Cybersecurity Awareness Month: Week 3 – Securing Internet- Connected Devices in Healthcare

The healthcare industry is increasingly relying upon internet-connected devices and solutions to improve patient care, organizational efficiency, crisis response speed, and much more. The emergence of telemedicine, digital health records, internet-connected medical devices, patient wellness apps, and an increasing amount of third parties entering the health supply chain has created many benefits. Still, it has also exposed the industry to vulnerabilities that cybercriminals regularly attempt to exploit. The third week of National Cybersecurity Awareness Month will delve into the healthcare industry (hospitals, care facilities) and consumer (telemedicine patients) implications of internet-connected device use and what steps both can take to stay safe. 

The healthcare sector was significantly impacted by events throughout 2020. The unanticipated global pandemic has indeed emphasized how vital healthcare organizations are. Unfortunately, COVID-19 will not be the only significant hurdle that defines 2020 for organizations in healthcare. Data breach incidents and targeting from cybercriminals have historically held a significant impact on healthcare organizations; this trend has continued into 2020 and will likely continue. According to research conducted by ForgeRock and published in their Consumer Identity Breach Report, healthcare was the most targeted industry in 2019, accounting for 382 breaches and costing over USD 2.45 billion.

In this blog, we will provide an overview of cyber threats that have impacted and affected the healthcare industry in 2020, identify potential reasons why healthcare organizations remain at the top of the target list and provide recommendations on how consumers and employees within the healthcare industry can #BeCyberSmart.

Review: Healthcare Industry in 2020

As much as we all want to forget about 2020, there have been some significant implications as a result of activity across the cyber threat landscape. When analyzing incidents impacting the healthcare industry, 2020 can be defined by ransomware and increased nation-state espionage activity.

Ransomware

The inherently sensitive nature of the information held by healthcare providers increases the likelihood that a successful ransomware attack will result in a payment. This observation subsequently results in increased targeting.

Many ransomware operators publicly announced their intentions to cease targeting organizations in the healthcare vertical due to COVID-19. However, ransomware impacting health care organizations continued to increase throughout 2020 (see figure 1). Evidence suggests that at the height of COVID-19, the targeting of health-related entities appeared to spike.

This increase is also alarming when comparing 2019 ransomware activity statistics to that of 2020. Throughout the entire year of 2019, Digital Shadows (now ReliaQuest) published 13 intelligence alerts involving ransomware and healthcare. Comparatively, at the time of writing, Digital Shadows (now ReliaQuest) has published 56 intelligence alerts involving ransomware and healthcare since the beginning of 2020, increasing 330%. Evidence suggests that this trend is going to continue well into 2021.

Nation-state activity

Espionage motivated attackers aim to steal intellectual property and sensitive information by targeting healthcare and pharmaceutical entities. This type of activity is typically conducted by nation-state-associated advanced persistent threat (APT) groups, which target foreign organizations in line with competitive economic and political priorities. 

The United States and the United Kingdom both released advisories detailing espionage campaigns conducted against healthcare and pharmaceutical organizations. The advisories included reporting of activity performed by threat actors believed to be associated with Russia (APT29) and the People’s Republic of China (PRC). Notably, the alerts note the targeting of information relevant to the development of COVID-19 vaccines. The global nature of the pandemic and the race to find a vaccine makes it fairly apparent as to why this information would prove valuable. The healthcare sector’s risk from espionage will likely remain constant, particularly as countries continue to develop their COVID-19 vaccines.

Espionage activity in this space is certainly not something new. As mentioned above, the nature of organizations’ data in this area gains the attention of threat actors with varying malicious intentions. More specifically, having access to medical research data can be used as a competitive advantage in developing medicines. Furthermore, having an in-depth understanding of citizens’ health in countries deemed adversarial would reveal a treasure trove of useful information. Knowing the ailments that are particularly prominent in any country could be used for many purposes and would be an obvious intelligence requirement. The threat of espionage to healthcare organizations is certainly not going anywhere, and it’s something organizations in this space should indeed be aware of.

Why are healthcare organizations so attractive?

As established, healthcare organizations hold some of our most sensitive and personal data; companies in the healthcare sector are often targeted in cyberattacks due to the perceived value of the information they possess. Financially motivated cybercriminals aim to steal data that can be resold on criminal marketplaces or leverage ransomware attacks to extort organizations for monetary gain. On the other hand, nation-state threat actors attempt to collect sensitive data and intelligence to carry out espionage activities. 

Legacy systems

2020 saw the end of life (EOL) for Windows 7 devices, meaning systems still on this operating system (OS) would no longer receive security updates. The apparent concerns of that are implied, and threat actors are also aware of this fact. If history is an example of the potential results of using systems after their EOL date, one would not have to look far to find the impact that legacy systems have had on healthcare organizations.

The infamous WannaCry, Petya, and NotPetya attacks created significant turmoil in the healthcare sector by leveraging vulnerabilities in the unsupported Windows XP operating system (OS), which met its EOL in 2014. Research published in February 2020 by Cynerio, an organization providing medical device and Internet of Medical Things (IoMT) security solutions, notes that over 20% of all medical devices in the global clinical ecosystem run the unsupported Windows 7 OS. This figure emphasizes the presence of legacy systems in the healthcare vertical, and it’s important to note that this does not include other outdated OSs.

Legacy systems are a result of the medical devices outliving the OS that they are built upon. These costly devices have warranties and support that can keep them operable well over the 20-year mark. Comparatively, most operating systems reach their EOL at about ten years. Sure, organizations can update systems, but this requires downtime and significant planning. The extensive effort detailed in the transition to Windows 10, taken on by a Houston-based health clinic, which reportedly spent two years planning their migration, highlights this challenge.  

Laura DiDio, a Principal Analyst at ITIC, stated that “the migration is particularly complex for healthcare organizations, because they must ensure that their electronic medical records systems will function properly with Windows 10 and that any changes they make will comply with stringent privacy regulations.”

In many ways, this is no small feat.

Interconnectedness of systems

The nature of health services and timeliness of patient care requires health systems to have the ability to quickly and succinctly distribute information. 

“The principle of interconnectivity in healthcare allows for the accessible and actionable exchange of clinical information — including the insights extracted from EHR, medical imaging systems, and other sources.” — Heidi Bullman, Future Healthcare Today.

Although seemingly a positive characteristic of healthcare networks, there are some unfortunate consequences of a network compromise. Interconnectivity allows for network infections, especially in ransomware encryption cases, to be wide-spread and impactful. An example being the ransomware attack, which occurred in September 2020 and targeted Universal Health Services (UHS). The infection spread through the UHS network, allegedly infecting their systems throughout the US with reports of impacted hospitals in states spanning the entire country, from California to Washington DC. The wide-spread infection increases the impact of an attack and results in a higher likelihood of ransom payment.

#BeCyberSmart

Maintaining a secure environment in healthcare remains challenging due to many connected devices, the length of time that those devices will be deployed, the difficulty of large-scale asset management, and the dependency on Operational Technology for some devices involved in direct patient care. Many systems rely on outdated technology due to the financial constraints involved with upgrades. While the risks affecting the healthcare and pharmaceutical industries are complex and dynamic, Digital Shadows (now ReliaQuest) recommends implementing the following mitigation strategies to protect organizations’ data, assets, and reputation:

• Utilize multi-factor authentication (MFA) for professional and personal accounts, remote network access, sensitive database access, and administrator accounts.
• Enforce the use of lengthy, unique, and complex passwords for employee and patient accounts.
• Implement a robust asset discovery and vulnerability management program for all servers, computers, networking components, and medical devices.
• Implement Network Level Authentication on services, like Remote Desktop Protocol(RDP), turn off unnecessary services, and block sensitive ports.
• Frequently perform and test system backups. Maintain reliable backups at an off-sitelocation
• Implement defense-in-depth best practices, such as integrating antivirus andanti-malware programs on servers and computers.
• Educate individuals involved in conducting academic or medical research on what can be shared and where to share it
• Implement the Traffic Light Protocol (TLP) to facilitate secure information sharing practices.
• Implement and use workforce access auditing of health record systems and sensitive data.
• Establish cyber threat information sharing with other healthcare organizations.
• Educate employees and researchers on security awareness, including how to identify and report suspicious emails.
• Encrypt data at rest and in transit.
• Develop a ransomware playbook and test it regularly in tabletop exercises.
• Do not store or send sensitive data or research via unencrypted email.
• Maintain an updated record of organizations or individuals that store or have access to your intellectual property
• Implement pre-procurement security requirements for vendors.
• Store intellectual property data in segmented, monitored, and encrypted databases.
• For all people involved in sensitive research who may have a public presence, use a different public-facing email account, which is in no way identical in form or related to the internal email account.
• Implement centralized logging in conjunction with real-time incident alert capabilities.
• Conduct regular security audits to identify physical- and software-related vulnerabilities.