A recent ransomware presentation… while the Petya attack was underway

I was recently invited to present two talks on ransomware at EMR-related seminars attended by physicians, clinical staff and service providers, held last week in British Columbia.

Interestingly, the last seminar took place just as news was emerging that morning of Petya, described as a new, massive ransomware attack, was spreading across the Ukraine, Europe, and the US. We are now learning that, because it encrypts entire hard disks but does not appear to have the capability to decrypt them, Petya may not have been ransomware at all. Instead, some analysts believe it may have been designed to be a weapon to cripple systems, possibly targeting infrastructure in the Ukraine. This gives little comfort to organizations around the world that have been hit with it, including shipping companies, a multinational law firm, and the giant pharmaceutical firm, Merck.

What was immediately apparent during the morning of the attack, however, is that it won’t be the last.  The need to protect information systems in health care clinics is more important than ever.

My presentation summarizes some of the information that is described in more detail here:

 

Update 20170630: More information is emerging concerning the Petya attack. For further information, here is the latest update from US National Health Information Sharing and Analysis Center (NH-ISAC)

Cybersecurity and Patient Safety

With the WannaCry ransomware attack fresh on our minds, a new report has just been published by the US Department of Health and Human Services, (HHS) Cyber Security Task Force on improving cybersecurity across the health care industry.

Although it presents recommendations that are well worth reading, what is particularly striking about this report is the focus it has on cyber security and patient safety.  The task force producing the report writes that it reflects “a shared understanding that for the health care industry, cyber security issues are, at their heart, patient safety issues.” Further to this, they write, “As health care becomes increasingly dependent on information technology, our ability to protect our systems will have an ever greater impact on the health of the patients we serve”.

An editorial in the BMJ (formerly the British Medical Journal)  last month contained essentially the same message when it highlighted “the poor state of cybersecurity in the NHS and the failure to recognize it as a fundamental matter for patient safety.”

The BMJ editorial cites risks incurred through “the extremely fragmented governance of cybersecurity in the NHS”, and that this was a core issue “underpinning the recent attack, and affects healthcare more profoundly than other critical sectors such as financial services, energy or central government”. If this sounds familiar, it is because these issues can be found across many countries, including Canada.  And while a considerable amount of effort is being undertaken to support privacy and cybersecurity best practices across Health Authority hospitals and health care institutions here in British Columbia, there is much to be done to provide the same level of support in physician offices and dental clinics.

Cybersecurity risks to networked medical devices and connected IT networks cited in the HHS report which can impact patient safety include:

  • Failure to provide timely security software updates and patches to medical devices and networks to address related vulnerabilities
  • Malware which alters data on a diagnostic device
  • Device reprogramming which alters device function by unauthorized users, malware, etc
  • Denial of service attacks which make a device unavailable
  • Unauthorized access to the health care network
  • Uncontrolled distribution of passwords, disabled passwords, hard-codes passwords for software intended for privileged device access
  • Security vulnerabilities in off-the-shelf software due to poorly designed security features
  • Misconfigured networks or poor network security practices
  • Open, unused communication ports on a device which allows for unauthorized, remote firmware downloads.

These risks impact confidentiality, integrity, and availability of health care information in varying degrees, and in different ways. As do, the HSS report cites, risks arising from the complex mix of applications, programs and interfaces from a variety of vendors supporting Electronic Health Records (EHRs).  But, according to the HSS report, they all have a direct effect on patient safety.

This raises some important questions.

When it comes to managing health care information, are clinics doing enough to protect patient safety? And if more must be done, how can clinicians be better supported, so that their patients are not put at risk?

We will be writing more about recommended privacy and cybersecurity best practices for health care clinics here in western Canada. In the meantime, there is much you can do already. When you have a moment, check out our growing collection of posts on Best Practices.

If you need help, contact us.

No “pwn” intended: how do I know if someone has hacked a site where I have an on-line account?

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Part 7 of our series on Privacy and Data Security Best Practices.

“Pwned accounts”, you might be interested to know, is a term that went viral across the Internet thanks to a simple typo.  Someone reporting that a hacker had ‘owned’, i.e., illegally ‘took ownership’ of a web account, typed the word “owned” a bit too quickly and hit the juxtaposed keyboard letter “p” instead of “o”. Voila, a brand new geeky word was born.  Today, tens of millions of accounts have been “pwned”, i.e., “owned” by hackers from companies around the world. And you can find them being actively distributed as part of a lucrative underground business on “the dark Net”,  places on the Internet where most law-abiding folks don’t ever want to visit.

Pwned accounts are important for clinicians to be aware of because if they are not carefully handled, they can become an ‘Achilles heel’, allowing attackers to gain access to even more confidential data.

So, other than the affected company emailing you directly with a warning, how can you find out if one of your accounts might have been compromised?

The website ‘;–have i been pwned? , created by Troy Hunt, a well-known web security analyst, keeps track of over 3.7 billion accounts that have been hacked, exposing userIDs, passwords, and frequently other personal information. The site will look up any email address you enter to see if accounts associated with it have been reported to be “pwned”.

Keep in mind though, that the information on this database exists only because website breaches listed there are now widely available on the Internet.  If your email address is not listed in the database, this doesn’t necessarily mean that all of your accounts associated with it are safe. Sometimes it can take years before a company knows it has been breached.

So here are five steps to help protect yourself before you find yourself on the list, and especially if you find your account has been pwned:

  1. Change the password on any pwned accounts immediately, if you have not done so already.  Consider the incident to be a potential breach, and investigate accordingly.
  2. Even if a particular web service is of relatively little importance to you, these accounts, if compromised, may be used to gain access to much more sensitive information.  Called “credential stuffing”, this hacking technique relies on the fact that many individuals use the same or very similar passwords elsewhere.  Therefore protect yourself by NEVER using the same password twice for any account.  If you use the same or similar passwords for any other account, you are just asking for trouble.  How do you keep your sanity while maintaining all of all of these unique, complicated passwords? Use a password manager.
  3. If you use a password manager, let it generate very strong, unique passwords for you. Wherever possible, we use passwords with 16 or more complex characters for pretty much every account we have.  However, we never need to remember them because the password manager will automatically pop the user id and password into the login field on your browser or smartphone.  All you need to remember is the master password for all of your accounts.
  4. Use 2-step verification for Gmail, Facebook, LinkedIn, Office 365, your clinic EMR (if it doesn’t allow this as an option, they should), and any other web service that allows it.  And, of course, use a password manager that is designed to support 2-step authentication for its own master password.  “2-step” codes, sent via your smartphone or simple to use devices such as a Yubikey at the moment you start to login, changes every minute. This goes a long way towards protecting yourself from hackers collecting passwords through breached websites or malware.
  5. Check your web accounts, especially old ones, to make sure you have not configured the ‘password reset’ feature with what is now a little-used email address.  If hacked, that ancient email account could become a ‘back door’ to gain access to any other account that uses it for a ‘password reset’.  Use an email address that is very unlikely to change over time… a personal Gmail account, for example. And please make sure you have set that email account up with 2-step verification so that it doesn’t become the weak link, allowing hackers to change the password to all web accounts configured to send the ‘password reset’ message to this email address, locking you out, and giving them access.

What password manager should you use? It’s best to check the latest reviews, and carefully select it based on your clinic security policies.  There are free applications out there that can generate and store passwords, but because we value our accounts, we have elected to purchase yearly subscriptions to a robust commercial product that supports smartphones, 2-step verified master passwords, etc.

For more information on protecting your clinic’s accounts, see our Best Practices post entitled How can I protect access to my confidential accounts? Lessons learned from the PharmaNet breach.

If you need help, contact us.

Ransomware revisited

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A few months ago, we wrote an article on Ransomware: ten ways you can help protect your clinic .  Since then, the Doctors Technology Office (DTO), at Doctors of BC, has published a brief indicating there has been an increase in reports from doctors about attacks by ransomware.

We agree with the DTO’s statement in their accompanying technical bulletin called “Ransomware – What should I do?“, “It’s spreading like the plague. Healthcare organizations must know that they ARE a target and will be attacked”.

Furthermore, the DTO indicated, quite rightly, that antivirus software does not provide sufficient protection from ransomware. The best practices we’ve published above, and the DTO’s technical bulletin, provide some helpful measures to assist in preventing some of the most common ways clinics may be hit with ransomware.

What we have been observing since our first report is that ransomware and malware tools are rapidly evolving to trick users into installing it onto their computers.  And attacks are becoming increasingly sophisticated. For example,

  • If you are scanning your email for possible “phishing” attempts to get you to download malware, be aware that no matter how carefully you examine the embedded link, it can be almost impossible identify malware websites based on the URL.
  • It used to be thought that PDF documents were safe. No longer. A new ransomware variant has emerged that will embed itself inside a PDF document.
  • Some variants that are emerging will also leak your data if you don’t pay the ransom.  Will keeping your patient files on a server outside the clinic help prevent this? Perhaps, but remember that for network efficiency reasons temporary files are frequently generated on local computers every time files are downloaded and reports are printed, all of which may contain confidential data.

Since our last “best practices” post was published, we have noticed it seems a number of clinicians and even some IT technical support staff have mistaken ideas about the threat of ransomware in medical and dental clinics.  Here are some examples.

“I don’t keep my electronic medical records (EMR) data on my Windows laptop. It is stored on a Linux server, so if ransomware hits my computer, it won’t be affected”.  Simple answer, no, that’s not correct.

  • Linux systems are not immune to ransomware. And more and more cross-platform threats are appearing, due to multi-platform frameworks that are available nowadays under Linux. Frameworks such as Adobe Flash and Reader, Java, JavaScript, Perl, PHP, Python, Ruby, etc.
  • In addition to mapped network drives which are always at risk, Microsoft Active Directory is now being used by some ransomware for reconnaissance and to spread across an entire network, encrypting files on every server and computer.
  • There is nothing to prevent other malware to be installed along with ransomware that could exploit vulnerabilities on any system.

“If ransomware hits my computer, I have other computers that I can use until I get my laptop back”.  Don’t depend on this. Some types of ransomware can propagate across a network. And besides, if your clinic is unfortunate enough to experience it, you will be immediately affected, without warning. Do you really want to have to deal with this problem when you have a waiting room full of patients?

If I am hit with ransomware, I’ll simply recover my data from backups”  We agree, backups are essential to recover from an attack. But only if backups are done right.

  • Any information you have entered that has been encrypted by ransomware since the last backup may not be recoverable.
  • We have seen cases where perfectly good backups have been overwritten with later scheduled backups where dormant malware will simply reinfect the computer when it is restored.
  • If the backup is located on a shared drive that a user can access with a network-connected computer, ransomware can encrypt those backups, too.

“If ransomware strikes, I’ll pay the ransom to get my files back.”  That, of course, is your decision, and with respect to some forms of ransomware, the FBI has actually recommended this. But just know that:

  • There are known variants of ransomware that will encrypt your data, but the ‘unlock’ key you receive after paying the ransom may not actually unlock it.  In the case cited, involving a hospital, the extortionist tried asking for more money.
  • Attendees at an RSA cybersecurity conference in February learned that 31% of victims have been hit multiple times, and 25% did not get their data back, even after they paid the ransom.
  • Even if you pay the ransom, this doesn’t necessarily resolve the risk of personal health information having been disclosed.  It should be treated as a potentially serious privacy breach.

The impact:  Ransomware may do more than just lock you out from using your laptop or desktop computer. Once it gets a foothold in your clinic, it can be difficult and costly to eradicate. The threat to clinic business continuity and protecting patient personal health information is considerable. Understanding the specific risks your clinic may have at this time is a vital first step towards taking proactive measures to mitigate them and ensuring you have well-tested procedures to quickly recover if needed.

The bottom line:  Please take the threat of ransomware in your clinic seriously.  Make sure you have tested, proactive measures in place to mitigate risks before ransomware hits.

If you need help, contact us.

 

How can I protect access to my confidential accounts? Lessons learned from the PharmaNet breach.

The recent PharmaNet breach in BC, where it appears that several incidents allowed for unauthorized access to personal health records over the past five months and affected 7,500 residents, provides a number of useful lessons that physicians and clinic managers should think about with respect to safeguarding clinic health data.

First, it underscores statistics cited in one of our recent blogs that 80% of breaches are undetected for months.  If this can happen with a province-wide service such as PharmaNet, is it possible that some clinics with electronic medical record (EMR) systems are already compromised and don’t know it?

Second, and this is not unusual when data breaches are discovered, there were warnings and even incidents that had occurred long before the most recent one.

Third, unauthorized access appears to have occurred through a physician’s login userid and password.

Fourth, the impact of the breach was significant. As the Ministry of Health warned on February 6th, breaches of this nature are a ‘starting point’ for identity theft.

So what does this mean for private medical and dental clinics, where thousands of confidential medical records may be stored in an EMR and are accessed on a daily basis, employing userids and passwords not unlike the ones used to access PharmaNet,  on computers and servers that are completely managed by the clinic or their contracted providers?

  1. Don’t wait, especially if you have nagging concerns over how health care data is being managed in your clinic.  If you have not done so within the past few months, take the time to conduct a thorough review of your clinic privacy and data security practices. With ransomware threats now targeting health care, the urgency to conduct a review of this nature cannot be overstated. This is as important as having an earthquake kit in your home, and probably more urgent to your business.
  2. Use best practices.  When it comes to protecting your clinic, the value of doing things right will more than pay for itself if it avoids a catastrophic breach or clinic disruption. There is lots of excellent advice available to help you. Our own blogs on this topic are a good starting point.
  3. Be vigilant.  To safeguard your patients and your clinic’s daily operations, all staff must be engaged in creating a culture of privacy and security that is consciously maintained, and always alert to risks that could endanger it.

Are there any other lessons that might be learned from the most recent PharmaNet breach?

4. Use stronger methods to authenticate your accounts than just passwords.  This is part of best practices noted above, but because the PharmaNet breach is on everyone’s mind in BC right now, it merits special attention.  There are so many ways that accounts with even very strong passwords can be quickly compromised, experts in the healthcare data security industry are saying using just passwords is not enough. In fact, the BC Office of the Information & Privacy Commissioner (OIPC) states that, as a minimum security requirement, 2-factor authentication should be used whenever handling sensitive personal information, including financial information (see section 13.23 of the OIPC Self-Assessment Tool that is mentioned in Part 4 of our series on Best Practices). If your EMR vendor and service providers are not providing 2-factor authentication as an option that your clinic can implement, ask why they are not doing so. While doing this, ask about convenient technologies such as Yubikeys, adaptive authentication and other methods that could make this method of securing your accounts easy to use in a clinical practice.

If you need assistance, contact us.

My clinic data has been breached. What do I do now? Four critical steps.

Part 6 of our series on Privacy and Data Security Best Practices.

I have just returned from the IAPP/ISACA KnowledgeNet conference in Vancouver this week, where the focus of the afternoon was on Privacy & Security in Healthcare. Some interesting facts arose from the forum:

  • The cyber security threat targeting healthcare information systems is real and is dynamically changing. Hackers are changing attack campaign strategies on a weekly and even daily basis.
  • It is no longer a question of whether your clinic or healthcare organization is going to be attacked by hackers, but how often.
  • If broken into, 60% of data is stolen within hours.
  • 80% of breaches remain undetected for months.
  • Malware and Ransomware are continuing to evolve. New and stealthier versions frequently bypass antivirus software.

So, let’s assume the worst.  You have walked into your clinic in the morning and found you could not access your EMR due to ransomware.  Unfortunately, this is not a hypothetical risk. Or, as an example, imagine that you have received a call from a patient who has discovered his confidential health information has been made available to someone who should never have accessed it, and he is certain your clinic provided it.

What to do?

Let’s begin by saying that, before any of this happens, make sure you have a plan to deal with it before it occurs.  Once you are hit with a breach, this is not the time to be looking for a plan or to begin making one up as you go. The SANS Institute strongly recommends that you be well prepared to handle this situation at a moment’s notice.

According to the Office of the Information and Privacy Commissioner of BC (OIPC), a privacy breach occurs anytime there is unauthorized access to or collection, use, disclosure or disposal of personal information.  What is unauthorized?  In British Columbia, this means any activity that occurs in contravention of the Personal Information Protection Act (PIPA) or part 3 of the Freedom of Information and Protection of Privacy Act (FIPPA). While cybersecurity threats are a very real danger, the most common privacy breach occurs when personal information of patients or staff is stolen, lost or mistakenly disclosed. This might include, for example, if a computer containing personal information is stolen or personal information is emailed to the wrong individual.

Doctors of BC, the OIPC and the College of Physicians and Surgeons of BC, have published a four-step guide to deal with breaches, called “Responding to a Privacy Breach – Key Steps for Physicians“.  More recently, the OIPC has published some very helpful resources on what to do when responding to a breach, including “Privacy Breaches: Tools and Resources“. Both documents focus on four key steps:

  1. Contain the breach. Take immediate action to limit the breach. In the case of ransomware, The Doctors Technology Office (DTO) at Doctors of BC has an excellent technical bulletin that may be of help. Additional resources such as the site managed by two European police agencies, Intel and Kaspersky called No More Ransom, and ID Experts ebook called What to do when your data is held hostage, may also be useful. For example, disconnect affected system(s) from the clinic network and the Internet, but don’t power them down.  That could make matters worse. Instead, get expert technical advice.
  2. Evaluate the risks. Other immediate steps may be needed. It is essential to determine what personal information was involved, the cause and extent of the breach,  who and how many individuals were affected by the breach, and what foreseeable harm might arise from it.
  3. Notification.  It is important to notify affected individuals if it is necessary to avoid harm or mitigate harm to them. Equally important is to know when, and how to notify them, as well as who else should be contacted. Make sure to read the OIPC’s recommendations in the document above, on what you should consider when determining whether to notify individuals affected by the breach.
  4. Prevention. Once immediate steps have been taken to mitigate risks, it is vital to thoroughly investigate the cause of the breach. This may require a detailed physical and technical security audit.  Doing this will help you to develop or improve whatever is necessary to safeguard data going forward.

The OIPC Tools and Resources document also contains a checklist we would suggest placing in your clinic policy and procedures manual, in case it is necessary to respond to a breach in your clinic.  The checklist will help you to decide whether or not to report a breach to the OIPC.  In general, reporting to the OIPC should be considered:

  • If the personal information is sensitive
  • If there is a risk of identity theft or other harm, including pain or suffering or loss of reputation
  • A large number of people are affected by the breach
  • The information has not been fully recovered
  • A similar breach has taken place before, or if it was the result of a systematic problem
  • Your clinic needs assistance in responding to the privacy breach
  • You want to ensure steps taken comply with your clinic’s obligations under privacy legislation.

Legal note to all of the above: This is intended for general information only. It is not intended to provide legal or other advice.  The key message here is: make sure you have policies and procedures in place that will help you to recover from a privacy breach, before it occurs.

Here are some additional best practice resources you can use to be proactively prepared:

If you need assistance, contact us.

Ransomware: Ten ways you can help protect your clinic

Part 5 of our series on Privacy and Data Security Best Practices.

A highly-respected physician here in British Columbia recently told me that many clinicians he has spoken to tend to view privacy leaks and unauthorized access as a government or health authority issue. While this may be the case, a threat has emerged that not only has the potential of instantly endangering the confidentiality of personal health information, but also the operation of your clinic, and your bottom line.

The threat is ransomware.

According to Symantec, more than 1600 incidents per day hit Canadian firms in 2015, the last time these statistics were reported. And the threat is growing.  Last summer, Solutionary, a large security services firm, reported that ransomware became the single biggest response engagement for the company during the previous quarter, and across industries, 88% of all detected ransomware engagements targeted healthcare. Some of the most well-publicized healthcare ransomware attacks last year, including an attack in Ottawa, involved hospitals. Indications are that with increasingly sophisticated exploit techniques, hackers are moving towards data-intensive businesses, including medical practices, hospitals, financial services and legal services industries.

It is not difficult to imagine why healthcare data breaches are far more dangerous to victims than other breaches. Even small 1-2 physician medical clinics can host 3,000-6,000 confidential electronic medical records.  While privacy risks are serious and could jeopardize your clinic’s compliance to PIPA if breached, ransomware can, in addition, hold computer systems and medical data hostage by encrypting files and locking out access until a ransom is paid. Frequently the ‘hostage note’ will indicate data will be destroyed unless this is done within a given time. The disruption to patient care could be significant. And ransomware software is rapidly evolving. One of the latest variants, Doxware, lets hackers hold computer systems hostage like other ransomware, but takes the attack further by threatening to release personal information publicly unless the ransom is paid.

How many clinics have already been affected in western Canada? We don’t know. It is quite possible that some clinics, like many Canadian businesses, have quietly paid ransoms to get control over their systems. According to one study, Canadian companies are 75% more likely to pay ransoms compared to the  US, UK and Germany, and that if they didn’t pay, 82 percent lost files.  The cost to pay ransomware extortionists has ranged from $1,000 to $50,000. And it is not uncommon for the same businesses to be hit more than once, by the same hacker or by others.

How can you protect your clinic?  The following 10 recommendations are based on suggested actions by Public Safety Canada and others.

  1. Backups: Backup and regularly test them to make sure you can recover your data. Having encountered very unfortunate cases where owners thought their backups were working, we cannot say enough how important this is. Backups must be secure, encrypted, and not connected to your computers or network.  If cloud-based (and this, of course, could be questioned from a privacy perspective), avoid persistent synchronization techniques that could be locked by some ransomware variants. This includes Dropbox, Google Drive and One Drive.
  2. Good Email Hygiene: Do not open ANY email attachments from unknown senders, and treat ALL with suspicion. Inspect the URLs or any links inside email body copy before clicking. Don’t click on ‘URL shortened’ links as it is impossible to know where you are being directed.  Don’t click on any email that seems ‘out of the ordinary’, especially from a CEO, president or managing partner. Instead, confirm it through a new email you create, or by phone or in person. If you can, configure your email server to block suspicious email attachments similar to that done by UBC, and destroy emails with known malicious URLs.
  3. Application whitelisting: Implement application whitelisting, an IT technique used to prevent malicious software and unapproved programs from running.
  4. Security patches: Keep your computers up to date with the latest patches. Vulnerable systems and applications are the targets of most attacks. This, of course, includes servers hosting clinic data. A compromised client computer is often just the entry point from where exploits are launched to attack other systems inside a secure network.
  5. Anti-virus: Make sure antivirus is kept up to date and running on all of your systems. Scan all downloaded software before executing it.
  6. Basic Computer Security: Limit access.  Never use an admin profile as a user.  Apply the principle of ‘Least Privilege’ to all systems and services to help prevent malware from spreading.  Never download software from unknown sites. Be extremely critical of ‘free’ software.
  7. Macros: Disable macros unless absolutely required. Consider using Office Viewer software instead of MS Word when viewing email from clients or vendors. Receiving malware from unknowing senders you trust is a well-known technique.
  8. Web Browsing: Use safe practices when browsing the web not only within the clinic but when you take your laptop or mobile device home. A laptop can by itself become a trojan horse if taken from an untrusted home environment or public internet location and connected back into your secured, carefully managed medical clinic.
  9. Network Security:  Install a commercial grade firewall with active web filtering. The cost will more than pay for itself if it prevents a breach.  Physically segregate critical data on different systems to limit risks.
  10. Focus on awareness and training:  Make sure your staff knows the risks involved, and what to do to prevent ransomware from hitting your clinic.  The most common contributor to successful phishing attacks is a lack of knowledge and human behavior. To protect your clinic from ransomware, an intelligent human firewall is one of the best defenses you can have.

The Doctors Technology Office (DTO) at Doctors of BC has an excellent technical bulletin that may be of help. Further advice can he found in advisories by Public Safety Canada (2013 and 2016), advisories issued last September by the US-CERT , the FBI , and No More Ransom, a site built through the work of several European police agencies, Kaspersky and Intel.

If you need help, contact usPrevention is much less costly.

In the next post in our series of privacy and data security best practices, we will discuss what you can do to reduce risks to your clinic in case of a security breach.