My recent interview with Bruce Steinburg MD, EVP of HIMSS International at the Singapore eHealth and Health 2.0 Summit.
The Maturity Paradigm
In healthcare we have an insatiable appetite to adopt new technology
Could Russia orchestrate cyberattacks against the west?
GB News Breakfast Show
Should we be worried
About state-sponsored attacks against hospitals?
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
Who'd want to be a CISO?
Challenging job, but increasingly well paid
Medical Tourism - Growing in Popularity
Safe, fun, and much, MUCH more cost-effecitive
The Changing Face of the Security Leader
The role is changing, but what does the future hold?
Cyber Risk Insurance Won't Save Your Reputation
Be careful what you purchase and for what reason
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.
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 Other Articles on the Rising Tide of Medical Tourism
This article in the New York Times is about US companies that are paying their covered plan participants to travel to Mexico and Costa Rica for elective surgery - with American surgeons.
This NPR article covers why American Travelers Seek Cheaper Prescription Drugs In Mexico And Beyond and what an increasing number of them are doing about US prescription Drug costs.
Read how PEPH a Utah Health Insurer, offers a program for public employees to travel to save money on prescription drugs and is sending an ever increasing number of state employees out of the country to fill their prescriptions in Mexico.
The Costa Rica Tourist Board now features Medical Tourism as one of the reasons for visiting the nation.
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 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? Am I 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 direct mail flyers 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 or last. We all 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 luxury 5 star hotel, enjoy a highly comprehensive health check - including in my case a full workup, ultrasounds, chest X-Ray, etc. 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 (Joint Commission) accredited hospitals in the world, it has one of the best hospital workflows I have ever seen - (and I work in US healthcare!) They have the health check workflow down to an art. You move seamlessly between one medical station and the next, taking your file with you as you go. Finish one test and a nurse is there to guide you to the next one and so it goes on all day. It truly was a pleasure to witness and observe and was in stark contrast to my experience as a patient in the US health system where I am always kept waiting for long periods of time unless I have the first appointment of the day. Why western hospitals can't seem to institute effective scheduling combined with efficient patient workflow is an anathema to me. Especially when you consider that THEY issued you the appointment in the first place!
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 US healthcare savings debit card and pay for your medical treatments with pre-tax US earnings. If you have an international health plan you can usually charge the lot to your insurer who is happy to pay non-US healthcare rates for such a valuable service that would cost an order of magnitude more in the USA.
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 a week long stay so you have time for any additional follow up before you hit the beach or need to head home.
What we like to do is to schedule the first couple of days in Bangkok for health, optical and dental checks, then head to the islands for a week, hit the beach and splash around in the sea, then return to Bangkok for our last 3 or 4 days to pickup glasses, or undergo any minor surgeries, purchase pharmaceuticals, and do some tax free shopping before heading home.
One 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. All of the doctors at Bumrungrad are top notch and as good as, or better than, anyone you would see back home.
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 normal business hours anyway with tourist stuff.
Bear in mind that hospital pharmacies are usually 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 for non-opioids.
Bear in mind that hospital pharmacies are usually 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 for non-opioids.
Pharmacies abound on every street and every mall in Bangkok so you have your choice of pharmacies. If you are going to other major towns, pharmaceutical drugs are even cheaper. I stocked up one year in Chiang Mai and it was about half the price of the pharmacies I usually go to in Bangkok. Just be sure to check the expiration date of drugs if you are buying a year's supply. Also, especially if you are on some less common drugs leave time to pick these up back in Bangkok before flying home just in case you can't get them in smaller town's and cities.
Pharmacies are licensed in Thailand and I have never seen or heard of issues with tainted pharmaceutical drugs in the country. I have found drugs to be top quality, manufactured in Europe, Japan, or America from reputable well known companies. Compare that to the no-name generic prescription you usually pick up from your US pharmacist.
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 in perfect English. That being said, they are not MDs so if in doubt, find another pharmacy with exactly what your doctor prescribed for you.
Our Vision Check
So while we were in Bumrungrad for a follow-up appointment, we thought why not get our eyes checked. I had managed to sit on my reading glasses before flying to Bangkok and while they still were functional they would never quite be the same again. So off we went up to the floor of the hospital that deals with vision and booked an appointment for a prescription check to have our eyes tested.
Surprisingly they were able to see us within 10 minutes, so we delayed dinner plans and had a full vision check. My wife's prescription hadn't changed, but mine had slightly so I concluded that it was a good excuse for a new pair of reading glasses since I spend so much time in front of a computer screen. It took me longer to decide on the frames than the extensive test and selection of lens features from a long list available to me. I ended up selecting a very nice pair of usually very expensive name brand frames, paired with lenses with all the bells and whistles for about 70% of what I would have paid in the US after all the sales incentives, gimmicks and discounts were applied. What's more they would be ready the next day I was told to pick up or they could courier them for free to my hotel. I elected to pick them up in case any adjustments were needed. Now that I am home, I am using these computer reading glasses to write this article. In short my new glasses are perfect and far better than what I would have been able to purchase in the US for what I paid.
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 mere $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.
[Since writing this article several years have elapsed and City Dental Clinic lost its building and has closed. On my last visit to Thailand I found a great but slightly more upmarket alternative in Truth Dental Clinic not far from Bumrungrad Hospital. The prices were slightly higher but scheduling an appointment in this larger better equipped dental clinic was a lot easier. Simply 'Line' or 'WhatsApp' their reception at +66 86-393-6231 before you leave home for an appointment no matter what time zone you are in.] Need 4 back-to-back or simultaneous appointments for the family - they will find a time slot for you!
Our Vision Check
So while we were in Bumrungrad for a follow-up appointment, we thought why not get our eyes checked. I had managed to sit on my reading glasses before flying to Bangkok and while they still were functional they would never quite be the same again. So off we went up to the floor of the hospital that deals with vision and booked an appointment for a prescription check to have our eyes tested.
Surprisingly they were able to see us within 10 minutes, so we delayed dinner plans and had a full vision check. My wife's prescription hadn't changed, but mine had slightly so I concluded that it was a good excuse for a new pair of reading glasses since I spend so much time in front of a computer screen. It took me longer to decide on the frames than the extensive test and selection of lens features from a long list available to me. I ended up selecting a very nice pair of usually very expensive name brand frames, paired with lenses with all the bells and whistles for about 70% of what I would have paid in the US after all the sales incentives, gimmicks and discounts were applied. What's more they would be ready the next day I was told to pick up or they could courier them for free to my hotel. I elected to pick them up in case any adjustments were needed. Now that I am home, I am using these computer reading glasses to write this article. In short my new glasses are perfect and far better than what I would have been able to purchase in the US for what I paid.
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 mere $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.
[Since writing this article several years have elapsed and City Dental Clinic lost its building and has closed. On my last visit to Thailand I found a great but slightly more upmarket alternative in Truth Dental Clinic not far from Bumrungrad Hospital. The prices were slightly higher but scheduling an appointment in this larger better equipped dental clinic was a lot easier. Simply 'Line' or 'WhatsApp' their reception at +66 86-393-6231 before you leave home for an appointment no matter what time zone you are in.] Need 4 back-to-back or simultaneous appointments for the family - they will find a time slot for you!
To Summarize
Why would anyone NOT take a trip to Thailand or other parts of the world for elective procedures and proactive health checks? It 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 US legal system written by lawyers to encourage the use of ....... lawyers for every little disagreement.
Why would anyone NOT take a trip to Thailand or other parts of the world for elective procedures and proactive health checks? It 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 US legal system written by lawyers to encourage the use of ....... lawyers for every little disagreement.
There are also no Pharmacy Benefit Managers (PBMs) or vertically integrated healthcare mega corporations that deliberately raise prices to drive their profits and may their CEOs tens of millions of dollars annually. Corruption exists in every country but the unregulated US healthcare industry takes the prize!
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 in the US. 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
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 in the US. 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. For such a wealthy country it has alarmingly high infant mortality and untreated psychological illness rates. It also suffers from an alarmingly unequal access to health services dependent upon income and where you live. Furthermore, thanks to recent tweaks to reduce upfront health insurance premiums it is also afflicted with largely high-deductible health insurance system that disincentivizes those covered, from going to see the doctor for preventative care till its an emergency.
Competition for your scarce healthcare dollar is pretty much non-existent if you happen to reside in a small or rural community, and that's where providers are inclined to charge whatever they like - simply because they can, in an almost totally unregulated private marketplace with near vertical demand for life sustaining health services.
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 at US drug prices.
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 on end, till patients have met their annual deductible and are no longer dis-incentivized to visit their medical providers by the lack of insurance coverage.
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 or less. It’s no wonder that so many Americans stock up on their prescriptions when on vacation abroad, often 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
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
HIMSS19
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| 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.
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.
Converging Paths
Patient safety has always been a major concern for healthcare providers but never before has it been so inextricably linked with cybersecurity. This is a subject I have blogged about, lectured to students of healthcare and cybersecurity, and spoken about to audiences of senior healthcare leaders at conferences and summits all over the world.
It's a convergence that we all need to become familiar with as enterprise risks change across the industry and the threats to the business evolve as we increasingly digitize.
Today, I had the pleasure of sharing this message with the HIMSS Cybersecurity Community. A community of healthcare leaders, technologists and security professionals that do their best to make sure that your non-public information remains confidential, integral and available, and that the IT systems employed to diagnose, treat, and monitor you as a patient, do not become compromised by nefarious nation states or cyber criminal actors. The HIMSS Security Community does a great job of sharing information across thousands of providers globally, to help leaders protect their patients and their patient data.
We all know that the global healthcare industry has problems and needs all the help in can get at a time of aging populations, static budgets and increased cyber risk. What compounds these concerns is a long history of under funding for the day-to-day security of hospitals and clinics, and the longer term maintenance and replacement of end of life IT systems.
This is a subject that I will be addressing in more detail with Jason Hawley, CIO and CISO at Yuma District Hospital at the HIMSS Annual Conference this year in Orlando on Monday February 11th. If you are planning to attend HIMSS19, please come along to the Security Forum and join us as we dig deeper into this subject.
For those able to attend my webinar today, many thanks and it was great to address many of your questions. For those unable to attend I have posted a link to the WebEx recording and to my presentation slides below.
Webinar Recording
Presentation
The Cybersecurity Skills Shortage
I read a great article this morning by Dr. Magda Chelly published in the Singapore Independent.
The article discussed the cybersecurity skills shortage and the
immediate need for more cyber professionals to fill existing job
vacancies in Singapore.
The shortage of cybersecurity professionals is a global concern however, and Singapore is far from alone in its need for more qualified and experienced technical and managerial security professionals. The Cisco Annual Security Report has, for the past three years, highlighted a huge gap between demand for security professionals and the available supply, and that defenders are outnumbered five to one by attackers. Universities across the globe are struggling to adapt to changing demands from government and business in order to train the workforce of the future. A future where nearly everything will be conducted virtually via cyberspace and the inter-network of government agencies, businesses and individuals that power commerce, education and just about everything else. Securing that future will be critical for everyone.
Even in the United States where arguably there are more certified cyber professionals than any other country, a recent survey found 82,000 open positions requesting a CISSP yet at last count there were only 79,000 CISSP holders in the USA, nearly all of whom were already working at least one full time job. In fact, a recent study conducted by (ISC)2 found that cybersecurity workforce gap has increased to more than 2.9 million globally. The report goes on to state that of the 2.93 million overall gap, the Asia-Pacific region is experiencing the highest shortage, at 2.14 million, in part thanks to its growing economies and new cybersecurity and data privacy legislation being enacted throughout the region.
The (ISC)2 CISSP (Certified Information Systems Security Professional) is not the only cybersecurity certification however; GIAC Security Expert (GCE) and ISACA (Information Systems Audit and Control Association) certifications in security governance (CGEIT), security audit (CISA), information risk (CRISC) and security management (CISM) are equally prized. Most however require some level of experience putting potential candidates in a catch-22 position – you can’t get the certificate without experience; and you can’t get the security job in order to build the experience without the certificate. Maybe recruiters need to re-think this demand and look for broader skill sets and capabilities from entry or mid-level candidates!
That’s also one of the reasons why many people looking to enter the profession are completing university degrees in a cybersecurity related discipline. In fact, there are a heap of accredited universities today offering quality bachelors, masters and doctoral degrees, especially in the Australia and United States. Many of these are available entirely online and therefore accessible to Singaporeans, just as they are to residents of other countries who are willing and able to invest in the time and effort in their future. The nice thing about online degrees is that you can study at nights and weekends while holding down the current day job and salary, rather than take an unpaid sabbatical for 2 years or more to attend a bricks-and-mortar university as was the case just a few years ago.
A cybersecurity degree not only says a lot more about you as a candidate compared to someone who simply paid and took the CISSP or other exam, it also in many cases, will exempt you from the work experience requirement, thus opening the door for you to have both a degree and a professional qualification at the end of the day.
Unlike a professional qualification however, your cybersecurity degree will not expire if you forget or elect not to pay the annual club membership fees to the body issuing the certificate. Let’s not forget that these bodies have made a highly profitable business out of certifying cybersecurity professionals and each requires the payment of annual maintenance fees along with evidence of continuing education for you to keep your certification. A degree on the other hand is a qualification for life and will never expire.
So when should you embark upon an academic qualification like a cyber degree and when or who should just go for the CISSP or other professional certificate? The fact is, that depending on your age and experience, you will likely benefit from both. However, no qualification is a substitute for experience and that’s probably why it makes most sense for those in the profession with 5 to 10 years’ experience to get their CISSP or other professional qualification, and those entering security management to get their CISM. However, there’s nothing like a Masters or Doctoral degree to show a prospective employer that you really are an expert with deep cybersecurity and information assurance knowledge.
The profession needs more practitioners at all levels however and there are good rewards for those at the top of their game as I wrote about in a prior article discussing the role of the CISO or Chief Information Security Officer. A role which is quickly changing with the times.
My friend and fellow security evangelist Dr. Mansur Hasib from the University of Maryland University College has spoken extensively at numerous security conferences, as have I and many others, about the cybersecurity skills shortage. No matter where you are located, there is a drastic need for more entry-level security professionals, so if you are reading this while contemplating your future, this is one profession you should probably look at closely. With a 12x demand over supply for security professionals, a career in cybersecurity is not one about to go away any time in the near future. What’s more, where ever demand outstrips supply, professionals are usually going to be well paid and well looked after.
Warning – Highly Competitive Environment: Once established, you may be mildly harassed by recruiters wishing to hire you away from your current role for double the money to work somewhere else! (At least, for the immediate future.)
This blog is also posted on Linkedin
The shortage of cybersecurity professionals is a global concern however, and Singapore is far from alone in its need for more qualified and experienced technical and managerial security professionals. The Cisco Annual Security Report has, for the past three years, highlighted a huge gap between demand for security professionals and the available supply, and that defenders are outnumbered five to one by attackers. Universities across the globe are struggling to adapt to changing demands from government and business in order to train the workforce of the future. A future where nearly everything will be conducted virtually via cyberspace and the inter-network of government agencies, businesses and individuals that power commerce, education and just about everything else. Securing that future will be critical for everyone.
Even in the United States where arguably there are more certified cyber professionals than any other country, a recent survey found 82,000 open positions requesting a CISSP yet at last count there were only 79,000 CISSP holders in the USA, nearly all of whom were already working at least one full time job. In fact, a recent study conducted by (ISC)2 found that cybersecurity workforce gap has increased to more than 2.9 million globally. The report goes on to state that of the 2.93 million overall gap, the Asia-Pacific region is experiencing the highest shortage, at 2.14 million, in part thanks to its growing economies and new cybersecurity and data privacy legislation being enacted throughout the region.
The (ISC)2 CISSP (Certified Information Systems Security Professional) is not the only cybersecurity certification however; GIAC Security Expert (GCE) and ISACA (Information Systems Audit and Control Association) certifications in security governance (CGEIT), security audit (CISA), information risk (CRISC) and security management (CISM) are equally prized. Most however require some level of experience putting potential candidates in a catch-22 position – you can’t get the certificate without experience; and you can’t get the security job in order to build the experience without the certificate. Maybe recruiters need to re-think this demand and look for broader skill sets and capabilities from entry or mid-level candidates!
That’s also one of the reasons why many people looking to enter the profession are completing university degrees in a cybersecurity related discipline. In fact, there are a heap of accredited universities today offering quality bachelors, masters and doctoral degrees, especially in the Australia and United States. Many of these are available entirely online and therefore accessible to Singaporeans, just as they are to residents of other countries who are willing and able to invest in the time and effort in their future. The nice thing about online degrees is that you can study at nights and weekends while holding down the current day job and salary, rather than take an unpaid sabbatical for 2 years or more to attend a bricks-and-mortar university as was the case just a few years ago.
A cybersecurity degree not only says a lot more about you as a candidate compared to someone who simply paid and took the CISSP or other exam, it also in many cases, will exempt you from the work experience requirement, thus opening the door for you to have both a degree and a professional qualification at the end of the day.
Unlike a professional qualification however, your cybersecurity degree will not expire if you forget or elect not to pay the annual club membership fees to the body issuing the certificate. Let’s not forget that these bodies have made a highly profitable business out of certifying cybersecurity professionals and each requires the payment of annual maintenance fees along with evidence of continuing education for you to keep your certification. A degree on the other hand is a qualification for life and will never expire.
So when should you embark upon an academic qualification like a cyber degree and when or who should just go for the CISSP or other professional certificate? The fact is, that depending on your age and experience, you will likely benefit from both. However, no qualification is a substitute for experience and that’s probably why it makes most sense for those in the profession with 5 to 10 years’ experience to get their CISSP or other professional qualification, and those entering security management to get their CISM. However, there’s nothing like a Masters or Doctoral degree to show a prospective employer that you really are an expert with deep cybersecurity and information assurance knowledge.
The profession needs more practitioners at all levels however and there are good rewards for those at the top of their game as I wrote about in a prior article discussing the role of the CISO or Chief Information Security Officer. A role which is quickly changing with the times.
My friend and fellow security evangelist Dr. Mansur Hasib from the University of Maryland University College has spoken extensively at numerous security conferences, as have I and many others, about the cybersecurity skills shortage. No matter where you are located, there is a drastic need for more entry-level security professionals, so if you are reading this while contemplating your future, this is one profession you should probably look at closely. With a 12x demand over supply for security professionals, a career in cybersecurity is not one about to go away any time in the near future. What’s more, where ever demand outstrips supply, professionals are usually going to be well paid and well looked after.
Warning – Highly Competitive Environment: Once established, you may be mildly harassed by recruiters wishing to hire you away from your current role for double the money to work somewhere else! (At least, for the immediate future.)
This blog is also posted on Linkedin
A Pattern of Complacency
A recent story which ran on CBS News entitled “How medical devices like pacemakers and insulin pumps can be hacked” highlighted deficient plans and processes by the US Food and Drug Administration for addressing medical device cybersecurity compromises. The report issued by the Inspector General has been disputed by the FDA which says that it has worked proactively on the issue with security researchers and ethical hackers to identity and fix many of the problems.
This may be the case, but the fact remains that the industry as a whole has been largely in a state of denial over the breadth of depth of cybersecurity vulnerabilities in medical devices and has been very slow to inventory and remediate risks – even when researchers have shown evidence that many security vulnerabilities pose a significant patient safety concern.
The FDAs close working relationship with manufacturers and its preference for constructive ‘guidance’ rather than ‘enforcement’ has been criticized many times before. Despite a growing body of evidence of medical devices being hacked in research lab environments and live on stage at security conferences around the world dating back nearly a decade, it is only within the last couple of years that new devices were forced to undergo any sort of cybersecurity risk assessment prior to being approved for use on patients. Some say the FDA acted too slowly to bring about change and that nobody yet has really dealt with the legacy device problem. Medical devices have long expected life-cycles and more expensive systems like X-ray, CT and PET scanners are often depreciated over 15+ years, meaning that near-term replacement of insecure legacy devices is not a feasible option.
Whatever the case, the fact remains that most manufacturers have not taken any sort of proactive role to risk assess the security of their legacy devices in use today, even when informed of security vulnerabilities long before public disclosure. The onus for risk assessment of these devices currently seems to be placed squarely on the shoulders of providers, who in turn are ill-equipped to assess or remediate problems. Solving this problem will take a strong and concerted effort on all sides with robust leadership and oversight provided by the FDA.
The issues highlighted in the CBS report is remarkably similar to another case that I wrote about in 2016 concerning St Jude Medical, (now owned by Abbott Labs). Despite being informed of major patient safety risks to its implanted Cardiac Rhythm Devices (pacemakers), St Jude Medical chose not to do anything about these risks till Muddy Waters Capital made an example of the company by trading on futures while engaging a security firm to hack and disclose significant weaknesses in the St Jude devices, thus gaining from a downward adjustment of the St Jude stock price.
The St Jude disclosure caused the first ever FDA intervention in medical device security after mass public concern. The fact however remains that security vulnerabilities in medical devices are likely not limited to only a few manufacturers, but common across the thousands of vendors and hundreds of thousands of medical devices that are in circulation globally. Many, of not most of these are responsible for keeping patients alive. The trouble is that we don’t really know the true extent of vulnerabilities and the risks posed to patients by these potentially insecure devices.
Manufacturers do not have programs to risk-assess and penetration test their legacy medical devices and only the most recently approved devices were tested at all from a cyber risk perspective – all other testing being primarily functional in nature, in order to obtain FDA approval.
Hospitals and other healthcare delivery organizations that use or surgically implant medical devices in people’s chests rarely if ever test medical devices either. Even devices that remain in hospitals like network attached morphine and insulin pumps, X-Ray and CT scanners are rarely tested for their cybersecurity vulnerabilities, let alone devices that leave with patients and may not be seen again.
Without testing and without performing a thorough and bone-fide risk assessment to NIST SP800-30 standards in line with HIPAA and OCR requirements, we will probably never really know just how big a problem this is across the entire industry.
Until such times as a full forensic examination of implanted medical device takes place, rather than simply being burned or buried with the patient, we will probably never know the true number of deaths caused by device failure, how these devices failed exactly and whether a cyber-attack against the device caused its failure and the premature death of the patient.
The United States does a great job of evaluating and under-writing all kinds of risks – everything from crop yields, to natural disasters, to the likelihood of flood, fire or theft, yet as a country we really are rolling the dice when it comes to medical risk, and particularly medical device risk. In short, we as a nation, are gambling on the security of the medical devices that keep many of our citizens alive each day.
Third Party Vendor Risk Management
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| Richard Staynings addresses the need for better Third Party Risk Management @VAHIMSS18 |
Lets face it, most Healthcare Covered Entities do a lousy job of managing risk - especially cyber risk in a world where data is flowing everywhere to meet government Meaningful Use requirements. In fact as an industry, we almost myopically interpret risk to refer to clinical procedures or hospital-borne post operative infection rates. In an HDO, risk is all about patient safety. But patient safety is much more than clinical risk, it includes the availability of IT systems to diagnose, monitor and treat patients; its about being sure of the validity and integrity of health IT data in order to treat patients; and it includes the entire healthcare delivery supply chain.
Cyber risks in healthcare are not just confined to the data center, to nursing stations or to the PHI data that flows back and forth between health insurers, HIEs, government agencies and patients. The risk web is very much bigger than that. It includes thousands of suppliers, vendors, and partners that stretch right the way across the globe. Everything from business process and IT outsourcers in India, to complex manufacturing supply chains for medical equipment in China, Brazil, Germany, the UK and Australia. It includes the company that provides hot meals to patients and food and coffee for the hospital cafeterias, to the pharmaceutical companies conducting clinical trials, and biomedical engineering companies that provide prosthetic limbs to your patients or an IMD that leaves the hospital with them. Anyone in fact who has physical access to your sites, network access to your IT, or who processes your data, regardless if they ever see one of your patients or not.
A recent Vendor Vulnerability Index research report released by Bomgar, showed that breaches occurring from third parties account for two-thirds of the total number of reported cyber breaches. The study found that only 46% of US companies said they know the number of log-ins that could be attributed to vendors and that less than 51% enforce policies around third party access. Furthermore, 69% of respondents said they 'definitely' or 'possibly' suffered a security breach resulting from vendor access in the past year.
Lets not forget that the Target breach of 40 million credit cards and 70 million customer records was caused by weak security of one of Target's HVAC vendors. It cost Target over $300 million and the jobs of everyone on the leadership team as well as lasting damage to the store's reputation.
The consensus by security professionals is that the risk posed by third parties is not only substantial, but it is increasing each and every year. Gartner stated in its June 2017 Magic Quadrant for IT Vendor Risk Management that by 2020, 75% of Fortune Global 500 companies will treat vendor risk management as a board-level initiative to mitigate brand and reputation risk. So why is it then, that health system CEOs are focused on other things? It could be that the healthcare industry has SO MANY challenges that TPVRM is just further down the list, it could be the fact that very few HDOs feature in the prestigious Fortune 500 list, or it could just be that healthcare CCOs, CROs and CISOs, just haven't gotten the message across to their CEO yet. Either way they need to!
I shared a number of tips and suggestions during my presentation today at the VAHIMSS Annual Conference to aid executives to construct or refine their TPVRM process. My slides can be found here.
Thanks to everyone who attended and asked some great questions and to the leadership of sponsors of the conference who helped to put on a great 3 day event in Williamsburg, VA.
Cyber risks in healthcare are not just confined to the data center, to nursing stations or to the PHI data that flows back and forth between health insurers, HIEs, government agencies and patients. The risk web is very much bigger than that. It includes thousands of suppliers, vendors, and partners that stretch right the way across the globe. Everything from business process and IT outsourcers in India, to complex manufacturing supply chains for medical equipment in China, Brazil, Germany, the UK and Australia. It includes the company that provides hot meals to patients and food and coffee for the hospital cafeterias, to the pharmaceutical companies conducting clinical trials, and biomedical engineering companies that provide prosthetic limbs to your patients or an IMD that leaves the hospital with them. Anyone in fact who has physical access to your sites, network access to your IT, or who processes your data, regardless if they ever see one of your patients or not.
A recent Vendor Vulnerability Index research report released by Bomgar, showed that breaches occurring from third parties account for two-thirds of the total number of reported cyber breaches. The study found that only 46% of US companies said they know the number of log-ins that could be attributed to vendors and that less than 51% enforce policies around third party access. Furthermore, 69% of respondents said they 'definitely' or 'possibly' suffered a security breach resulting from vendor access in the past year.
Lets not forget that the Target breach of 40 million credit cards and 70 million customer records was caused by weak security of one of Target's HVAC vendors. It cost Target over $300 million and the jobs of everyone on the leadership team as well as lasting damage to the store's reputation.
The consensus by security professionals is that the risk posed by third parties is not only substantial, but it is increasing each and every year. Gartner stated in its June 2017 Magic Quadrant for IT Vendor Risk Management that by 2020, 75% of Fortune Global 500 companies will treat vendor risk management as a board-level initiative to mitigate brand and reputation risk. So why is it then, that health system CEOs are focused on other things? It could be that the healthcare industry has SO MANY challenges that TPVRM is just further down the list, it could be the fact that very few HDOs feature in the prestigious Fortune 500 list, or it could just be that healthcare CCOs, CROs and CISOs, just haven't gotten the message across to their CEO yet. Either way they need to!
I shared a number of tips and suggestions during my presentation today at the VAHIMSS Annual Conference to aid executives to construct or refine their TPVRM process. My slides can be found here.
Thanks to everyone who attended and asked some great questions and to the leadership of sponsors of the conference who helped to put on a great 3 day event in Williamsburg, VA.
Strategic Cybersecurity | Making Intelligent Cybersecurity Investment Decisions
This was the subject of my webinar today with members of the College of Healthcare Information Executives (CHIME).
Listen to the recorded session below to learn what Boards and Executive Teams are demanding from their privacy, security, compliance, risk management and procurement teams to improve their return on security investments (ROSI).
Panaceas, Shiny Objects and the Importance of Managing Risk in a Healthcare Environment – Part 3
Is there a more challenging position anywhere in information security than that of a healthcare organization’s cyber risk management leader? If there is, I can’t think of what it would be. Whether your title is CISO, CSO, CTO, CIO or some variation thereof, the task is daunting.
As we mentioned in Part 1 of this series, healthcare as an industry has a huge target on its back. Cyber attackers focus on healthcare not only because patient information is valuable, but also because patient lives are at stake. That can make threats such as ransomware attacks more effective. Cyber attacks in other industries – banking, for example – can have devastating financial consequences, but people’s lives aren’t generally at risk, as they are in healthcare.
At the same time, healthcare IT environments are exceedingly complex, which makes managing information security that much more complicated. The healthcare IT ecosystem typically includes dozens – if not hundreds – of applications, including the electronic health record (EHR) system, administrative and operational applications (scheduling, patient tracking, billing, claims, insurance and payer systems and interfaces), clinical applications (patient monitoring systems, radiology information systems, lab results reporting, clinical decision support, patient portals, etc.) and others too numerous to mention.
On top of this, add the countless devices that connect to a healthcare organization’s network, from the desktop computer at the registration desk, to the tablet the physician or nurse uses, to the smart infusion pump at the patient’s bedside, to BYOD devices like the smartphone a patient uses to access lab results through a patient portal.
Enterprise-wide Cyber Risk Assessment
Because of this complexity, no single “shiny object” or new security tool will be sufficient to mitigate all of the critical information security risks in a healthcare environment. As we discussed in Part 2 of this series, the only way to approach cyber risk management in a complex healthcare organization is to begin with a comprehensive, OCR-quality, security risk assessment and analysis.
Healthcare organizations must conduct this type of analysis in order to be HIPAA-compliant. But just as important is the fact that healthcare organizations cannot begin to develop a meaningful and effective cyber risk management program without first gathering the information that a comprehensive risk analysis provides.
As mentioned in the previous post, a security risk analysis essentially boils down to three tasks:
- Identifying risk
- Rating risk
- Prioritizing risk
Task 1: Identifying Risk
Risk identification begins with creating an information asset inventory that documents each asset that creates, receives, maintains or transmits electronic Protected Health Information (ePHI). This includes not just the obvious choices, such as laptops, servers, and enterprise applications, but also less obvious choices, including medical devices, backup media, and nonclinical, internet-connected assets such as building management applications and networks.
As noted in my previous post, creating an asset inventory is only the first step in risk identification. Risk has three components: an asset, a threat and a vulnerability. OCR guidance specifies that healthcare organizations must identify and document threats and vulnerabilities to each asset, in addition to creating an inventory of information assets.
Task 2: Rating Risk
Once you have exhaustively inventoried every aspect of risk – including every asset, and each of the threats and vulnerabilities associated with each asset – the HIPAA Security Rule and subsequent OCR guidance specifies that you must also estimate the likelihood (probability) and impact (magnitude of loss) of potential harm from each asset/threat/vulnerability combination. This is the risk rating.
NIST provides guidance for these tasks. NIST SP 800-30, Appendix G, includes several examples of assessment scales related to threat event likelihood. Appendix H, in the same publication, offers examples of scales for measuring impacts.
Task 3: Prioritizing Risk
After all information assets have been identified; after all potential threats and vulnerabilities have been documented; and after the likelihood and impact of each asset/threat/vulnerability combo has been calculated, each asset/threat/vulnerability combination will have an assigned risk rating.
As part of the cyber risk assessment/analysis process, every healthcare organization should establish a risk threshold. Establishing a risk threshold is part of the information security governance process. The risk threshold will be unique to the organization and will take into account the organization’s unique risks and resources. For example, using the 25-point scale, one organization might establish 15 as their threshold, meaning that any risk with a rating of 15 or below falls into the acceptable risk category, and will not be a priority with respect to mitigation.
A comprehensive information security risk analysis, combined with the organization’s established risk threshold, enables a healthcare organization to make informed, strategic decisions about which cyber security risks require urgent mitigation versus those that can be put on the “back burner” until more resources are available.
The Bottom Line
Conducting a comprehensive risk assessment is necessary for both HIPAA compliance and for establishing the foundation for a healthcare organization’s enterprise cyber risk management system (ECRMS). It is challenging, but not impossible, for a healthcare organization to conduct this analysis using only internal resources and guidance that is available on the internet.
Alternatively, healthcare organizations can use the specialized solutions and professional expertise to quickly and efficiently conduct a comprehensive cyber risk analysis. Because ultimately, completion of the analysis is only the first step. The sooner a comprehensive security risk analysis is completed, the sooner a healthcare organization can begin addressing vulnerabilities and mitigating high priority risks.
Read more in this series:
Medical Device Security and CIO Insomnia
During a conversation over drinks with a number of CIOs at a recent healthcare conference, I discovered that the number one concern that keeps most healthcare executives up at night is the security of their medical devices. That was somewhat unexpected, especially following press-grabbing headlines last year about ‘WannaCry’ and other ransomware attacks rendering a large part of the British NHS and other health systems useless for several weeks or months.
Reason 1: Management
Part of their concern is that medical devices are not typically managed by hospital IT (overseen in most cases by the CIO) but by clinical / biomedical engineering staff who power on and attach devices to hospital networks but have little understanding of the cybersecurity risks that are created by connecting an unprotected medical device to the hospital business clinical network. Connected medical devices can by-and-large be compromised easily, used as a foothold on hospital networks, or re-programed to execute patients or hold them to ransom.
This is not fiction! It has been demonstrated numerous times at security conferences most recently by McAfee at BlackHat and Defcon in Las Vegas last month. New Zealand ethical hacker Barnaby Jack started the trend of exposing medical devices vulnerabilities, when in 2011 at the MacAfee Focus Conference he demonstrated a hack of a wireless insulin pump causing the pump to deliver its entire reservoir of insulin into a mock patient. In 2012 he followed this performance up with a hack of a Pacemaker causing the device to administer an 815volt shock directly to the heart of the mock patient. Both demonstrations would have been fatal to a real patient and that might explain why in 2007 Vice President Dick Cheney had the wireless interface disabled to his own pacemaker at the insistence of Doctors and the US Secret Service. Jack demonstrated the ease at which a patient could be harmed or executed once their Implantable Medical Device or IMD had been hacked. Others followed at subsequent security conferences with hacks of network-attached infusion pumps, reprogramming the device to give a continuous maximum dose of Morphine till the reservoir was empty and the patient likely dead.
Reason 2: Lack of Security
The CIOs second concern is that medical devices have almost no built-in security found on a typical workstation or laptop and cannot readily be patched or upgraded. Nor can security tools and supplicants like anti-malware or a host firewall be installed as the limited capacity of devices will not support the additional memory or processing requirements needed.
To compound these issues, medical device manufacturers are notoriously reluctant and slow to release patches for their devices even when known security vulnerabilities have been discovered. This has resulted in some high profile shaming of manufactures as in the case of Muddy Waters Capital, an Options Trader, against St Jude Medical and the first ever FDA recall of a medical device as a result of the public disclosure. Would the Food and Drug Administration (FDA) have acted if it weren’t for the very public disclosure? It’s hard to tell. Would St Jude Medical have spent any time fixing known security vulnerabilities in some of its pumps? Based upon past performance, it’s highly unlikely. In fact, that was the reason for Muddy Waters penetration test in the first place, thus driving down the share price of St Jude Medical stock, allowing Muddy Waters to profit from its options trades.
The fact of the matter is that most medical devices unless afforded extra layers of protection and defense-in-depth security, are extremely vulnerable to cyberattack. Especially if connected to the main hospital network, let alone allowed to talk to the Internet.
Why are Medical Devices so Vulnerable to Attack and Compromise?
Medical devices take 5 to 6 years to go through testing and clinical trials before they receive FDA approval. The same is true in most other countries. That means that brand new devices arriving in hospitals today were designed at least 5 or 6 years ago using technology that was available at the time. Anyone connecting their 2012 era Windows computer to the Internet tomorrow without any security software or updates would more than likely be compromised inside 10 minutes, yet that’s what we do with medical devices. Only with medical devices, we use them not to surf the web or check email, but to monitor and treat patients - and in some cases keep them alive. That’s where unmitigated risks surface that results in CIO insomnia.
The HIPAA Security Rule (45 CFR (§164.308(a)(1)(ii)(A)&(B) requires a Risk Analysis and ongoing Risk Management be conducted of any and all devices that create, maintain, transmit, or receive ePHI or other sensitive data. Yet most hospitals don’t even have an accurate inventory of their medical device assets so how can they possibly assess their risks? The identification and profiling of medical devices has not been easy for hospitals, most of which have had to rely upon labor-intensive ad-hoc manual discovery processes. New tools and services from IoMT / HIoT vendors in the space that can identify and profile medical devices is beginning to change this however. A full asset inventory and medical device profile can now be exported from these tools and entered into enterprise risk analysis tools to perform compressive risk analysis to meet the very strict requirements of OCR and HIPAA.
The concern however is a lot deeper than mere HIPAA Compliance and the protection of PHI. Patient safety has become a major worry for healthcare providers where changes to the integrity and programming of medical devices can have far reaching effects. Hackers have already demonstrated the removal of safety limits and have over-written calibration data and dosages and changed drug libraries. Not only is the integrity of medical devices a growing concern but also their resiliency. Most devices will crash or blue screen when a simple virus or multi-cast traffic appears on the subnet. In particular, device availability for patient telemetry systems is critical to alert care staff to patient Codes or other conditions where speedy action on their behalf is required to save a life. Integrity and availability attacks are far more concerning than confidentiality attacks against PHI, and is where the real damage can be done.
To date, the OCR has only issued written guidance on the risk analysis of medical devices containing PHI, although audits show that OCR is beginning to take a broader look at all medical devices regardless of whether they create, receive, store or transmit PHI. The FDA continues to issue guidance, NCCoE and NIST have written a guide to secure medical infusion pumps resulting in NIST Special Publication 1800-8, and the Cloud Security Alliance (CSA) and Open Web Application Security Project (OWASP) recently joined forces to publish a revised Medical Device Deployment Guide. The fact remains however, that numerous medical devices are extremely vulnerable and are not being adequately managed from a risk perspective.
To date, the OCR has only issued written guidance on the risk analysis of medical devices containing PHI, although audits show that OCR is beginning to take a broader look at all medical devices regardless of whether they create, receive, store or transmit PHI. The FDA continues to issue guidance, NCCoE and NIST have written a guide to secure medical infusion pumps resulting in NIST Special Publication 1800-8, and the Cloud Security Alliance (CSA) and Open Web Application Security Project (OWASP) recently joined forces to publish a revised Medical Device Deployment Guide. The fact remains however, that numerous medical devices are extremely vulnerable and are not being adequately managed from a risk perspective.
The average cost of a data breach according to Ponemon is $3.8 million. The damage and impact to a hospital’s reputation following a medical device attack resulting in patient death is pretty much unlimited. This may sound a little far-fetched but a recent study by the University of California Cyber Team found that several hospitals had self-reported adverse events from compromised healthcare infrastructure cybersecurity events, like ransomware, malware, or compromised EHRs. The study found that adverse events impacted between 100 and 1,000 patients. Furthermore, the 80 percent of survey respondents that reported risks in medical devices, is way higher than what the FDA reports.
Risk Management
Once identified, risks to critical systems should be addressed immediately. When remediation or retirement of a medical device is not possible, effective compensating security controls should be implemented to isolate and protect the device from attack and compromise. Many of the larger hospital systems are turning to micro-segmentation of their medical device network assets using Cisco TrustSec or other tools to essentially white-list network communications to and from each medical device and drop all other traffic. GE Health and Unisys do this by routing all medical device traffic through proxy servers. Others have segmented their medical device VLANs by use of internal firewalls. These solutions all increase the complexity of networks and leave many smaller hospital systems with tight budgets and limited capabilities out in the cold.
What’s being done to harden medical devices and prevent them from being hacked?
Guidance (and its only guidance to date) has been published by the FDA, NIST, NCCoE, CSA/OWASP and others to improve the deployment and security of medical devices. The onus however is squarely being placed upon healthcare providers to secure the medical devices they procure and utilize. At the same time manufacturers are being pressured to improve the security design of their devices and now have to perform a risk analysis of medical devices before FDA approval. But with a 5 to 6-year development cycle, the results of ‘improved security by design’ may take many years to reach hospitals and patients. With a 15 to 20-year lifespan for many medical devices, the security problem is not about to go away any time soon. That means hospitals need to implement compensating security controls immediately and keep them there for the foreseeable future.
Somewhat alarmingly however, a recent Ponemon Report on Medical Device Security showed that despite known vulnerabilities “roughly one third of device makers and healthcare delivery organizations (HDOs) are aware of potential adverse effects to patients due to an insecure medical device, but despite the risk only 17 percent of device makers and 15 percent of HDOs are taking significant steps to prevent such attacks.”
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