Healthcare hacking incidents have been steadily rising for a number of years. There was a 45% increase in hacking/IT incidents between 2019 and 2020, and in 2021, 66% of breaches of unsecured electronic protected health information were due to hacking and other IT incidents. A large percentage of those breaches could have been prevented if HIPAA-regulated entities were fully compliant with the HIPAA Security Rule.
The Department of Health and Human Services’ Office for Civil Rights explained in its March 2022 cybersecurity newsletter that compliance with the HIPAA Security Rule will prevent or substantially mitigate most cyberattacks. Most cyberattacks on the healthcare industry are financially motivated and are conducted to steal electronic protected health information or encrypt patient data to prevent legitimate access. The initial access to healthcare networks is gained via tried and tested methods such as phishing attacks and the exploitation of known vulnerabilities and weak authentication protocols, rather than exploiting previously unknown vulnerabilities.
Prevention of Phishing
Phishing is one of the commonest ways that cyber actors gain a foothold in healthcare networks. Coveware’s Q2, 2021 Quarterly Ransomware Report suggests 42% of ransomware attacks in the quarter saw initial network access gained via phishing emails. Phishing attacks attempt to trick employees into visiting a malicious website and disclosing their credentials or opening a malicious file and installing malware.
Anti-phishing technologies such as spam filters and web filters are key technical safeguards to prevent phishing attacks. They stop emails from being delivered from known malicious domains, scan attachments and links, and block access to known malicious websites where malware is downloaded or credentials are harvested. These tools are important technical safeguards for ensuring the confidentiality, integrity, and availability of ePHI.
OCR reminded HIPAA-regulated entities that “The Security Rule requires regulated entities to implement a security awareness and training program for all workforce members,” which includes management personnel and senior executives. “A regulated entity’s training program should be an ongoing, evolving process and be flexible enough to educate workforce members on new and current cybersecurity threats (e.g., ransomware, phishing) and how to respond,” said OCR.
The Security Rule also has an addressable requirement to send periodic security reminders to the workforce. OCR said one of the most effective forms of “security reminders” is phishing simulation emails. These exercises gauge the effectiveness of the training program and allow regulated entities to identify weak links and address them. Those weak leaks could be employees who have not fully understood their training or gaps in the training program.
“Unfortunately, security training can fail to be effective if it is viewed by workforce members as a burdensome, “check-the-box” exercise consisting of little more than self-paced slide presentations,” suggested OCR. “Regulated entities should develop innovative ways to keep the security trainings interesting and keep workforce members engaged in understanding their roles in protecting ePHI.”
Prevention of Vulnerability Exploitation
Some cyberattacks exploit previously unknown vulnerabilities (zero-day attacks) but it is much more common for hackers to exploit known vulnerabilities for which patches are available or mitigations have been made public. It is the failure to patch and update operating systems promptly that allows cyber actors to take advantage of these vulnerabilities.
The continued use of outdated, unsupported software and operating systems (legacy systems) is common in the healthcare industry. “Regulated entities should upgrade or replace obsolete, unsupported applications and devices (legacy systems),” said OCR. “However, if an obsolete, unsupported system cannot be upgraded or replaced, additional safeguards should be implemented or existing safeguards enhanced to mitigate known vulnerabilities until upgrade or replacement can occur (e.g., increase access restrictions, remove or restrict network access, disable unnecessary features or services”
The HIPAA Security Rule requires regulated entities to implement a security management process to prevent, detect, contain, and fix security violations. A risk analysis must be conducted and risks and vulnerabilities to ePHI must be reduced to a reasonable and appropriate level. The risk analysis and risk management process should identify and address technical and non-technical vulnerabilities.
To help address technical vulnerabilities, OCR recommends signing up for alerts and bulletins from CISA, OCR, the HHS Health Sector Cybersecurity Coordination Center (HC3), and participating in an information sharing and analysis center (ISAC). Vulnerability management should include regular vulnerability scans and periodic penetration tests.
Eradicate Weak Cybersecurity Practices
Cyber actors often exploit poor authentication practices, such as weak passwords and single-factor authentication. The 2020 Verizon Data Breach Investigations Report suggests over 80% of breaches due to hacking involved compromised or brute-forced credentials.
“Regulated entities are required to verify that persons or entities seeking access to ePHI are who they claim to be by implementing authentication processes,” explained OCR. The risk of unauthorized access is higher when users access systems remotely, so additional authentication controls should be implemented, such as multi-factor authentication for remote access.
Since privileged accounts provide access to a wider range of systems and data, steps should be taken to bolster the security of those accounts. “To reduce the risk of unauthorized access to privileged accounts, the regulated entity could decide that a privileged access management (PAM) system is reasonable and appropriate to implement,” suggests OCR. “A PAM system is a solution to secure, manage, control, and audit access to and use of privileged accounts and/or functions for an organization’s infrastructure. A PAM solution gives organizations control and insight into how its privileged accounts are used within its environment and thus can help detect and prevent the misuse of privileged accounts.”
OCR reminds regulated entities that they are required to periodically examine the strength and effectiveness of their cybersecurity practices and increase or add security controls to reduce risk as appropriate, and also conduct periodic technical and non-technical evaluations of implemented security safeguards in response to environmental or operational changes affecting the security of ePHI.
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