This month, the Healthcare and Public Health Sector Coordinating Council (HSCC) Cybersecurity Working Group (CWG) published guidance to help healthcare delivery organizations effectively manage cyber risks associated with legacy technology. In healthcare, a great deal of attention has been focused on addressing cybersecurity risks associated with legacy medical devices, but they are not the only type of legacy technology in use in healthcare environments. Many different technologies are used that similarly become more vulnerable as they age, and continue to be used after end-of-life has been reached and support is withdrawn. Technologies include FDA-regulated devices, non-FDA-regulated devices, laboratory equipment, building and facilities technology, and a host of other technologies.

While the obvious solution from a security perspective is to upgrade to modern, supported systems ahead of the technologies reaching end-of-life, that is often not practical or possible. Instead, healthcare delivery organizations need to effectively manage the risks associated with these technologies. Vulnerabilities in these technologies can be exploited by malicious actors, which can threaten patient privacy and patient safety. Unfortunately, many healthcare organizations that use legacy technologies have limited staff and resources to devote to protecting these technologies, which means vulnerabilities can persist indefinitely.

The guidance – Health Industry Cybersecurity – Managing Legacy Technology Security (HIC-MaLTS) – details best practices and makes several recommendations for healthcare delivery organizations, medical device manufacturers, and other technology providers whose products are used in healthcare environments. The guidance explains that all of these entities have a shared responsibility to ensure legacy technologies can be used securely in clinical environments while staying one step ahead of modern cyber threats. HSCC encourages healthcare delivery organizations, medical device manufacturers, and other technology providers to work together to effectively manage risk.

The guidance is the result of three years of work by 67 industry and government member organizations, including healthcare delivery organizations, medical device manufacturers, trade groups, government representatives, security experts, and health IT companies. The guidance covers the four core pillars of a comprehensive legacy technology cyber risk management program: governance, communications, cyber risk management, and future-proofing legacy technologies, and includes general and specific recommendations for each of those pillars in an easily actionable format.

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The U.S. Cybersecurity and Infrastructure Agency (CISA) has launched a new pilot program in response to the increase in ransomware attacks on critical infrastructure entities. The aim of the pilot program is to help critical infrastructure entities better protect their systems against ransomware attacks by fixing exploitable vulnerabilities in their Internet-facing systems.

The Ransomware Vulnerability Warning Pilot (RVWP) program is authorized under the Cyber Incident Reporting for Critical Infrastructure Act (CIRCIA) of 2022 and commenced on January 30, 2023. Under the program, CISA conducts scans to determine if Internet-exposed systems contain vulnerabilities that could potentially be exploited by ransomware actors to gain access to their networks. Alerts are then sent to those entities by CISA’s regional cybersecurity personnel to inform them that vulnerabilities exist, which will allow timely action to be taken to fix the flaws before they can be exploited by ransomware gangs or other malicious actors. CISA says critical infrastructure entities may be unaware that they have exploitable vulnerabilities in their systems and may only discover unpatched vulnerabilities once they have been exploited in a ransomware attack. CISA said the RVWP program leverages existing services, data sources, technologies, and authorities including CISA’s Cyber Hygiene Vulnerability Scanning Service and the Administrative Subpoena Authority granted to CISA under Section 2009 of the Homeland Security Act of 2022.

The program is focused on identifying vulnerabilities in Internet-facing systems that are known to have been exploited by ransomware gangs in previous attacks. Under the RVWP program, CISA has already notified almost 100 critical infrastructure entities that they have systems with unaddressed ProxyNotShell vulnerabilities in Microsoft Exchange. ProxyNotShell vulnerabilities have been widely exploited by ransomware gangs over the past few months.

“Ransomware attacks continue to cause untenable levels of harm to organizations across the country, including target rich, resource-poor entities like many school districts and hospitals,” said Eric Goldstein, Executive Assistant Director for Cybersecurity, CISA. “The RVWP will allow CISA to provide timely and actionable information that will directly reduce the prevalence of damaging ransomware incidents affecting American organizations. We encourage every organization to urgently mitigate vulnerabilities identified by this program and adopt strong security measures consistent with the U.S. government’s guidance on StopRansomware.gov.” CISA also encourages critical infrastructure entities to report ransomware attacks to the U.S. government via the FBI’s Internet Crime Complaint Center or CISA’s incident reporting system.

The RVWP program is one of several initiatives launched by CISA in the past two years in response to ransomware attacks on critical infrastructure entities and government agencies, including the attacks on Colonial Pipeline, JBS Foods, and Kaseya. These efforts include the addition of a Ransomware Readiness Assessment (RRA) module to its Cyber Security Evaluation Tool (CSET), the formation of a public-private partnership – the Joint Cyber Defense Collaborative (JCDC) to proactively gather, analyze, and share actionable cyber risk information– and the launch of its Stop Ransomware website, which serves as a one-stop-shop for alerts and ransomware resources.

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The Health Sector Cybersecurity Coordination Center has issued a security advisory warning about data exfiltration in healthcare cyberattacks, highlighting the extent of the practice and sharing several recommended mitigations. Data exfiltration typically occurs once a threat actor has gained access to a network, elevated privileges, and moved laterally. Data exfiltration is one of the last stages of the cyber kill-chain and the primary objective in many cyberattacks.

There are several reasons for data theft. Nation-state actors often steal data for espionage purposes, cybercriminal groups steal healthcare data as it can be easily monetized and as leverage for extortion, and insiders steal data for financial gain, competitive advantage, and blackmail. When ransomware first started to be used by cybercriminal groups, files were simply encrypted; however, data exfiltration is now common. Data theft allows ransomware actors to profit from attacks when ransoms are not paid, and oftentimes it is the threat of publication of stolen data that prompts victims to pay up. Such is the incentive to pay to prevent data exposure that ransomware gangs are even dispensing with file encryption and are conducting extortion-only attacks.

In the security advisory, HC3 draws attention to the extent to which data exfiltration is occurring. HC3 explains that breach notifications to the HHS show 28.5 million records were exposed in the second half of 2022, up 21.1 million records from 2019. Across all 588 reported data breaches in 2022, more than 44 million patient records were exposed. At least 24 healthcare ransomware attacks occurred in 2022 impacting operators of 289 U.S. hospitals, and sensitive data were exfiltrated in 70% of those attacks.

Data exfiltration is not limited to ransomware attacks. Data theft is common in attacks involving other types of malware, such as information stealers, and several cyber threat groups have emerged that concentrate on data exfiltration and extortion, including the Donut Leaks, Karakurt, and the Lapsus$ threat groups. Nation-state-sponsored Advanced Persistent Threat Actors often gain persistent access to networks and remain undetected for years in order to exfiltrate sensitive data over extended periods. One attack, identified by WithSecure, saw the Lazarus APT group steal more than 100GB of sensitive data from the medical research and technology sector before being detected. As more organizations move from on-premises to cloud storage, threat actors have also been increasingly targeting cloud resources to steal data, and often delete cloud backups to prevent recovery from ransomware attacks.

Data exfiltration is often the most harmful aspect of a healthcare cyberattack. In addition to hardening defenses to prevent initial access to networks, network defenders should be monitoring for attempted data exfiltration and should take steps to prevent, block, and limit data exfiltration. HC3 has made several recommendations in the alert, including high-level mitigations such as integrating security awareness and security best practices, evaluating risks associated with every interaction with computers, applications, and data, and conducting periodic audits to verify that security best practices are being followed.

HC3 also recommends implementing monitoring systems that generate alerts about unusual data access, data movement, unsanctioned software and hardware (shadow IT), and unauthorized data access, and ensuring logs are generated by networks, workstations, servers, email, databases, web applications, firewalls, authentication services, and cloud resources. Those logs should be managed centrally and closely monitored. While data exfiltration by cyber actors is commonplace, employees should be monitored closely, especially departing employees. Access to resources should be promptly terminated and extra attention should be paid to the activities of those individuals in the lead-up to their departure.

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A joint cybersecurity advisory has been published by CISA and the FBI, sharing details of the tactics, techniques, and procedures (TTPs) used by the Royal ransomware gang and Indicators of Compromise (IoCs) to help network defenders better protect against attacks.

Royal Ransomware is a relatively new threat actor that was first observed conducting attacks in 2022. The group is believed to consist of highly experienced cybercriminals who are well-versed in conducting ransomware attacks, including operators that were once part of Conti Team One. Conti was one of the most prolific ransomware groups over the past 3 years and was formed by the group behind Ryuk ransomware. Royal has previously used the encryptors of other ransomware operations, then switched to using its own – Royal – in September 2022, and has now overtaken Lockbit to become the main player in the ransomware market.

Like Conti and Ryuk before it, the Royal ransomware group is focused on attacks in the United States, especially critical infrastructure entities, including those operating in the healthcare and public health sector. The group uses a variety of methods to gain initial access to victims’ networks, with phishing the most common initial access vector. Phishing has been used in 67% of known attacks, where employees at victim organizations are tricked into installing a malware loader via emails with PDF attachments, which deliver the Royal ransomware payload. The group is also known to use malicious adverts – malvertising – to direct traffic to websites where malware is downloaded.

Remote Desktop Compromise (RDP) has been used in around 13% of attacks and, to a lesser extent, the group also gains access to networks through public-facing applications and buys access through initial access brokers who harvest virtual private network credentials from stealer logs.  Once access is gained, the group downloads a range of tools to strengthen the foothold in victims’ networks, then escalates privileges and moves laterally, including leveraging PsExec for lateral movement. The group is known to maintain persistence using various remote monitoring and management tools, including AnyDesk, LogMeIn, and Atera, and has been observed using the penetration testing tool, Cobalt Strike, and Ursnif/Gozi for data exfiltration. The group uses Windows Restart Manager to identify where targeted files are in use or are blocked by other applications, uses the Windows Volume Shadow Copy service to delete shadow copies to hamper attempts to recover files without paying the ransom, and exfiltrates data to a U.S. IP address before triggering the encryption routine.

CISA and the FBI strongly recommend taking immediate action to improve defenses against attacks, including prioritizing and remediating known exploited vulnerabilities, training the workforce how to identify phishing attempts, and enabling and enforcing multifactor authentication. Full IoCs and TTPs are detailed in the cybersecurity alert. An Analyst Note on Royal Ransomware has also been published by the Health Sector Cybersecurity Coordination Sector.

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In what is believed to be a first, the BlackCat ransomware gang has published naked images of patients that were stolen in one of its attacks on a healthcare organization in an attempt to pressure the victim into paying the ransom. Lehigh Valley Health Network (LVHN) recently announced that it was dealing with a ransomware attack that was detected on February 6, 2023. LVHN confirmed that the BlackCat ransomware group was behind the attack and had issued a ransom demand, payment of which would see the decryption keys provided and would prevent the release of data stolen in the attack. Brian A. Nester, LVHN President and CEO, confirmed that LVHN refused to pay the ransom and operations were unaffected.

Nester said the attack was on the network supporting a physician practice in Lackawanna County and the computer system involved stored clinically appropriate patient images for radiation oncology treatment and other sensitive patient information. “Attacks like this are reprehensible and we are dedicating appropriate resources to respond to this incident,” said Nester.

In an attempt to pressure LVHN into paying the ransom, BlackCat started leaking some of the stolen data on its data leak site. While data leaks are now common when victims of ransomware attacks refuse to pay the ransom, BlackCat took matters a step further and published patient images stolen in the attack. Images of three breast cancer patients, naked from the waist up, were published on the data leak site along with screenshots of patient data showing diagnoses. “This unconscionable criminal act takes advantage of patients receiving cancer treatment, and LVHN condemns this despicable behavior,” said LVHN spokesperson, Brian Downs.

The HHS recently issued a security advisory about the Blackcat ransomware group which actively targets organizations in the healthcare and public health sector and warned that the group engages in aggressive triple extortion tactics. While many ransomware groups use double extortion involving data theft and threats to release stolen data in addition to file encryption, BlackCat uses a third tactic – threatening to conduct Distributed Denial of Service Attacks (DDoS) on victims until they pay up.

BlackCat is not the only ransomware gang to try new tactics to get victims to pay up. The Medusa ransomware gang recently attacked the Minneapolis Public Schools (MPS) District, stole sensitive data, then encrypted files. When payment was not made, MPS was added to the group’s data leak site and a threat was issued to publish the entire trove of data stolen in the attack. The group issued a ransom demand of $1 million, with the data leak site also offering the stolen data to anyone willing to pay the same amount. In a novel twist, the group also published a video showing the data stolen in the attack. The video, which is 51 minutes long, was added as proof of the extent of the data exfiltrated from MPS’s systems.

Ransomware gangs have had to adopt more aggressive tactics as fewer victims are paying ransom demands. According to Coveware, in Q4, 2022, only 37% of victims paid a ransom following a ransomware attack, compared to 76% of victims in 2019. Coveware says several factors are driving the reduction in the profitability of ransomware attacks. Greater investment in security and incident response planning means organizations are better prepared for attacks and are less likely to suffer a material impact from a successful attack. The FBI and other law enforcement agencies are still pursuing the perpetrators of these attacks, but they are also now putting more resources into helping victims recover. Coveware also points out that as revenues fall, operating costs to carry out attacks increase, which means fewer ransomware actors can make a living from distributing ransomware and even large ransomware groups are feeling the effect, hence the need to adopt new tactics to pressure victims into paying up and improve the profitability of attacks.

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A new guide has been published by the Health Sector Coordinating Council (HSCC) Cybersecurity Working Group and the U.S. Department of Health and Human Services (HHS) to help healthcare organizations align their cybersecurity programs with the NIST Framework for Improving Critical Infrastructure Cybersecurity.

The NIST Cybersecurity Framework is one of the most widely adopted frameworks for identifying and managing cybersecurity risks. The framework was released by NIST in 2015, updated in 2018, and the NIST CSF 2.0 is due for release later this year. The NIST CSF is based on five core functions – Identify, Protect, Detect, Respond, and Recover – and suggests cybersecurity controls that can be implemented in all five functional areas. The framework also includes four tiers against which organizations can rate their adoption of the framework, which allows them to communicate how there are achieving their cybersecurity objectives in a standardized way. The NIST CSF has become the standard cybersecurity framework for government agencies and private sector companies for managing cybersecurity risks.

The healthcare industry is extensively targeted by cybercriminal groups and nation-state actors and must defend against increasingly sophisticated and numerous threats. Healthcare organizations typically have fragmented infrastructures, legacy systems, huge numbers of applications, and must protect an ever-increasing number of network-connected medical devices. Consequently, many healthcare organizations struggle with managing cybersecurity effectively.

“Healthcare cyberattacks are among the fastest growing type of cybercrime – jeopardizing patient care, damaging the integrity of health care systems, and threatening the U.S. economy,” said Dawn O’Connell, HHS  Assistant Secretary for Preparedness and Response. “Health care organizations must safeguard their information technology systems to help prevent attacks and create a culture of cyber safety in the health care industry.”

According to the HSCC, a comprehensive cybersecurity framework – such as the NIST CSF – will “provide a common language and structure for discussions around risk and the methods and tools used to manage risk to a level that is not only acceptable to the organization but to other stakeholders such as business partners, customers, and industry and governmental regulators.” Healthcare organizations that base their cybersecurity programs on the NIST CSF can better direct capital, operational, and resource allocations to lines of business generating the greatest return on protecting assets/information and minimizing risk exposure.

While the NIST CSF has been developed to be suitable for organizations of all sizes in all industry sectors, some healthcare organizations have struggled to adopt the framework. The Cybersecurity Framework Implementation Guide is intended to help healthcare organizations adopt the NIST CSF and details specific steps that can be taken to immediately manage cyber risks to their IT systems and better protect against the full range of cyber threats. The guide will help healthcare organizations to assess their current cybersecurity practices and risks and identify gaps for remediation.

“With data breaches having doubled over the past five years and ransomware attacks reaching almost 400 in the same period, it is clear that the healthcare industry needs to up its game, said Bryan Cline, industry lead for the guide and Chief Research Officer for HITRUST. “Health industry stakeholders of all sizes and subsectors can reduce their cyber risk exposure by implementing this resource and many others produced by the HSCC and government partners.”

The Cybersecurity Framework Implementation Guide was jointly developed by the HSCC and the HHS, and NIST and other federal agencies contributed substantially to its content. “The guide supplements an earlier joint publication of the HHS/HSCC 405(d) Program – the ‘Health Industry Cybersecurity Practices’ –which is aligned with the NIST Cybersecurity Framework.  With this toolkit, organizations of all sizes can implement cybersecurity best practices, protect their patients, and make the sector more resilient,” said HSCC Cybersecurity Working Group Chair and Intermountain Healthcare CISO Erik Decker.

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A new guide has been published by the Health Sector Coordinating Council (HSCC) Cybersecurity Working Group and the U.S. Department of Health and Human Services (HHS) to help healthcare organizations align their cybersecurity programs with the NIST Framework for Improving Critical Infrastructure Cybersecurity.

The NIST Cybersecurity Framework is one of the most widely adopted frameworks for identifying and managing cybersecurity risks. The framework was released by NIST in 2015, updated in 2018, and the NIST CSF 2.0 is due for release later this year. The NIST CSF is based on five core functions – Identify, Protect, Detect, Respond, and Recover – and suggests cybersecurity controls that can be implemented in all five functional areas. The framework also includes four tiers against which organizations can rate their adoption of the framework, which allows them to communicate how there are achieving their cybersecurity objectives in a standardized way. The NIST CSF has become the standard cybersecurity framework for government agencies and private sector companies for managing cybersecurity risks.

The healthcare industry is extensively targeted by cybercriminal groups and nation-state actors and must defend against increasingly sophisticated and numerous threats. Healthcare organizations typically have fragmented infrastructures, legacy systems, huge numbers of applications, and must protect an ever-increasing number of network-connected medical devices. Consequently, many healthcare organizations struggle with managing cybersecurity effectively.

“Healthcare cyberattacks are among the fastest growing type of cybercrime – jeopardizing patient care, damaging the integrity of health care systems, and threatening the U.S. economy,” said Dawn O’Connell, HHS  Assistant Secretary for Preparedness and Response. “Health care organizations must safeguard their information technology systems to help prevent attacks and create a culture of cyber safety in the health care industry.”

According to the HSCC, a comprehensive cybersecurity framework – such as the NIST CSF – will “provide a common language and structure for discussions around risk and the methods and tools used to manage risk to a level that is not only acceptable to the organization but to other stakeholders such as business partners, customers, and industry and governmental regulators.” Healthcare organizations that base their cybersecurity programs on the NIST CSF can better direct capital, operational, and resource allocations to lines of business generating the greatest return on protecting assets/information and minimizing risk exposure.

While the NIST CSF has been developed to be suitable for organizations of all sizes in all industry sectors, some healthcare organizations have struggled to adopt the framework. The Cybersecurity Framework Implementation Guide is intended to help healthcare organizations adopt the NIST CSF and details specific steps that can be taken to immediately manage cyber risks to their IT systems and better protect against the full range of cyber threats. The guide will help healthcare organizations to assess their current cybersecurity practices and risks and identify gaps for remediation.

“With data breaches having doubled over the past five years and ransomware attacks reaching almost 400 in the same period, it is clear that the healthcare industry needs to up its game, said Bryan Cline, industry lead for the guide and Chief Research Officer for HITRUST. “Health industry stakeholders of all sizes and subsectors can reduce their cyber risk exposure by implementing this resource and many others produced by the HSCC and government partners.”

The Cybersecurity Framework Implementation Guide was jointly developed by the HSCC and the HHS, and NIST and other federal agencies contributed substantially to its content. “The guide supplements an earlier joint publication of the HHS/HSCC 405(d) Program – the ‘Health Industry Cybersecurity Practices’ –which is aligned with the NIST Cybersecurity Framework.  With this toolkit, organizations of all sizes can implement cybersecurity best practices, protect their patients, and make the sector more resilient,” said HSCC Cybersecurity Working Group Chair and Intermountain Healthcare CISO Erik Decker.

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Cybercriminal groups have been experiencing declining revenues. Just like the businesses they attack, when profits start to fall, changes need to be made. Cybercriminal groups appear to be mirroring legitimate businesses and are using similar tactics when faced will falling profits, according to a recent report from Trend Micro.

Ransomware gangs in particular have seen profits take a nosedive, with ransom payments decreasing by 38% year-over-year as victims refuse to pay up, even when there is the threat of publication of stolen data. The gangs have responded by changing their tactics and are becoming more professional. When their brand image becomes tarnished, they simply rebrand. This helps them to stay under the radar but also deals with the image crisis. Conti, one of the most prominent, active, and professional ransomware groups, disbanded when the brand became toxic, with its members splitting into several smaller groups such as Black Basta, Karakurt, Royal, and BlackByte.

Cybercriminal groups have started diversifying their portfolios, placing less reliance on the ransomware attacks that are becoming less profitable. Several ransomware gangs have developed ransomware variants in Rust, which allows them to expand their attacks from Windows and MacOS to Linux systems. Trend Micro also reports that ransomware groups have shifted their focus to monetizing exfiltrated data and are moving to other criminal business models such as BEC attacks, stock fraud, cryptocurrency theft, and money laundering.

While cybercriminals are working on ways to maximize profits once access to victims’ networks has been gained, the methods used to gain initial access have largely remained unchanged. The most common method of access is targeting remote services, often using valid accounts for services that accept remote connections such as telnet, SSH, and VNC. Once access is gained, they proceed as the logged-in user and attempt to expand their footprint by escalating privileges and moving laterally.

Cybercriminals are relying less on phishing as an initial access method following the move by Microsoft to start disabling macros in Office documents by default in documents downloaded from the Internet. Following that move, cybercriminals have started exploring alternative initial access vectors such as malvertising and HTML smuggling.

Trend Micro reports an increase in the use of malicious adverts for key business search terms, with the adverts directing users to malicious sites. HTML smuggling involves HTML attachments to emails, with the HTML file smuggling a ZIP file with an ISO file that has a LNK file that loads a malicious payload. There has also been an increase in living-off-the-land techniques, such as abusing penetration testing tools such as Cobalt Strike and Brute Ratel.

The number of critical vulnerabilities reported in 2022 doubled from 2021, due to the rapidly evolving attack surface. Trend Micro also reports a sizeable increase in the number of failed patches, which the company attributes to vendors rapidly releasing patches to fix a problem, without investing the time to investigate and fix the underlying issue.

In 2022, threat actors switched from exploiting Microsoft Exchange vulnerabilities to Log4J vulnerabilities to gain access to networks. Threat actors are staying up to date on the latest vulnerabilities and are rapidly adding new exploits to their arsenals and are conducting their attacks before organizations can implement the patches. There was also a notable rise in attacks on cloud infrastructure, notably for crypto mining attacks.

SonicWall reported a 2% year-over-year increase in malware detections in 2022; however, Trend Micro’s data suggest a much more alarming increase of 55%. The company reports a 242% increase in blocked malicious files, an 86% increase in backdoor malware detections, and a 103% increase in web shell detections, which are now the most common malware.

In 2022, ransomware attacks were still common, with LockBit and BlackCat the top ransomware families. Rather than target large organizations, there has been growth in attacks on small and mid-sized organizations, where the attacks are likely to have the biggest impact. More than 79% of all attacks were conducted on small or mid-sized organizations (under 10,000 employees), with 51% of attacks on organizations with fewer than 200 employees.

“Threat actors are leaning into more legitimate business tactics and professional operations, employing the same kinds of programs and corporate strategies as their victims. Not only are they innovating in terms of tools and targets, but they are also building resilient organizations that do not rely on singular methods of attack or a particular target pool. They can exploit multiple areas of the attack surface in a single campaign,” explained Trend Micro in the report.

Implementing an effective security strategy can be a challenge, especially due to the current shortage of cybersecurity professionals. Trend Micro suggests in the report that organizations should ensure they cover asset management, secure their cloud infrastructure, implement proper security protocols to minimize the potential for vulnerability exploitation, and ensure they gain visibility into the full attack surface and put systems in place to protect all potential access points.

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