in ransomware activity toward the end of the year and that surge has continued in 2023. That surge has coincided with increases in ransom demands, paid ransoms, and ransomware recovery times.  In 2022, the average ransom demand and payment increased in 6 out of the 8 industries tracked. In healthcare, the average ransom demand was $3,257,688 (median: $1,475,000) in 2022, and the average payment increased by 78% to $1,562,141 (median: $500,000). Across all industry sectors, paid ransoms increased by 15% to $600,688.

Network intrusions also increased and were the most common type of security incident, accounting for almost half of all data incidents covered in the report. BakerHostetler notes that companies have been getting better at detecting and containing these incidents, with dwell time decreasing from an average of 66 days in 2021 to 39 days in 2022. The time taken for containment fell from 4 days to 3 days, and investigation time decreased from 41 days in 2021 to 36 days in 2022.

The increase in hacking and ransomware attacks has prompted companies to invest more heavily in cybersecurity, and while security defenses have been enhanced, cybercriminals have found new ways of circumventing those defenses and attacking systems. Techniques that have proven successful in 2022 include MFA bombing, social engineering, SEO poisoning, and EDR-evading malware.

The cost of cyberattacks increased significantly in 2022, with forensic investigation costs increasing by 20% from last year in addition to increases in the cost of business disruption, data reviews, notification, and indemnity claims. Legal costs from data breaches have also increased significantly as it is now common for multiple lawsuits to be filed in response to data breaches.

Data breaches of 10,001 to 500,000 records see an average of 12-13 lawsuits filed and lawsuits are even being filed for smaller data breaches, with breaches of less than 1,000 records typically seeing 4 lawsuits filed. According to BakerHostetler, lawsuits have doubled since last year and we are now at a stage where legal action is almost a certainty following a data breach. There have been increases in lawsuits for violations of state privacy laws, and with a further 4 states enacting new privacy legislation in 2022 and one more due to introduce a new privacy law in 2023, the compliance landscape is becoming more complicated.

In the summer of 2022, a report was published by the Markup/STAT detailing an analysis of the use of pixels (tracking technologies) on hospital websites. These code snippets are typically added to websites to track visitor activity to improve websites and services, but the code also transmits identifiable visitor information to third parties. The extent to which these tools were being used – without the knowledge of website visitors – attracted attention from the HHS’ Office for Civil Rights (OCR) and the Federal Trade Commission (FTC) with both issuing guidance on the use of these tools. OCR and the FTC have confirmed that Pixel-related violations of HIPAA and the FTC Act are now an enforcement priority, with the FTC having already taken action against entities over the use of these tracking tools. Law firms have been quick to sue healthcare organizations over these privacy breaches. More than 50 lawsuits have been filed against healthcare organizations in response to Pixel-related breaches since June 2022 when the report was published.

A further study of the use of Pixels by healthcare organizations suggests almost 99% of US non-federal acute care hospital websites had pixels on their websites that could transmit sensitive data, yet only a handful of healthcare organizations have disclosed Pixel-related data breaches to OCR so far. There could well be a surge in HIPAA enforcement actions by OCR and huge numbers of lawsuits filed in response to these breaches over the coming months.

There are also likely to be enforcement actions against HIPAA-regulated entities and non-HIPAA-regulated entities in the healthcare space for privacy violations involving reproductive health information, as both the FTC and OCR have stated that reproductive health information privacy will be an enforcement priority. OCR’s HIPAA Right of Access enforcement initiative is still ongoing, and compliance remains a priority for OCR.

BakerHostetler has also issued a warning about HIPAA compliance for non-healthcare entities, stressing that HIPAA applies to employer-sponsored health plans. There was an increase in data breaches at employer health plans in 2022 and these are likely to come under increased regulatory scrutiny, not just by OCR but also the Department of Labor which is increasingly conducting follow on investigations focusing on the overall cybersecurity posture of these plans. State Attorneys general have also started taking a much more active interest in the activities of healthcare entities, with investigations by state attorneys general into violations of HIPAA and state laws increasing in 2022.

BakerHostetler also identified a major increase in snooping incidents in 2022. These incidents include healthcare employees snooping on healthcare records and attempting to divert controlled substances. The increase confirms how important it is to create and monitor logs of system activity to detect malicious insider activity quickly. BakerHostetler notes that having systems in place that monitor for system activity anomalies is also key to rapidly detecting hacking and ransomware incidents.

“Securing an enterprise is a significant challenge — there are a lot of risks and just spending more money does not automatically equate to more effective security,” said Craig Hoffman, co-leader of BakerHostetler’s national Digital Risk Advisory and Cybersecurity team. “We see a lot of incidents, including what allowed them to occur and what was done to address the issue. Because enterprises do not have unlimited budgets and staff to implement and maintain new solutions, being able to share objective data about security incidents — from causes to fixes to consequences — helps clients decide where to prioritize their efforts.”

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