Last week, SearchHealthIT discussed how the Health Care Industry Cybersecurity Task Force declared cybersecurity a public health issue. This week, SearchHealthIT takes an in-depth look at the six imperatives laid out by the cybersecurity task force.
The Health Care Industry Cybersecurity Task Force (HCIC Task Force), created by Congress as part of the landmark Cybersecurity Act of 2015, gathered information from external stakeholders and subject matter experts from across the healthcare industry, as well as other sectors, to better understand what changes need to be made and what goals need to be achieved in order to improve cybersecurity in healthcare.
In a report, they list six cybersecurity imperatives:
Better define leadership, governance, and expectations for healthcare cybersecurity
There are many opportunities for confusion when it comes to cybersecurity in healthcare, the report said.
“The technical infrastructure underlying health systems is inordinately complex. It must support not only patient records but also a diverse suite of medical devices used in diagnosing, monitoring, and treating patients,” the report said. “Understanding and managing cybersecurity risks for this mission-critical environment is challenging as the healthcare system has a mixture of state-of- the-art applications and devices, as well as older legacy devices that use unsupported operating systems or networking protocols.”
Furthermore, there are multiple frameworks for addressing cyber risk, the report said. This only adds to the confusion and the opportunity for vulnerability.
Because of these complexities and confusions, the cybersecurity task force said in their report that a consistent cybersecurity framework is needed.
The task force also recommended creating a cybersecurity leadership role within HHS.
Increase the security and resilience of medical devices
The report explains that there is a misalignment when it comes to medical devices and other healthcare technologies. For example, operating systems and other platforms such as commercial off-the-shelf software are misaligned with medical devices and electronic health records (EHRs), which can be utilized for 10 to 20 years or more.
“Some foundational challenges that will need to be addressed in order to enhance the cybersecurity of medical devices and EHRs include legacy operating systems, secure development lifecycle, strong authentication, and strategic and architectural approaches to product deployment, management, and maintenance on hospital networks,” the report said.
Develop healthcare workforce to prioritize cybersecurity
The cybersecurity task force said in their report that there are several challenges to creating a healthcare workforce that will prioritize cybersecurity:
- Finding people and tools to address the small and medium-sized healthcare organizations which usually can’t afford full-time technical resources.
- Limited resources for reinvestment in cybersecurity, especially for small and medium-sized organizations.
- Identifying cybersecurity leadership roles to identify risk.
- The growing involvement of patients in their own care also increases the exposure to threats.
Improve cybersecurity awareness and education
The report suggests three action steps the healthcare industry should take to achieve awareness and education:
- “Increase outreach for cybersecurity across all members of the health care workforce through ongoing workshops, meetings, conferences, and tabletop exercises.
- “Provide patients with information on how to manage their health care data by developing consumer grading systems for non-regulated health care services and products.
- “Develop cyber literacy programs to educate decision makers, executives, and boards of directors about the importance of cybersecurity education.”
Identify mechanisms for protecting from attacks and exposure
The Task Force recommends doing this by developing guidance for the industry on creating economic impact analysis and loss for cybersecurity risk, and researching how to protect healthcare big data sets.
Improve sharing information about industry threats, risks, and mitigations
“Together, industry and government should work together to ensure that the best resources are leveraged from the various systems and tailored toward the unique needs of health care while protecting privacy and maintaining appropriate legal protections,” the report said.
A federal task force called healthcare cybersecurity a “public health concern” that needs “immediate and aggressive attention,” and said increased digital connectivity places a greater responsibility on healthcare organizations to secure their equipment and patient data.
After a record-breaking year of data breaches last year, experts have predicted that the healthcare industry will increase cybersecurity spending in 2017. Threats to cybersecurity for healthcare facilities range from technical exploits such as ransomware to insider threats such as employee negligence. Both types of threats can potentially expose patient data and leave it susceptible to fraud and identity theft.
To address these and other challenges of cybersecurity for healthcare, Congress established the Health Care Industry Cybersecurity Task Force. In a recent report to Congress, the task force used information gathered from briefings, public meetings and expert consultations to identify six imperatives to help improve cybersecurity for healthcare as an industry.
- Define and streamline leadership, governance and expectations for healthcare industry cybersecurity – A single person should be responsible for coordinating cybersecurity activities within and outside of HHS.
- Increase the security and resilience of medical devices and health IT – Ensure that legacy systems are secured and track medical device vulnerabilities.
- Develop the healthcare workforce capacity necessary to prioritize and ensure cybersecurity awareness and technical capabilities – Identify cybersecurity leadership within an organization with the authority and expertise to prioritize cybersecurity issues and initiatives.
- Increase health care industry readiness through improved cybersecurity awareness and education – Develop programs geared toward executives and boards of directors about the importance of cybersecurity education.
- Identify mechanisms to protect research and development efforts and intellectual property from attacks or exposure – Develop guidance for the healthcare industry and academia to evaluate cybersecurity risks for healthcare R&D.
- Improve information sharing of industry threats, weaknesses, and mitigations – Streamline the sharing of cybersecurity information and guidance to make it easier to use for small and medium-sized healthcare organizations.
The task force also identified best practices from the financial services and energy sectors, including conducting comprehensive information sharing and implementing baseline protections, such as patching systems against known vulnerabilities. The task force also recommended boosting communications and collaboration across the industry in order to educate portions of the sector that may not have had access to information about the latest threats to cybersecurity for healthcare organizations.
Health IT experts have lauded the benefits artificial intelligence (AI) will bring to healthcare for some time now. They range from improving cybersecurity to improving the workflow of a hospital. However, only the wealthiest countries and wealthiest healthcare organizations are able to purchase and use AI technologies.
Margaret Chan, director general of the World Health Organization (WHO) said at an AI summit that this technology must benefit everybody, not just the wealthiest countries and organizations, according to a Wired article.
“Enthusiasms for smart machines reflect the perspectives of well-resourced companies and wealthy countries,” Chan said in the article. “We need a wider perspective.”
Chan illustrates this disparity and how, quite frankly, silly AI technologies seem to those who don’t even have electricity and running, clean water.
“Any discussion of smart machines revolutionizing healthcare must be alert to these huge gaps in capacities,” Chan said in the article.
However, Chan said one thing everyone has in common regardless of wealth is the need to address chronic diseases such as heart disease, diabetes and hypertension. Here is where Chan believes AI technologies and wearables could provide great value.
In addition to addressing the disparity issue, Chan also warned against the over-reliance on technology, asserting that while machines will aid doctors in their work and streamline processes that lead to decisions, technologies like AI will never replace doctors and nurses when it comes to their interactions with patients.
Furthermore, Chan said that sometimes these technology tools give a false sense of safety and security. “Wearables for monitoring cardiovascular performance are already being questioned,” she said, for example.
In addition to disparity issues and warning against over-reliance of technology, Chan also pointed out that when it comes to AI technologies there are also many regulatory issues that need to be addressed.
“What if a smartphone app misses a symptom that signifies a severe underlying disease?” Chan said in the article. “Can you sue a machine for medical malpractice?”
Chan said that medical devices are heavily regulated for good reason but how can a machine be programmed to think like a human? She pointed out that doctors and nurses are not only licensed to practice medicine but also undergo continued study.
But with AI, there are many questions, she said. “We do not have the answers to many questions around AI. We’re not even sure we know all the questions that need to be asked.”
The U.S. Department of Health and Human Services (HHS) will soon launch a healthcare focused cybersecurity center, according to a press release. Christopher Wlaschin, chief information security officer at HHS, announced this news at a forum in April. The cybersecurity center will be called the Health Cybersecurity and Communications Integration Center (HCCIC) and will be modeled after the Homeland Security Department’s National Cybersecurity and Communications Integration Center (NCCIC), Wlaschin said.
The purpose of HCCIC will be to seek to reduce the extensive “noise” in the healthcare industry about cyberthreats and to analyze and deliver best practices, Wlaschin said. He added that the cybersecurity center will also help smaller providers and doctors’ offices to understand the two or three things they can do to protect patient privacy and ensure information security when it comes to the various technologies they may be using. HHS also envisions HCCIC working with mobile health app developers to help promote data security in that fast-growing area.
Wlaschin said HHS anticipates that HCCIC will reach initial operating capability in late June.
Mark Scrimshire, the innovator behind CMS’ Blue Button initiative, told Federal News Radio that his team has already written an API to allow health applications developers to verify their security with a trusted source.
In the wake of highly concerning cyberattacks such as the WannaCry ransomware attack that have happened recently, it’s not surprising that interest and investment in cybersecurity is taking center stage in healthcare.
HHS and CMS’ focus on mobile and security also makes sense since the number of mobile health applications has been increasing steadily and rapidly, the Federal News Radio article said.
“Every single data holder in the industry has this problem of who do they trust with the keys,” Scrimshire said in the article. “What we’re trying to do is say, ‘Let’s try and sort this out as an industry.’ We’ve actually put together code to allow the technologists to do it.”
From February through April 2017, Black Book Research crowdsource-surveyed 8,845 physician practices about the transition to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 which aims to transition healthcare from fee-for-service-reimbursement to value-based reimbursement.
The survey found this transition is proving to be tricky for physician practices.
Here are the top four health IT trends that could prove challenging to providers during this transition:
1) Physician practices unaware of certain MACRA and MIPS details
- 54% of respondents were unaware that the Centers for Medicare and Medicaid Services (CMS) will publish data on their Physician Compare website. This data will also be accessible via Yelp, Angie’s list, Health Grades and Google.
- 69% of the surveyed physician practice managers are aware they need to report on six quality measures; however, only 22% are aware that they had the option of choosing the metrics they believe represent the strengths of the practice.
- 94% of respondents were unaware or unsure of how to predict their Merit-Based Incentive Payment System (MIPS) — a new program that is part of MACRA that measures eligible professionals on quality, resource use, clinical practice improvement and meaningful use of certified EHR technology — scores for 2017.
2) The market for MIPS technology is booming
Of physician practices with three or more clinicians that responded to the survey, 77% seek to buy MIPS Compliance Technology Solutions by Q4. However, 92% of respondents were not aware of any branded technologies that support MACRA and MIPS measures for 2017 reporting other than their EHR.
Interestingly, the primary reason for provider organizations to acquire MIPS technology was not quality measurements but because they were having trouble deciphering their MACRA earning potential, 89% of respondents said.
“Given the magnitude of the changes, the hunt is on for the best MIPS incentive enablement resources,” said Doug Brown, managing partner at Black Book Research, in a press release. “Finding one stop solutions shop for MIPS support is becoming easier with quality measure monitoring dashboards and enterprise analytics vendors.”
3) Ambulatory EHR Optimization sparked by MACRA and MIPS
The eight largest EHR systems include Cerner, Epic, Allscripts, eClinicalWorks, NextGen, athenahealth, Practice Fusion, and GE Healthcare, according to the survey. Of the physician practices surveyed, 72% said they are using EHR products not considered as part of those top eight EHRs and stated that they were not working with their EHR vendor to make sure they are prepared for MIPS measures and can properly report data.
“The replacement market is heavily leaning to these largest 8 EHRs from small EHR vendors and expected to increase through 2018 as some providers had previously invested in EHRs that do not acclimate to agile change at scale like MACRA demands,” Brown said in the press release. “EHR companies are not required by MACRA to update their technology so providers are ill-equipped should the practice stick with their uncertified EHR.”
4) Physician practices struggle to align data
The survey found that 81% of respondents said they have not grasped how to align data with reporting measures.
“Seemingly, the MACRA requirements appear fairly easy to meet, you simply attest to at least one performance improvement activity. However, the reality will be significantly more difficult as smaller practices in particular begin preparing for risk,” Brown said in the press release.
Healthcare data breaches hit an all-time high in 2016, according to a report by Bitglass. However, the volume of leaked records caused by 2016 healthcare data breaches decreased from the previous year, according to the report. In 2015, however, 113 million Americans were affected, including 11 million Premera Blue Cross customers and 78.8 million Anthem customers.
Furthermore, so far in 2017, only 1.5 million records have been breached, suggesting that the total number of breaches will continue to decline. However, healthcare organizations need to remain diligent to prevent breaches from occurring.
Although the number of individuals affected in 2016 decreased compared to 2015, when it comes to healthcare organizations, that is not the case. In 2016, healthcare data breaches affected 328 healthcare firms, surpassing the previous record of 268 in 2015.
Experts believe that the industry will be playing catchup as far as cybersecurity spending in 2017 to combat the growing number of threats. There are also new cybersecurity technologies, such as identity access control, that can make it harder for hackers to gain entry into the hospital network.
Five of the largest 2016 healthcare data breaches (80%) were due to hacking or IT incidents. In 2017, the largest breach was due to theft and the next four largest were due to hacking.
The Bitglass report also found that unauthorized disclosures comprised 40% of 2016 healthcare data breaches, making it the leading cause of breaches. Unauthorized disclosure includes non-privileged access to protected health information and personally identifiable information.
In Pennsylvania, health IT contributed to 889 medication mistakes in hospitals over a six month period from January 1, 2016, to June 30, 2016.
During this time period the Pennsylvania Patient Safety Authority found that the majority of these medication mistakes were due to errors in hospitals’ computerized physician order entry (CPOE) and EHR systems. These medication mistakes included dose omission (13.8%), wrong dose or over dosage (10.9%), and extra dose (10.7%), according to a report by the Pennsylvania Patient Safety Authority. Of the 889 medication mistakes made, 69.2% reached the patient, and eight of the 889 medication mistakes resulted in patient harm, the report said.
While the majority of medication mistakes occurred due to errors with CPOE and EHR systems, these mistakes spanned across all health IT components which also include pharmacy systems, electronic medication administration record (eMAR), clinical documentation systems, clinical decision support systems, and bar coded medication administration (BCMA) system, the report found.
CPOE and EHR errors
“The CPOE system was cited most often as an HIT component that contributed to the top three error event types,” the report said.
The report found that half of the 889 medication mistakes cited the CPOE system as a contributing factor while EHR components — including the clinical documentation and clinical decision support systems — contributed to 13.8% of the errors.
Of the errors reported concerning the EHR system, 56 were identified as communication issues with the majority of those 56 errors (69.6%) being due to prescriber free-texting instructions in the order comments field.
“More than a third of the free-text orders (35.9%) specified when to hold or discontinue the medication, which is a workaround that prescribers may use instead of modifying the end date within the CPOE medication order,” the report said.
The report concludes that ongoing health IT system surveillance and remedial interventions are needed.
“Oftentimes, failures in the HIT systems are attributed to human error, which hinders the investigation into secondary causes of the patient safety event such as limitations in software interoperability, usability, and workflow processes,” the report said. “The interaction between clinician and software is a key component that is to be taken into consideration when trying to improve the safety of HIT.”
A new ONC challenge is seeking ways to ensure the accuracy and reliability of health data, also known as data provenance. Data provenance refers to information about when the data was created, by whom, and whether it was changed during its electronic exchange.
Data provenance — and ensuring data is accurate and reliable — is important in healthcare because inaccurate data, incomplete data, or data that has been altered during health information exchange, can have a negative impact on patient safety and the quality of care delivery.
Providers must also be able to verify that the data originated from a trustworthy source. As patient-generated data becomes more common, healthcare providers may be skeptical about the source of health data.
The purpose of the ONC challenge is to identify current capabilities and methods used in health IT to convey the provenance of health data as it used to support clinical care.
Participants in the ONC challenge must identify and articulate the challenges of data provenance as it relates to clinical care. The first phase will focus on real world data provenance challenges and explain why they are important to solve. The second phase will require participants to test their solutions to the problem they identified in phase 1.
ONC is asking participants to submit white papers for the first phase of the challenge by May 22, 2017. ONC will award a cash prize of $20,000 to up to four winners. The second phase will run from June 14, 2017, to January 22, 2018. The first place winner will receive a cash prize of $60,000, and the second place winner will receive $40,000.
Participants can register for the ONC challenge on the CC Innovation Center website.
The FBI’s cyber division notified the private industry that cyber criminals are targeting File Transfer Protocol (FTP) servers in order to get their hands on protected health information (PHI). FTP is a protocol used to transfer data between network hosts. The FTP servers these criminals are targeting are usually FTP anonymous authentication servers, are associated with medical and dental facilities, and handle PHI and personally identifiable information (PII), the FBI’s notification said. The FBI explained that the reason these criminals are targeting FTP is to not only get their hands on PHI, but also to intimidate, harass and blackmail the business owner(s).
When an organization has set their FTP servers to operate in anonymous mode, the FBI explained that this means the FTP server has been configured to allow anonymous access. Therefore, a user can authenticate to the FTP anonymous authentication server with a common username such as “anonymous” and they are not required to submit a password or e-mail address. This can potentially expose sensitive data stored on the servers. The FBI cited research conducted in 2015 by the University of Michigan called “FTP: The Forgotten Cloud” where researchers found that over 1 million FTP servers were configured to allow anonymous access.
The FBI added that cyber criminals could also attack an FTP anonymous authentication server that not only allows anonymous access but may also allow “write” access to store malicious tools or launch targeted cyberattacks.
Having an FTP server configured in either of these ways exposes that business to potential data theft and may be compromised by cyber criminals, the FBI said.
The FBI recommends that medical and dental healthcare organizations request their IT services personnel check networks for FTP servers running in anonymous mode. And if an organization has a legitimate reason for operating FTP servers in anonymous mode– for example, if certain documents needs to be made readily available to the public– administrators should ensure sensitive PHI and PII are not stored on that server.
Financial services may have replaced healthcare as the most breached industry in 2016, but that doesn’t mean healthcare is in the all-clear.
According to a report by IBM Security, the healthcare industry suffered fewer medical record breaches in 2016 compared to the previous year. In 2015 cyberattackers leaked 100 million records. That number dropped to 12 million last year.
However, that doesn’t mean that the healthcare industry is becoming immune to medical record breaches or cyberattacks. Ransomware will continue to be a concern for the healthcare industry in 2017, and experts predict the number of attacks will double by 2018. Ransomware accounted for 85% of malicious attachments to spam email, according to the IBM Security report.
Healthcare organizations will also need to be on the lookout for insider threats. Last year, internal threats comprised 71% of attack sources, and inadvertent actors– users who were unaware that they were causing a security event– caused nearly half of those attacks. The amount of insider attacks may be due to the healthcare industry’s susceptibility to phishing attacks, the report said.
Internal threats are a common theme for many organizations. After a record-breaking month of breaches in November 2016, Protenus, which publishes a monthly data breach barometer, said “hacking pales in comparison to insider breaches.” One way to prevent medical record breaches by internal and external attackers is to implement a security awareness campaign and conduct regular employee training.