By Emilie DiChristina MBA, for PracticeFirst
In the NEWS…RANSOMWARE
Last week, approximately June 28, 2017, major organizations in Europe and the US were attacked by the “Petya” RANSOMWARE. In Pittsburg, Pennsylvania, Heritage Valley Health System were hot by this malware, impacting the safety and treatment of patients across their hospitals and health centers.
About 6 weeks ago everyone heard of the RANSOMWARE attack on the Erie County Medical Center Corporation, and of course on companies across the world.
Possibly the first RANSOMWARE attack in our immediate area, occurred in May 2016 impacting the public, mental and health departments of the Niagara County Health Departments?
Whether you are a provider or a patient, having your records held hostage is scary. The risk of incorrect prescribing, delayed surgeries, unknown allergies and delayed test results and possibly completely lost records cannot be oversold.
Having your records possibly viewed by a hacker is scary. Although the medical information loss is worrisome, the loss of vital identifiers can also be frightening. Your DOB, SS, address, bank account information…shall we go on?
Even scarier, the inability to get the information back, explaining to the government why you were unable to secure your data, and possible law suits, penalties and the loss of trust.
Let’s review what you, as a covered entity are required to do regarding electronic data…
CMS requirements for Electronic Security for any “covered entity” which means anyone:
- Any provider of medical or other health care services or supplies who transmits any health information in electronic form in connection with a transaction for which HHS has adopted a standard
- Any individual or group plan that provides or pays the cost of health care (e.g., a health insurance issuer and the Medicare and Medicaid programs).
- Health Care Clearinghouses – A public or private entity that processes another entity’s health care transactions from a standard format to a non-standard format, or vice-versa.
Why then, if healthcare providers are following the CMS Electronic Security Rules, are they falling victim to RANSOMWARE attacks, or in fact, any virus?
CMS/HIPAA General Rules of meeting the Security Standard includes the following safeguards:
ADMINISTRATIVE – Security Management Process – Assigned Security Responsibility – Workforce Security – Information Access Management – Security Awareness and Training – Security Incident Procedures – Contingency Plan – Evaluation – Business Associate Contracts and Other Arrangements
PHYSICAL – Facility Access Controls – Workstation Use – Workstation Security – Device and Media Controls
TECHNICAL SAFEGUARDS – Access Control – Audit Controls – Integrity – Person or Entity Authentication – Transmission Security
So therefore, if an organization has policies, procedures, and documentation requirements in place to meet the CMS requirements for electronic device and information security, viruses and RANSOMWARE should not be a problem…Right?
Unfortunately, there are 2 major issues (and a host of minor ones) that may put your organization at risk from either a violations of the EPHI security requirements of CMS, or of suffering a virus or RANSOMWARE attack.
THE THINGS THAT PUT YOUR ORGANIZATION AT RISK
The first MAJOR RISK is that we all use, or are, PEOPLE.
The 2017 Level 3 Healthcare Security Study conducted by HIMSS Analytics and sponsored by Level 3 Communications found that approximately 80% of surveyed health IT executives and professional report that employee security awareness is their greatest concern regarding healthcare data security.
In large organizations there are large numbers of people, from the big guns of the Administrators and Providers, extending to housekeeping, students, security and Business Associates.
These big entities have people writing HIPAA and E-Security policies, giving inservices, even auditing HiPAA and e-Security. The job of these “people” are specifically to insure that the rules of CMS are followed up to and including those regarding E-Security.
So, why have these big entities been hit by viruses and RANSOMWARE?
Unfortunately, the sheer volume of people in these organizations make security a real issue both in physical plant (how to prevent someone claiming slip and fall injury), ID theft (people stealing a patient’s demographic information), HIPAA violations (both inadvertent such as the lobby conversation and deliberate as in reviewing the info of a VIP patient), and of course in E-Security.
E-Security can also be the defining factor in the theft of patient information or HIPAA data breaches as well as malware and viruses entering your IT system. Just think how many people have personal phones or other devices such as IPADs, as well as institution provided electronic devices. How many Medical and Dental residents are coming into these places in July, each getting their own usernames, passwords, VPN access to all kinds of IT systems and programs?
People are the issue in small and medium sized healthcare businesses as well. In these situations, the problem may be too little people, with not enough expertise to handle IT concerns, or a feeling that as a small business neither CMS nor RANSOMWARE attackers will come after you.
Personnel working in smaller practices may use their personal electronic devices for work, or may, as with any business plug them into the workstation by USB. Further, people in smaller organizations often travel between offices, take home HIPAA material or electronic devices. Also, more often than not, you begin to think of staff as family members or you have family members working there so you cannot conceive of them doing something that could harm your practice.
When you see this screen in smaller organizations, it is likely that data from your PC can be migrated to the personal device, or from the personal device. This is a common sources of virus and malware transmission as well as HIPAA breaches and data theft!
Bottom line? Unless every person you hire, use as a Business Associate, allow to intern, shadow, contract, clean, etc. for you is completely honest, follows all the rules, never opens personal email or uses personal devices on your system, never uses open Wi-Fi, and always turns off their computer at least once per week (not logging off, turning off) to allow for patches, people put you at risk.
The Identity Theft Resource Center and CyberScout released a survey in 2017 that showed the leading causes of healthcare data breaches was employee error or negligence.
The second MAJOR RISK(s) would be a combo of time, money and fatigue.
The HIMSS Analytics survey listed competing priorities and budget concerns as the top barriers in adopting a comprehensive security program.
While budget concerns may limit the number of people we have monitoring employee behavior, the ability to afford full time IT support, or even whether or not you have purchased licenses for the newest operating systems, the competing priority and fatigue issues may be worse.
In every organization, your specific priority depends on your role in the organization. A CEO or CIO will have different priorities that a clinical provider who just wants to log on, complete a task and get the job done.
The smaller practice gets impact by monetary priority fairly significantly as they cannot always afford IT personnel or regular updates to computer programs, they are often the entities using older Operating Systems, and many do not even have a written compliance and E-Security plan, let alone constantly reminding staff about it. If you are working in a small practice, go to your Administrator or Principle MD and say, “Does our practice have E-security threat intelligence, sandboxing or DDoS mitigation in place?” and watch their eyes glaze over.
And fatigue – One major reality of health care is overall fatigue, mental and physical. It is as real as what we call ICU alarm fatigue – too many things beeping and we tune everything out and miss something important.
We have been bombarded with HIPAA training for about 2 decades. When E-Security was added, we were already so exhausted by HIPAA, we barely listened to the new training.
We have passwords and usernames for so many programs we do the unthinkable, that is to use the same passwords where allowed or to write everything down and stick it near our work station or on our phones, etc.
We also, although trying to remember to log out of programs, or even the PC we are using, often do not turn the actual PC off (the necessary patches and updates to prevent malware can take place when the PC is turned back on0. The reason most of us conveniently forget to turn off the PC is the delay we experience when turning the PC back on, the patches and updates can take quite a bit of time if the machine hadn’t been turned off recently.
We are also so focused on getting our jobs done that we forget the exact policy or process related to IT security, for example clicking on an attachment in an email you think is from a colleague, or accessing streaming sites for radio, music, YouTube, or worse, accessing your Facebook from your work computer.
And we allow people to plug their personal USB or USB driven devices into their work stations!! Making it easy for malware to get into our system and for ePHI or Demographic data to be transferred to the personal device!!!
The HIMSS Analytics study also listed clinical workflows, employee awareness and in-house expertise as top security program barriers.
As they say – brown stuff happens, and sometimes it hits the fan!
So, if you have limited time, limited money, conflicting priorities, your best bet to protect your organization against malware, viruses or RANSOMWARE, even in the smallest organization, is to have a thorough and effective E-Security program as required by CMS.
Sounds too simple? Think about this…
RANSOMWARE attacks, virus intrusions, malware all violate the major 3 tenets of HIPAA Security:
Confidentiality – EPHI is accessible only by authorized people and processes (obviously if your system is hacked… someone unauthorized may be looking
Integrity – EPHI is not altered or destroyed in an unauthorized manner (RANSOMWARE threatens to destroy your data, which would include patient records if you don’t pay up, and even if you don’t pay, some data may still be lost depending on how long ago you backed up data.
Availability – EPHI can be accessed as needed by an authorized person (When a virus or RANSOMWARE locks up your system, and no one can access patient records… well you get the drift).
- Make sure you are following the regulations put forth by CMS, no matter how small your organization may be, and that you have the required policies, enforce those policies and audit staff performance under those policies. This may not stop RANSOMWARE or other malware but it can indeed mitigate some of the financial, penalty and risk fallout after the event.
- Updated the policies and procedures and have your people sign off on each of them or the entire manual, minimally yearly, when hired and if found to be doing something incorrect.
- Have a plan to work without your electronic medical records. How will you cancel patients, move patients, schedule patients? How will you treat those needing immediate care? How will you record your treatment, and then insure if gets updated into the full EMR later?
- Strictly enforce, and punish, use of personal devices, use of personal email, opening of streaming radio, YouTube, Facebook, and any email download without first putting through a virus check.
- Require all staff in small offices, offices where workstations are not shared, etc. to not only log off, but also shut down their PCs and workstations at the end of their work week so IT updates (if you have an active IT provider), operating system patches, and Anti-Virus and Malware program updates can be installed when the computer is turned on again at the beginning of the week.
- Make sure that all of your systems, EMR, medical equipment related, billing related, even things like Quickbooks, etc. are updated regularly.