Who'd want to be a CISO?

Challenging job, but increasingly well paid

Hong Kong Healthcare Crisis Easing

Capacity improvement measures beginning to have an impact

Security and the Board Need to Speak the Same Language

How Security Leaders speak to thier C-Suite and Board can make all the difference

Australian Cybersecurity Outlook

Aussie healthcare scrambles to catch up

The Changing Face of the Security Leader

The role is changing, but what does the future hold?

Just keeping its head above water

New Zealand Healthcare steams forward with minimal security

Cyberespionage, and the Need for Norms

Harvard Political Review (external link)

HIMSS AsiaPac19 Livestream

Livestream from HIMSS AsiaPac19

The Evolution of Healthcare

The author presents to the HIMSS19 Eurasia Health IT Conference and Exhibition in Istanbul, Turkey

Healthcare has been transformed over the past century from a largely palliative care delivery model for the sick and dying to an advanced technology-infused and increasingly digitized integrated healthcare delivery model. Technology has fueled massive improvements in patient outcomes. It has enabled us to improve the human condition, to beat diseases that used to ravage families and communities, and to live longer and better than ever before. This was the subject of my presentation today at the HIMSS19 Eurasia Conference held in Istanbul, Turkey.

Increasing use of artificial intelligence and personalized genomic medicines will continue to push the boundaries of care forward in a highly positive way. But digitization comes at a cost, and that cost is in the form of new cybersecurity risks to the confidentiality, integrity, and availability of personal health data and the IT systems that are relied upon to provide care to patients. In fact, in today’s healthcare delivery model, clinicians would find it extremely difficult to maintain the current levels of patient care if health IT systems—and increasingly healthcare IoT—are not available to diagnose, treat, manage, and monitor patients.

The author between the Turkish Minister for Communications and the Deputy Minister for Healthcare
L->R: Ömer Fatih Sayan, Richard Staynings, Ömer Abdullah Karagözoğlu, Mette Harbo, Dr. Mehmet Bedii Kaya.

The number of connected IoT systems surpassed the global human population sometime around 2007-2008. Today, there are in excess of 20 billion IoT devices connected to the Internet, and most have little to no security designed into them at all! Estimates suggest that by 2050 there will be in excess of 1 trillion connected devices—many of them employed in healthcare.

With so many endpoints in our hospitals and clinics, how do we even go about tackling this expanded threat landscape? A good start is adopting a risk-based approach to healthcare security.

You can’t assess what you don’t know about, and with such a large number of medical devices and other HIoT systems used across healthcare, identifying even a basic inventory of IoT assets is an almost impossible manual task given the ever-changing number of connected devices.

That’s where tools like Cylera's MedCommand™ platform come in.

Cylera's MedCommand™ platform will identify HIoT assets, perform a full risk analysis of each device and device type, profile the legitimate traffic patterns of each device type for zero-trust security controls, alert on any anomalous traffic detected outside of legitimate traffic patterns, and even automatically remediate discovered risks with compensating security controls via a hospital’s existing network access control and/or firewall technology.

Cylera's Richard Staynings and Timur Ozekcin
Cylera is proud to be a sponsor of the HIMSS Eurasia 19 Conference

Presenting Cybersecurity to the Board

Don’t speak "geek" to the Board or you will receive a cool reception

At some point in our careers, many of us will be called upon to present to the board of directors. This could be to report the findings of an audit, compliance, or risk assessment. It could be to provide an annual or quarterly update on ‘the state of the union.’ It could be to report a recent incident. Or it could be to request support for a new initiative.

Whatever the case, presenting to the board is no straight-forward task—and newbies would be well advised to thoroughly prepare for this kind of appearance, which differs greatly from meetings with the C-Suite, peers, auditors, consultants, and technology professionals.

Board members are elected or appointed by a corporation’s shareholders to represent shareholder interests and to ensure that the company's management acts on their behalf. A board's mandate is to establish policies for corporate management and oversight, making decisions on major company issues. Every public company must have a board of directors, and in healthcare—regardless of whether that health system is "for-profit" or "not-for-profit"—boards almost always govern and provide oversight to the C-Suite.

Hospital board members are drawn from shareholders, investors, independent industry, and cross-industry experts, and often include academics and notable physicians. Overall, they are business people and know how to run a business. Most don’t understand or speak technology—they are from business/finance/physician backgrounds after all. And almost none will speak or comprehend "cybersecurity". In fact, some might even have a difficult time spelling it! They do, however, understand business enterprise risk, profit and loss, and cost of risk acceptance, transfer, and remediation.

When addressing the board, CISOs need to speak in the terms and language that board members understand, rather than the language used to report to the CIO or other members of the C-Suite. Failure to do so will result in the message being lost or largely unheard.

Most board members picked up what little they know of cybersecurity from articles they read in the Wall Street Journal and other periodicals. They lack the technology backgrounds and domain expertise to go deep to understand the technicalities of cybersecurity. So how do you establish a common language and communicate understandable metrics to the board? By translating cybersecurity risks and strategies into business risks and strategies in order to make it relevant to board members. You likely won’t get money for tools to tackle APTs, but you might get money to ensure the business stays up and running following an attack.

Richard Staynings presents to the VA HIMSS Annual Conference this week

This was the subject of a presentation I gave this week to the Virginia HIMSS Annual Conference in Williamsburg, VA, where 300 or so healthcare leaders from across the region gathered to learn and share best practices on healthcare management, technologies, security, risk, and compliance. And of course to raise money in a day of charity golfing at the beautiful Kingsmill Resort.

So what were some of the takeaways?

Make Cybersecurity Part of Broader Enterprise Risk Management:

Use similar language being used to describe other business risks for how you talk about cybersecurity. Senior executives and boards are very familiar with assessing the probability and negative impact of risks, establishing a risk tolerance level, and developing risk management plans. If you use the same approach and terminology, it will help them to understand the big picture and make more informed decisions about the actions you suggest.

Talk about Program Maturity:

Maturity models are embraced by senior management and the board because they are familiar with them from many other programs, like quality management. Use the same tactics and language to discuss cybersecurity.

People, Process, & Technology:

Help senior management understand that cybersecurity requires the orchestration of people, processes, and technology—and that they have a critical role in it. Security practitioners usually fail by myopically focusing on just technologies and tools.

Establish a Culture of Cybersecurity:

Get everyone on-board with the mission to secure the organization; from the Board and CEO all the way to Interns. Buy-in from department leaders is especially important in order to establish cross-functional support for security initiatives.

Standards and Frameworks:

Aligning the security program with a widely used security standard or framework allows you to benchmark the program against other companies and that standard. Inevitably, senior management is going to ask you, “how are we doing against other companies?” If your program can reference the NIST Cybersecurity Framework, ISO27001, or CIS CSC, you will be able to compare the maturity of your program with a broad, diverse group of companies.

Addressing the Board

  • First impressions count, so dress and act appropriately. That means business formal— better to be over-dressed than under-dressed.
  • Research every board member on LinkedIn or in the press.
  • Get coaching from a board member or the CEO to understand what the board is looking for from you.

Define your Purpose

  • What are you there for? Own it!
  • Be succinct, honest, and direct—Corporate Chieftains don’t suffer fools lightly.
  • Coach members on the basics but don’t treat them as fools—they don’t come from your world but they need to be educated on the basics in order to make informed decisions.
  • Avoid the weeds—focus on the big picture and on business benefits, not security details.

Be Prepared

  • If you are lucky you will get 5 to 8 minutes to make your case—plan and use the time wisely.
  • Talk to the CEO or other executives beforehand to ask for tips and advice.
  • Prepare a well written brief and have the CEO’s admin print and bind copies ready for the meeting.
  • Use maturity models and frameworks. This is what board members want to see. This is how they think!
  • Understand how the company compares to others. Saying that something is simply a "best practice" won’t win you support.
  • Anticipate questions—you’ll get lots. Be prepared with smoothly delivered confident answers.
  • Be prepared for politics! Boards have their feuds and sub-agendas - try and see through the fog.

Be Strategic

  • Boards are strategic, not tactical—so stay out of the details. That’s for the C-Suite to understand.
  • Find metrics that tie into your mission for compliance, patient safety, up-time/availability, etc.
  • Talk about reputation—it’s the board’s responsibility to protect it.

Avoid Surprises
  • Boards hate surprises, so provide a pre-brief before the meeting to help them adjust to new information—especially if its bad information.
  • Keep things high-level and strategic—and above all business-focused.
  • Avoid talking about specific technology, types of attacks, and especially acronyms.

End Result
At the end of the day, the board needs to feel confident that you as the CISO know what you are doing, and that the organization is in good hands. Presenting to the board is as much about you building your reputation with them, as it is about your program gaining the active support and sponsorship it needs in order to be successful in protecting the company.

This blog was originally published here

AI Will Radically Change Healthcare Security

Cyber-attacks are becoming a major global concern. Not just against nation-states but also for a myriad of critical infrastructure services including healthcare which is firmly in the cross-hairs of perpetrators. Healthcare presents an easy and lucrative target for cyber-attackers for the value of PII, PHI and IP but also and increasingly so for the extortion value of holding sick patients or their medical data to ransom.

It’s no longer just a case of opportunistic criminals and organized crime hiding in remote parts of the world that lack effective local law enforcement, and criminals safe in the knowledge that paid-off officials and a lack of international extradition treaties means that they can continue their pursuits at will. It’s now a case of nation-state cyber-military units attacking other countries for political and economic advantage pushing at the boundaries of cyber war, carefully calculating that their actions will not cause a kinetic or major economic response from those attacked or those shocked and appalled at their actions.

But cyber-attacks are increasingly becoming automated using AI to get past cyber defenses by removing the human constraint factor that causes an attacker to pause for consideration and to prevent an attack from going too far. ‘Offensive AI’ mutates itself as it learns about its environment to stealthily mimic humans to avoid detection. It is the new cyber offensive weapon of choice and will automate responses to defensive measures rather like playing chess with a computer – it learns as it goes!

The author presenting how AI will radically change healthcare security at the HIMSS AsiaPac19 
Annual Conference in Bangkok, Thailand.

We are all used to critically evaluating an image to look for the tale-tale signs of photoshopping or other image manipulation before believing what we see. The same is true for audio recordings – was that really the President saying that or was it an impersonator? What we are not used to is video manipulation – this is new territory for our brains to critically process and evaluate for truth and accuracy. AI is increasingly being used in sophisticated technology to create ‘deepfakes’ where a face is superimposed on someone else’s body or the entire video is computer generated.

But AI’s intent is not just to steal information but to change it in such a way that integrity checking will be difficult if not impossible. Did a physician really update a patient’s medical record or did ‘Offensive AI’? Can a doctor or nurse trust the validity of the electronic health information presented to them? Ransom of patient lives may not be too far away – especially at times of heightened global tensions.

But AI is already being used very effectively for cyber defense across healthcare and other industries. Advanced malware protection that inoculates the LAN and responds in nano-seconds to anomalous behavior patterns. Biomedical security tools that use AI to constantly manage and secure the rising number of healthcare IoT devices as they connect and disconnect from hospital networks. AI-powered attacks will outpace human response teams and outwit current legacy-based defenses. ‘Defensive AI’ is not merely a technological advantage in fighting cyber-attacks, but a vital ally on this new battlefield and the only way to protect patients from the cyber criminals of the future.

Beverly Hills Healthcare Security Forum

California Healthcare Cybersecrity Forum in Beverly Hills. Photo: Pat Lambert.

An esteemed panel of biomedical and security leaders discussed "The Biomedical Elephant in the Room" at the California Healthcare Cybersecurity Forum today in Beverly Hills.

Healthcare IoT (HIoT) now extends from one side of healthcare delivery to the other and today that includes an increasing number of medical devices, robots, health automation systems and building management systems none of which hospitals can easily do without.

Most of these connected devices however are not traditionally managed by IT, many don’t appear in any asset management database, most are not patched against vulnerabilities regularly (if ever), and the vast majority are highly vulnerable to cyber-attack and extortion. Very few have effective compensating security controls like micro-segmentation to protect patients from being the subject of the attack rather than just the device attached to them.

A large number of network and implantable medical devices, pose a significant patient safety risk if not secured and could cause patient harm or even fatalities.
Dick Cheney, former Vice President of the United States, had the wireless interface to his own pacemaker disabled because of fears that me might be hacked or assassinated by a political opponent or foreign government via manipulation of the cardiac defibrillator keeping him alive. This scenario was the basis of an episode in the TV series Homeland, in which the Vice President of the United States was hacked and killed.

Edited: Homeland, Se2Ep10

The panel comprised of Chad Wilson, CISO at Standford Childrens' Health, Dr. Benoit Desjardins MD, Ph.D. Associate Professor of Radiology and Medicine at Penn Medicine, Harb Singh, Security Program Manager at Cedars-Sinai Medical Center, and Richard Staynings, Chief Security Strategist at Cylera, discussed what can be done to mitigate security risks and protect patient safety.

For those that missed this highly informative and educational session, Richard will be moderating a similar panel in Boston at the Healthcare Innovation, Healthcare Cybersecurity Forum, on Oct 4th.

Nation State Cyber Thieves Target Healthcare Research and Patient Data

State sponsored cyberattacks against Healthcare and the wide scale theft of PHI, PII and IP are increasing, putting the whole sector at increased risk report claims.

Not Petya (Nyetya), WannaCry, Stuxnet, Sony Pictures, Yahoo, US Office of Personnel Management (OPM), SingHealth, and Anthem breaches are all recent examples of nation state attacks. Some are indiscriminate, some target other nation states, and some are focused towards intelligence gathering of mass or targeted individuals. Some are thinly disguised criminal theft of intellectual property and trade secrets, or monetary theft and extortion to supplement what hackers get get paid by their government puppet-masters for 'official business'. They all have one thing in common, a well-funded and well-trained team of cyber warriors with the patience of saints, and the tenacity to get the job done. These are the advanced persistent threats (APTs) that mark a nation state adversary. They are usually stealthy and stay hidden till the last moment, or go unnoticed entirely as Yahoo eventually discovered after a subsequent attack.

Although WannaCry took out a large number of healthcare systems around the world including a significant number of UK NHS hospitals and healthcare trusts, it was by and large a broadcast extortion attack to generate money for the highly sanctioned government of North Korea (DPRK). The SingHealth and Anthem breaches were however highly targeted at healthcare institutions, and these are just the tip of the iceberg. Like the OPM breach, these attacks are thought to have originated from Peoples Republic of China (PRC).

Chinese fingerprints are all over many recent healthcare attacks.

A recent report by FireEye has indicated that state-sponsored attackers from the PRC have for some time been targeting medical data from the healthcare industry. This includes not only PII, PHI and in some cases even the prescription information of patients, but a broader focus upon the theft of academic and clinical research, drug and clinical trial data, research studies, formulary and procedural data, as well as plans for medical devices. Pharmaceutical companies, universities, hospitals and biotech / biomedical engineering companies have all been targeted according to FireEye’s “Beyond Compliance: Cyber Threats and Healthcare report”. In particular there has been a strong focus on the theft of research data into cancer treatments and artificial intelligence, both of which are top priorities for Chinese manufacturers the report adds.

FireEye has seen a “prevalence of multiple Chinese groups over the last several years, and continuing in what we see today, targeting medical researchers in particular," says Luke McNamara, a principle analyst at FireEye who worked on the research. The company says the Chinese-linked APT41, APT22, APT10 and APT18 have all been seen trying to obtain medical data in recent years. Additionally a group linked to Vietnam (APT32) and a group linked to Russia (APT28) also dabble in healthcare, the latter of which has so far targeted sports medicine providers responsible for ant-doping tests of Russian athletes.

Targeting medical research and data from studies may enable Chinese corporations to [patent and] bring new drugs to market faster than Western competitors,” FireEye said. The country’s ‘Made in China 2025’ campaign intends to replace all imports from multi-nationals with locally produced products.

In particular, the report added, China has exhibited a “growing concern over increasing cancer and mortality rates, and the accompanying national health care costs.” With massive levels of ground and water pollution in China that has poisoned the food supply with dangerous levels of cancer-causing heavy metals, and air pollution which in some cities is hundreds or thousands of times WHO safety limits, it’s no wonder that the costs of treating cancer is such a growing concern for a country which plans to have universal healthcare coverage for all of its 1.5bn citizens by 2025.

If things weren't bad enough already for hospitals and health systems outside of China, then they just got a whole lot worse!

Photo: Markus Spiske.

Nation State Attacks
Nation state sponsored cyberattacks have been on a sharp rise over recent years with North Korean attacks against Sony Pictures in 2014 in retribution for its movie “The Interview”, followed by the ‘WannaCry’ ransomware attacks of 2017, thought to have been designed to generate foreign currency for the hermit kingdom. Also of grave public concern, were Iran’s DDOS attacks against the US banking sector between 2011 and 2013 and an attempted hijacking of the Bowman Ave. Dam in New York, thought to be in retaliation for the US Stuxnet attack against Iranian uranium enrichment centrifuges.

Russia too has been a major perpetrator in more direct cyber-warfare attacks going back as far as the first Chechnya War in 1996, to literally hundreds of attacks against its neighbors - from the cyber attack against the Turkish-Georgian-Kazakh BTC oil pipeline in 2008, to the most recent attack against the Ukrainian power grid. However, it is the ‘Not Petya’ wiperware attacks of 2017 attributed to the Russian GRU that currently takes the prize as being the most destructive and most expensive cyberattack in history. Not Patya targeted companies doing business with Ukraine and resulted in approximately $8bn in damages to multi-nationals from all over the world. Not Petya destroyed tens of thousands of computer systems and shut down hundreds of companies, including some in Russia. Not only did the GRU open Pandora's box but they accidentally let Pandora out to run amok! Russia is also responsible, via a network of proxy groups who engage in simple criminal theft, for many attacks against retail merchants and financial institutions, and of course for the Yahoo breach of a billion users – the largest attack to date.

But it is the People Republic of China’s insatiable appetite for the theft of commercial intellectual property and trade secrets, combined with its wholesale theft of PII and PHI that is most notorious when it comes to nation state cyberattacks. The OPM breach of 21.5 million federal employee records between 2013 and 2014, and the 2015 Anthem Health breach that resulted in the theft of PII of 79 million people – healthcare’s largest, are typical of PRC attacks. While cyber espionage against military-defense secrets appears to be common across all states today, what differentiates China is its cyberespionage activities that plainly target non-military-defense commercial organizations and research universities. In China everything of significance is owned by or beholden to the state, and after 70 years of communism and isolationism, the peoples republic has had a long way to catch up with the rest of the world. It is not only China's intention to catch up, but also to surpass the rest of the world by whatever means are necessary. In China, that ambition is abbreviated as or ganchao in Chinese. What's more, China fully intends to surpass the west within the next five years under the central government’s ‘Made in China 2025’ initiative. Unfortunately, given the tight schedule, that may involve the theft of ideas and trade secrets from nearly every major company on the planet.

This blog was originally published here

Rocky Mountain Health IT Summit

Richard Staynings and Michael Archuleta address the Rocky Mountain Health IT Summit today.

Thanks to everyone who attended our presentation today at the Healthcare Informatics Rocky Mountain Health IT Summit in Denver, where Mike Archuleta, CIO of Mt San Rafael Hospital, and I greatly enjoyed sharing our thoughts and advice on how to secure....

Healthcare IT and IoT.

Unfortunately, today we live in an era of escalating cyber threats from bad actors and nefarious nation states intent on the disruption of our business and personal lives. Regrettably, this also includes life-sustaining healthcare technologies. If this weren't enough, the healthcare industry is also in the process of transforming to a near complete reliance upon information technology and internet of medical things (IoMT) technologies. In fact Healthcare IoT (HIoT) devices are growing at 20% per annum according to some sources which means the problem is getting bigger and bigger each and every day! This includes a proliferation of medical devices, pharmacy and surgical robots, AI-augmented labs and diagnostic systems, and networked connected hospital building management systems like elevators and HVAC systems, without which the modern day hospital cannot function for long. This provides hackers with a very large attack surface upon which to exploit a weakness or vulnerability and establish a beachhead for more nefarious purposes - perhaps the theft of medical records and personal identities, or to ransom hospital data or patients.

Effective cybersecurity has always been about the combination of people, process and technology and that still holds true today. However the perpetrators of cyber-crime are hell-bent on exploiting every weakness regardless of the patient safety issues of their actions. As cyber defenders we need to employ the best processes, skilled security resources, and best technologies in the defense of our diagnostic and clinical systems. It also means that old out-of-date and end-of-life systems should be replaced, while all other systems are updated regularly with security patches, especially if your hospital still runs some version of Windows. The costs of upgrading may appear to be prohibitively expensive, but the reputational and financial costs of a breach or ransom attack could be life threatening - for the business and its patients!

56% of Health Providers Still Rely on Legacy Windows 7 Systems

As a first step hospital CEOs and their boards need to gain an accurate understanding of their risks and that means a full inventory of all of their IT, HIoT and data assets - something most smaller hospitals have little to no idea about. Remediation of identified risks then needs to be prioritized in order to reduce overall enterprise risk and the threat to patient safety. That will require discipline, established and documented processes, and quality resources whether people or tools, or a combination thereof. Above all it requires effective cybersecurity governance sponsored at the highest levels of the board and reinforced all the way throughout the organization. Sadly, too many hospital CEOs and their boards have yet to take this step.

Fortunately however, many small facilities and critical access hospitals have prioritized security and are already reaping the benefits of their early investment in IT and cybersecurity. This allows them to offer more profitable and cost-efficient services to patients via among other services, secure online portals, telehealth and telemedicine, just proving that security does not need to be advanced rocket science, just the combination of good people, process and technology to add value to a business.

For anyone interested our deck can be downloaded here.  Please feel free to plagiarize for your own presentation to your CEO and Board if useful.

Singapore eHealth - Innovative Technologies and Security

The Author addresses the Singapore eHealth Summit. Photo: Dean Koh
Singapore faces many of the same problems affecting patient care in Europe and North America; an aging population, rising demand and increasing costs. The need to implement more value-driven initiatives to increase efficiency and improve patient outcomes will become critical here in Singapore just as it is in other countries with declining populations or unsustainable rising healthcare costs. This includes the need for wider mainstream adoption of new and disruptive technologies like data analytics, machine learning and artificial intelligence, combined with highly innovative procedures to accurately identify, diagnose and treat patients.

The recent Singapore eHealth and Health 2.0 summit was unique in that it brought together some of the best minds and best ideas from all over the world under one roof, to showcase a plethora of quality treatment ideas and disruptive emerging technologies which promise to revolutionize the healthcare industry.

As with the adoption of any new technologies, there are risks which must first be evaluated before a technology can be introduced, and in healthcare, increasingly these risks focus upon cybersecurity.

In Singapore, which suffered its largest ever breach last year with the theft of 1.5m SingHealth patient identities along with the prescription records of its Prime Minister and other V.I.P.s, security is of particular concern. Several smaller healthcare breaches this year including publication of the personal details of over 800,000 blood donors, and the exposure of 14,200 HIV patient records has compounded the need for the industry to get security right.

Confidentiality, Integrity and Availability

The ASEAN region, according to CIO Magazine, with its dynamic position as one of the fastest growing digital economies in the world has become a prime target for cyber-attacks, accounting for 35.9% of all cyber attacks globally in 2017. The targeted attack against SingHealth is perhaps a wake-up call for the region to do a better job of securing Confidentiality, Integrity and Availability (CIA) its healthcare and other critical services.

But the risks impacting healthcare are way more nefarious than just the disclosure of confidential patient information. Far more worrying is the threat to the INTEGRITY of health records and other clinical data, and the AVAILABILITY of HIT systems needed to treat patients.

  • What happens when a patient's blood type, allergies or past treatment records are altered by a hacker?
  • What happens when a ransomware attack locks up all Health IT systems as it did to many hospitals in the British NHS with the WannaCry attack?
Patient Care suffers and Patient Safety is placed at risk
The growth of medical devices and other Healthcare IoT (HIoT) is prolific and already outnumbers traditional computing systems. Compound growth in medical devices has reached 20% per year by some estimates. Furthermore, most are connected now to hospital networks and talk directly to core HIT systems like the Electronic Health Record. Hackers know this and have used the fact that HIoT systems are by and large unprotected against cyber-attack to launch their infiltration campaigns.

Many legacy medical devices can only connect to hospital WiFi using insure WEP encryption, which means any teenager with the right tools could gain access to core systems in most unsegmented healthcare networks with little more than a SmartPhone from a hospital waiting room.

Medical devices and other HIoT systems now pose the single greatest risk to patient safety according to many in the industry because of their lack of inherent security, inability to be patched or secured with AV or a host firewall as even a Windows PC can. What is more worrying is not that these devices are incredibly easy to hack or topple over, but the fact that they are most often connected to patients at the time providing critical life-sustaining care or telemetry.

On-stage demonstrations at security conferences like DefCon, Black Hat, and KiwiCon often feature the hacking of some sort of medical device that if connected to a real patient, would undoubtedly result in that patients death. Yet, the US FDA, Australia TGA, UK MHRA, and EU EMA, device manufacturers, and hospitals all downplay the risks, knowing that devices have a 15 to 20 year lifespan and few if any, are ever updated with security patches once sold.

The fact of the matter is that we have almost no idea if, and how many patients have died as a result of a medical device being hacked. No one currently is required to forensically investigate a failed medical device. Instead when is device is suspected of failing, all data is wiped to comply with HIPAA, GDPR, SPA, and other privacy rules and the device is shipped back to the manufacturer to be re-imaged, tested and put back into circulation. This is a subject I have written about in the past and one perhaps best demonstrated by Doctors Christian Dameff, MD and Jeff Tully, MD from the University of California Health System, in their realistic yet alarming presentation at the RSA Conference last year.

The need to better understand and evaluate risk in this growing sector of healthcare has reached a tipping point, as OCR in the United States and the TGA in Australia, starts to ask questions about risk analysis of these devices many of which are covered under the HIPAA Security Rule and the APA. However healthcare IT and Security teams face several daunting challenges before they can mitigate security risks and chase compliance.

1. In most hospitals, medical devices are owned and managed by Bio-Medical or Clinical Engineering, while other groups also outside of IT, manage building management and other hospital IoT systems. Consequently, there is limited security visibility, if any at all!

2. An accurate inventory of what HIoT assets are connected to the network is almost impossible to accomplish manually as devices change all the time and manual spreadsheets and traditional IT asset management systems have proven inaccurate.

3. Evaluating the risks of medical devices is difficult since most are connected to patients and cannot be scanned with normal security tools. Larger equipment like X-Ray machines, MRI, CT and PET scanners are in use 24/7 and cannot usually be taken out of service for regular security scans.

4. Inherent weaknesses in some HIoT protocols like DICOM allows a malicious actor to embed weaponized malware into a legitimate image file without detection, as researchers at Cylera Labs discovered recently.

5. Lack of internal network security allows a hacker to intercept and change a PACS image with false information during transmission between a CT scanner and its PACS workstation, adding a tumor to an image or removing one as security researchers at Ben Gurion University recently discovered.

Fortunately, new AI security tools from Cylera, created especially with healthcare in mind, are able to automate the entire risk management process to identify, profile, assess, remediate and manage HIoT assets in line with NIST SP800-30 standards. Just as healthcare delivery is moving towards disruptive innovative technologies, so are the security risk management tools being used to support the adoption of new technologies and new procedures.

Cylera’s 'MedCommand' solution, empowers healthcare providers to protect the safety of their patients, assets, and clinical workflows from cyber-attacks. 'MedCommand' provides clinical engineering and information security teams with a unified solution to manage and protect the entire connected HIoT environment including medical devices, enterprise IoT,
and operational technology.

The 'MedCommand' solution is built on Cylera’s 'CyberClinical' technology platform, which incorporates machine learning, behavioral analytics, data analysis, and virtualization techniques. Cylera has partnered with leading healthcare providers, experts, and peers to develop the most comprehensive and integrated HIoT security solution for healthcare.

Learn more about Cylera's innovative AI based approach to medical device and other HIoT endpoint management or contact us to schedule a conversation.

This blog was originally published here.

When Cyber Attacks Go Too Far

News today that Israel has responded to a cyber-attack with a kinetic reply is perhaps a first but, in many ways, to be expected, given a rising tide of global cyber-attacks by those who cause increasing levels of damage, yet hide from attribution by use of proxies or through assumed anonymity.

According to Forbes:

The escalating global threat of cyber-attacks against nation-states took a turn yesterday when Israel's military announced that it had "thwarted an attempted Hamas cyber offensive against Israeli targets. Following our successful cyber defensive operation, we targeted a building where the Hamas cyber operatives work….HamasCyberHQ.exe has been removed," the tweet concluded.

Now that the precedent has been set, it should serve as a very real warning to cyber criminals everywhere that just because they reside in a state that turns a blind eye to international lawlessness, they are not immune from being brought to justice.

This may not be the first kinetic response to an act of cyber warfare but its certainly the first one mass-publicized. The US has reserved the right to retaliate against cyber-attacks with military force since 2011, and in 2015 it launched a hellfire missile attack from a drone to assassinate British born Islamic state hacker Junaid Hussain as he walked down a street in Raffa, Syria.

Many people have been expecting a kinetic response to a cyber attack for some time and talking about the advent of hybrid warfare, but can either of these bombings be seen as the turning point?

The fact is that Hamas had recently launched over 600 missiles at Israel and Israel had conducted over 250 air strikes of Hamas targets in retaliation. In the case of Junaid Hussain, he was known to be actively planning terrorist attacks in the west. Both were thus legitimate targets in existing kinetic conflicts, and both appear to satisfy the UN Charter for 'National Collective Self Defense'. But will this latest attack be used to justify a kinetic response to a future cyber attack or the perceived threat of one by a credible adversary? Maybe!

The Israeli Defense Forces (IDF) certainly considered the threat real enough by Hamas hackers planning an attack on Israel to warrant dropping a very large bomb on top of their building, reportedly with them in it!

Iran should certainly watch its back, where we are told, there has been a steady escalation in threats against the United States over recent months. The recently announced positioning of the USS Abraham Lincoln Strike Group to the Persian Gulf together with a Bomber Strike Group may be seen as a strong warning to Tehran. It may also be considered as positioning for future retaliatory kinetic attacks for recent wave of cyber and other attacks against the United States. This may mark the return of more aggressive US policies against terrorists and others who attack the west with assumed impunity. Just as Reagan’s bombing of Libya in 1986 signified a line drawn in the sand for Qaddafi’s support of terrorism against United States citizens, with hawks like John Bolton and Mike Pompeo advising Trump things could escalate very quickly.

But Iran is not alone on the 'Bad Boy' list of cyber-attacks going too far. According to the Center for Strategic and International Studies most of the world’s cyber-crime is originated in four countries – the Peoples Republic of China, the Russian Federation, the Islamic Republic of Iran and the Democratic People's Republic of (north) Korea, as the chart below shows:

Russia has been using cyberwarfare arguably against its own people since the first Chechen war, but in 2008 the Russia military is attributed to blowing up the Turkish Baku-Tbilisi-Ceyhan (BTC) oil pipeline at Refahiye in eastern Turkey after hacking CCTV cameras to gain access to pipeline valves that were then used to super-pressurize the line until it blew up. The BTC pipeline, which links Baku in Azerbaijan to Ceyhan on the Mediterranean coast of Turkey, gives additional energy independence to oil-rich states on Russia's southern border at a time when Russia is seeking to reassert its control over former Soviet states.

In 2014 a massive cyber attack was launched against Sony Pictures Entertainment that involved the theft and release or destruction of a huge amount of data. It was the first destructive cyber attack conducted against the United States and the first time the US attributed a cyber attack to a foreign government. The attack was claimed by 'Guardians of Peace' and was eventually attributed to North Korea to a group of hackers known as 'Shadow Brokers'.

The 2017 'WannaCry' ransomware attack that brought down hundreds of organizations worldwide including the effective closure of a large number of British hospitals and other critical facilities, has also been attributed to the Shadow Brokers, an outfit that works in the PRC and PDK for the Kim regime of North Korea. According to an Op-Ed in the Wall Street Journal, Tom Bossert, then Homeland Security Advisor to President Donald Trump, firmly attributed the attacks to Kim Jong-Un who gave the order to launch the malware attack, he claimed. "We do not make this allegation lightly. It is based on evidence." Bossert stated. Canada, New Zealand, Japan, and the UK all independently agreed with the US attribution.

Right on the heals of WannaCry, the 'Not Petya' attacks of June 2017 were an act of cyber warfare instigated by the Russian GRU (ГРУ), according to a CIA analysis of the attack reported by the Washington Post. Not Petya or Nyetya as it is also known as, was disguised as a new variant of ransomware, but with no way to recover information or the hard drives storing the data, it destroyed millions of dollars of computer equipment and cost businesses the world-over, somewhere between $4bn and $8bn according to Wired. Not Petya thus became known as a broadcast 'wiperware" and as a cyber weapon by many.

According to the CIA, Russia's GRU created NotPetya, as an escalation of its existing kinetic and cyber war against Ukraine ongoing since popular revolution there ousted the pro-Russain former Ukrainian President and CCCP Communist Party Member Viktor Yanukovych. The attack which initially targeted Ukrainian accounting tax software company M.E.Doc, brought down virtually all of Ukraine’s government along with Ukrainian hospitals, power companies, airports, and banks. Since then there has been a steady stream of cyber attacks directed by Moscow against Ukrainian critical infrastructure and power utilities knocking them off-line, constant attacks against Ukrainian businesses, and various kinetic attacks including the military occupation and annexation of Crimea, the instigation of Russian nationalism, ethnic unrest and military support of separatists in Eastern Ukraine, that resulted in the death of 285 passengers and 15 crew aboard MH17 as it flew between Amsterdam and Kuala Lumpur in July 2014 when it was hit by a Russian surface to air missile.

The impact of Not Petya spread far beyond the borders of Ukraine and caused massive damage across the world. First investigated by the Ukrainian security agency, known as the SBU, it was quickly attributed to Russian security services, a fact reflected in other countries subsequent investigations into the cyber attack including all of the Five Eyes nations of the United States, UK, Canada, Australia and New Zealand. This was reflected by a White House statement issued February 15, 2018:

"In June 2017, the Russian military launched the most destructive and costly cyberattack in history, NotPetya "quickly spread worldwide, causing billions of dollars in damage across Europe, Asia, and the Americas. It was part of the Kremlin’s ongoing effort to destabilize Ukraine, and demonstrates ever more clearly Russia’s involvement in the ongoing conflict. This was also a reckless and indiscriminate cyber-attack that will be met with international consequences."

Putin's Russia has continued to push the boundaries of acceptability with each new attack from the hacking of the US Democratic Party and former US Secretary of State and presidential candidate Hillary Clinton, to influencing of the US and German presidential elections and the Brexit referendum via its social media bots, to literally hundreds of attacks against think tanks and NGOs according to Microsoft, most of which have been attributed to a group called 'Strontium' - otherwise known as 'Fancy Bear' or 'APT28'.

Meanwhile in the east, The Peoples' Republic of China has kept up a relentless attack against businesses the world over, in its quest to steal the intellectual property and business secrets of the leading global companies. Despite agreements between US and Chinese presidents in 2015, to stop the wholesale cyber-theft of intellectual property, the attacks continue as China tries to surpass the rest of the world with its home-grown companies, using stolen patents and trade secrets invented by others.

The big question is, "how far is too far"? At what point does it become necessary to send a loud and clear message that cyber-attacks will be met with real consequences? Israel certainly deemed it necessary to deal with a group in Hamas that was responsible for cyber attacks against its country and citizens.

Countries may not readily invade one another today as they once did in the nineteenth and twentieth centuries leading to major global conflicts and massive loss of life. That is, perhaps with the recent exception of China's building of military islands off the coast of the Philippines and Vietnam in international waters - an apparent land grab of most of the South China Sea. But we know from history, that if you don't stand up to a bully at least once, then the bullying will continue. Hitler's occupation of the Rhineland in 1936 is perhaps a good example of what happens when you ignore a problem for too long.

Sometimes we forget that cyber warfare is after all just another form of warfare!

Now that the precedent has been set, those involved in cyber espionage, wholesale theft of IP, extortion, and cyber attacks against businesses and critical infrastructure of countries might want to consider a new profession, or be on the lookout for things falling from the sky!

HIMSS TV Interview - C.I.A.

My recent interview with Bruce Steinburg MD, EVP of HIMSS International at the Singapore eHealth and Health 2.0 Summit.

The Growth of Medical Tourism 3

This is a multi-part story over 3 days. Take me to the beginning.

Trends in Medical and Dental Tourism

Patients Beyond Borders, a publisher of guidebooks for "medical tourists" estimates that more than 20 million people will travel to another country for medical treatment this year, up 25% from 16 million last year. Meanwhile, a 2016 report by Visa estimated that the medical tourism industry was worth $50bn a year, and continuing to grow.

In fact according to Deloitte medical tourism has been growing at 10% per annum or greater for the past 15 years. BCC Research predicts that double digit growth is expected to continue for at least another five years with destinations like Mexico, Thailand, Malaysia, Taiwan, UAE, and Costa Rica leading the popularity charts.

But it's not just a migration of US medical consumers to these locations. Its a global trend of Americans and Europeans looking to cut costs and avoid wait times on one side, and the super wealthy in developing nations like Saudi Arabia, China and India in search of specialist treatments not available in their own countries going the other way. The migration for services is both global and regional. Many Californians and Arizonans head south to Mexico to visit the dentist or pick up prescriptions. The same is true in the northern US states with trips to Canadian pharmacies and healthcare providers. The growth in demand for medical tourism is fueling major investments in healthcare, not just in towns close to US borders, but across the world in cities like Dubai and Abu Dhabi as I reported on in 2017 from the UAE which benefit from an influx of patients from Saudi Arabia and other gulf states as well as from Europe and the United States.

Despite its free National Health System, many UK residents are avoiding long wait lists for consults and procedures and traveling overseas for medical and dental treatment for less than half of private treatment at home. This includes cosmetic surgery and other treatments not covered under the NHS.

Medigo, a German-based medical travel company says that queries from UK residents jumped 53% last year. Official figures from the UK's Office of National Statistics also show that a rising number of people are going abroad for treatment.

The trend is similar in the US where the number of American health tourists goes up every year. About 422,000 traveled outside of the country for medical and dental procedures in 2017 according to the US National Travel and Tourism Office. That is up from 295,383 in 2000.

These figures exclude the massive and rising number of Americans who drive across the both US boarders each day, to get their prescriptions filled rather than pay the unregulated and exorbitant prescription drug prices in the United States.

As the number of uninsured Americans continues to climb, it seems more than likely that high deductibles and reductions in insurance coverage are pushing more Americans to search elsewhere for affordable medical and dental care. With more attacks underway against the US Patient Protection and Affordable Care Act, otherwise known as 'Obamacare', and employers increasingly shifting healthcare costs to employees, medical tourism looks to become a key facet of most people's future healthcare and dental care.

Read the entire story:

See also my post on health tourism and cybersecurity in the United Arab Emirates

Read also this article in the New York Times about US companies that are paying their covered plan participants to travel to Mexico and Costa Rica for elective surgery - with American surgeons.

The Growth of Medical Tourism 2

This is a multi-part story that launched yesterday.

My employer-sponsored-health-plan provides me and my family with an annual physical with our primary care physician. This normally involves a 40 to 60-minute appointment where a nurse measures my height and weight, checks my vision, draws some blood and has me pee in a cup before my doctor gives me a physical examination. Thanks to Obamacare this little interaction is annual and free, meaning no co-pay, no-deductible or other disincentive to see someone. It also provides the opportunity to discuss with my primary care provider anything that concerns me but didn’t warrant me shelling out money to book a regular appointment with the him or her. Finally, it also allows me to unlock and renew my prescriptions for the medications I am supposed to be on for another 12 months - even though I have been on the exact same stuff for more years than I can remember.

Sure, my free annual physical is valuable but just how valuable is it someone like me? I am at early risk of coronary heart disease, to a stroke, cancer or some ailment that will one day take me surprise and whisk me off to an early death, or worse, a lingering and expensive demise that medically bankrupts my family when my employer sponsored health insurance runs out? Welcome to US healthcare!

Would my 40 minute interaction with my doctor once a year actually discover such a risk?
Highly unlikely I suspect.

Would my health insurance pay for me to undergo a battery of tests to find out?
Also highly unlikely!

The current US Payer-Provider preventative care system is nowhere near as good as politicians would have us believe, and nowhere near as good as physicians would advise or recommend.

I guess my concerns are shared by many people over 40 and that may be why many of us receive flyers in the mail advertising advanced cholesterol or cancer screening – the “Plus Version” of an annual physical if you like. One where you are made to run on a treadmill while connected to an ECG and put through a battery of other tests not covered by your “free annual physical". “Prevention is better and cheaper than cure” as the saying goes and I’m sure all of us would agree.

So my wife and I looked into the costs of a comprehensive health check at home and abroad, including travel. We also looked into the costs of a dental checkup cleaning and treatments since we didn’t elect dental insurance this year. We both look after our teeth and the costs of dental insurance just didn’t make economic sense. What we found surprised us.

We could fly all the way to Bangkok, Thailand, stay in a 5 star hotel, enjoy a highly comprehensive health check - including in my case a full workup, get our teeth cleaned and fixed (and take a short vacation) all for significantly less than what it would cost us in the US..... And do it all at top-notch hospitals and dental clinics.

Our Medical Health Check

We selected Bumrungrad International Hospital in the heart of Bangkok for our health check and City Dental Clinic just down the road from the hospital for our teeth cleaning and maintenance. Not only is Bumrungrad reportedly one of the top ten JCI accredited hospitals in the world, it has one of the best hospital workflows I have ever seen. They have the health check workflow down to an art. It truly was a pleasure to witness and observe.

From the pleasant greeting upon entry to the five-star service throughout including lunch catered by the nearby JW Marriott, everyone spoke excellent English as well as half a dozen other languages to cater to guests from Europe, Australasia, the Americas, the Middle East and Asia, including a number of local Thai and Burmese.

No "nickel and diming" either and no unexpected costs. You select exactly what you want in advance from a menu of different health check options when you book your appointment, so you know what you need to pay when you show up on the day. If you need to add extras after your health check, like a consult with a specialist, the hospital will do its best to schedule you in that evening or the following day - even over the weekend. And the costs of an additional specialist consult? About $22 in my wife’s case.

What makes it all the more convenient, is that you can charge it to your healthcare savings card and pay for your medical treatments with pre-tax US earnings.

Need a procedure like a biopsy? $100 to $200 often on the same day and certainly while you are in town. Now if only US healthcare could be as efficient! For that reason, it’s probably best to schedule your health check on day 2 or day 3 of your stay so you have time for any additional follow up.

The only thing to look out for is that the hospital pharmacy is quite a bit more expensive than pharmacies outside. That's generally the case everywhere, but you don't have to purchase your meds from the Bumrungrad hospital pharmacy if you don't want to. You can just ask your doctor to write them down and have the billing clerk remove them from your bill when its time to pay for any extras if they were added. No need for official prescriptions in Thailand either. Pharmacies abound on every street and every mall in Bangkok so you have your choice of drug suppliers. Most Pharmacists speak excellent English and are very well trained and qualified. Don't have what you are looking for? The Pharmacist will be able to recommend a different drug and dosage and discuss side effects or other concerns with you.

The other thing to beware of is that some doctors will only schedule office hours in Bumrungrad on a couple of days per week so if you want to see a certain named specialist, then its best to plan a little extra time. Of course you could always opt for someone else in the same specialty area as we did and still get excellent advice. Many doctors we found will schedule office hours from 5pm onwards or weekends only, which was a little unusual from our experience in the US. In actuality, this worked out well for us as we were busy during the normal business day anyway.

Our Dental Checkup

Our dental checkups were equally as pleasant at the City Dental Clinic across the street from the hospital. A young but very well qualified dentist checked my teeth and then sonically cleaned them all for about $20. My wife needed a couple of fillings for a chipped tooth and some depleted enamel. Her clean and procedure came to a whopping $195 – way less than most people's dental insurance co-pay for a single filling let alone 3, and not including the the bi-weekly or monthly premiums most people waste on dental insurance.

Why would anyone NOT take a trip to Thailand or other parts of the world for elective procedures and proactive health checks? Beats me - that’s all I can say! In fact, we are already planning our checkups and dental cleanings for next year.

Concerns about quality medical and dental staff? Bumrungrad International Hospital achieved Joint Commission status years ago and continues to be one of the top hospitals in the world. It serves over 400,000 medical tourists annually who by all accounts save between 50% and 75% on medical expenses they would have incurred for similar services in the US. The hospital's repeat international clientele is probably testament to its reputation and the quality of service patients receive.

Everyone we met was top notch – as good as you would find at home – just with lower hospital billing and insurance overheads, and significantly lower malpractice premiums to pay, thanks to the absence of both ambulance-chasing lawyers in Thailand and a legal system written by lawyers to encourage the use of ....... lawyers for every little disagreement.

Why the US is falling so far behind the developing world should be obvious to all of us who work in the industry, but no one seems interested in fixing a broken system, removing overheads and getting healthcare costs down. With so many vested interests and different parties all wanting to keep their cut, that may never happen here. And so, medical tourism is likely to continue to expand as consumers vote with their feet.

Continue on to the final chapter of this story

The Growth of Medical Tourism 1

Despite the United States having arguably some of the best healthcare in the world, it also has the singularly most expensive. We have all heard the story of the hundred-dollar Aspirin. Many of us have witnessed or been fleeced by the ridiculous markups some US hospitals attempt to profit from - sometimes in excess of 1,000% or 1,500%. The US spends twice as much on healthcare as most comparable nations, yet has highly unequal access to healthcare services, and quite frankly, terrible patient outcomes if you happen to be poor, or live in the wrong part of the country.

As the costs of US health services continue to spiral, consumers are facing ever-increasing healthcare charges. This includes massive annual deductibles which effectively negate the value of health insurance, and combine with increasingly high co-pays that cause many to forgo their prescription medications and doctor visits in order to pay rent or put a meal on the table for their family. In fact according to physicians, 30% of prescriptions are never filled and another 30% are not taken as prescribed - many of which are eked-out to save having to pay for a refill.

Just ask anyone who works in the profession how the advent of high-deductibles and other rising out of pocket costs is affecting their businesses. Designed to contain employer and employee healthcare costs, high deductibles have led to much higher out of pocket costs for consumers and quite seriously changed user consumption patterns. Many medical practices are empty at the beginning of the calendar year when a fresh deductible kicks in, for all but the most serious of emergencies. What's more, it stays that way for months till patients have met their deductible and are no longer dis-incentivized to visit their medical providers.

Most of us who have tried to purchase medications in the US that are not included in our medical insurance formulary list have experienced first-hand unregulated US pharmaceutical prices that gouge consumers for $200 or more for the exact same medication that sells outside of the US for $20. It’s no wonder that so many Americans stock up on their prescriptions when on vacation abroad, regardless of whether they have health insurance at home or not.

Yes - Your over-the-counter drug price in other countries is often cheaper than your insurance co-pay at home!

But what other aspects of their healthcare are Americans looking abroad for?

In this multi-part blog, I explore the rise of medical tourism and how it is often better and cheaper to get on a plane and fly across the world for treatment in a modern top-notch accredited hospital rather than subject yourself to the co-pays, high-deductibles, obscured billing practices, and unexpected / underhanded out-of-network surprise charges not covered by your US health plan.

Read Part 2 of this story


Jason Hawley & Richard Staynings co-present at HIMSS19 today in Orlando.  Photo: Ty Greenhalgh.
Don’t Let Your IT and OT Systems Become Antiques.

The problem of out of date legacy hardware, operating systems and applications across the healthcare industry is endemic. This is especially so at small hospitals and clinics where tiny IT and security staffs and highly constrained budgets, prevent the upgrading of end-of-life and often vulnerable technologies. Aggressive sun-setting of Windows versions by Microsoft and near constant patching requirements compound the pressure on small IT staffs to support and secure their health IT infrastructure. This situation introduces risk into the healthcare delivery environment as IT systems continue to operate with unpatched CVEs and unsupported hardware and software.

Poor coordination between HIT vendors and Microsoft causes healthcare applications to break if patched or remain vulnerable if unpatched. Lack of support for current Windows operating systems means that new workstations and servers need to be downgraded in order to run EMR or other HIT applications.

"Windows 10 comes with .NET version 3.5 built in, however our EMR only supports .NET version 3.2, so when we upgraded our desktop OS from Windows 7 to Windows 10, we had to uninstall .NET and reinstall an old out-of-date version" claimed Jason Hawley, CIO of Yuma District Hospital and Clinics, a critical access system in rural Colorado. "We can no longer run automatic updates from Microsoft as patches break our EMR. HIT software developers are constantly behind the Microsoft development curve," he added.

Going to to the CFO and asking for money to replace and upgrade, just because systems are end-of-life doesn't work according to Hawley. "The money simply isn't available to upgrade or replace",  he states. "We don't have the man-power and we can't justify the re-licensing costs."

Jason is not alone in his experience. Many security and technology leaders in similar-sized facilities make the same complaint, where IT hardware is used till it breaks and software is run well beyond its vendor support.

So how can CIOs and CISOs of small or critical access facilities get away from having to support dangerous legacy hardware and software?

"The obvious solution is to move what you can to the cloud as soon as possible, but this presents challenges in itself," claims Richard Staynings with the HIMSS Cybersecurity Committee. Regulated data needs to be highly secured - especially if its being moved off-site. Consequently, many CEOs are reluctant to take the leap of faith needed to support this change.

However most cloud service providers probably do a better job of securing their customers' PII and PHI data than any critical access hospital is able to do anyway. Especially given small IT and security staffs, low levels of security expertise and limited budgets for upgrading. In fact for most critical access facilities migrating to the cloud is a major security improvement over the current state.

"Cloud providers have an added incentive to double-down on security as their reputation is highly dependent upon the security of their services," claims Staynings. "Educating the CEO and board to that fact is however a different issue and an often lengthy process that should probably be started sooner rather than later," he adds.

Moving the IT budget from a 'CapEx' model of asset purchase and depreciation over a long period of time to an 'OpEx' model of annualized services, will likely take some persuasion and the support of the CFO. However once approved will enable small providers to finally retire out-of-date and end-of-life assets.

"Cloud migration is not as straight forward as simply moving a VM from a data center hypervisor to a cloud one," claims Staynings. "There's a lot of planning and optimization that needs to take place to make sure that you don't get unexpected usage bills for running AV and other scans 24 by 7 on each of your systems. For that reason, if you've not done this before you should probably seek help"

In the mean time CIOs and CISOs have a duty to report the risks of legacy no-longer-supported hardware and software in the organization's Risk Register. This should include OT devices like hospital building management systems and medical devices which have even longer life-spans than IT systems like servers and workstations. Most of these OT devices have little to no built-in security and require compensating security controls such as network segmentation to protect themselves and the rest of the network from attack. But first you need to find these devices, which isn't easy. Fortunately there are some new tools from the likes of CyberMDX, ZingBox, ClearData and others entering the market to help you with your medical device asset inventory and initial threat assessment.

CEOs and their boards need to make well-informed risk management decisions to accept, transfer or remediate those risks. 'Ignoring' or 'avoiding' a risk should not be an option, which unfortunately is an all-too-common process being used today in small under-funded healthcare delivery facilities.

Jason Hawley is CIO, CSO and Biomed Director at Yuma Hospital and Clinics - a critical access system in rural Colorado. Richard Staynings is a Global Healthcare Security Strategist. Both currently serve as members of the HIMSS Cybersecurity Committee. Slides from their HIMSS presentation can be viewed or downloaded here.