When the COVID-19 pandemic first hit the U.S. hard in March, the Elmhurst Hospital was forced into a logistical nightmare.
It was a grim sign of the times, as the Queens, N.Y. hospital was flooded with hundreds of sick patients, with one medical resident describing conditions as “apocalyptic”. At the same time, hospitals also began a similar rush to increase capacity to keep up with growing infection rates, and scrambled to find personal protective equipment (PPE), ventilators and trained staff.
Lost in the chaos was IT security. In the early fog of the pandemic, cybersecurity took a back seat to keeping patients alive. But it did not take long before important hospital systems such as telehealth patient portals, backend billing and coding systems, connected medical devices and video-conferencing platforms were stressed.
Cybercriminals took notice. Cyberattacks targeting healthcare firms have increased 150 percent since the COVID-19 virus hit the U.S. shores. The pandemic’s unprecedented impact on healthcare lay bare the gaping holes in the healthcare industry’s cybersecurity defenses. It is a sobering wakeup call that security experts say will have a lasting impact on the healthcare industry well into 2021.
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Cyberattacks Target Vulnerable Systems
The goals for cybercriminals are varied. At one end of the spectrum, they’re targeting personally identifiable information to be later used in credential stuffing attacks or for resale on criminal black markets. At the other end, attackers have also launched costly ransomware attacks against insecure healthcare systems- potentially endangering patient lives.
“Frontline health professionals have been heroes during this pandemic, saving lives,” said Beau Woods, a Cyber Safety Innovation Fellow with the Atlantic Council.
Woods, who has worked for the past 10 years with small hospitals, healthcare focused nonprofits and government entities, added, “If technology goes offline, doctors and nurse practitioners can no longer give the quality of care that they were able to, or to as many people. Right now, with COVID-19, there’s a dramatic rise in the attack surface and the number and types of systems that are being used,” he said.
Of course, healthcare cyber-challenges aren’t new. Security researchers have long pointed out myriad threats facing this critical industry segment. For instance, the hospital equipment mix includes millions of insecure, single-purpose, connected medical devices, including insulin pumps and defibrillators, that are often open to hacks because they haven’t been updated. Medical environments are also rife with critical infrastructure that runs on legacy platforms (such as Windows XP).
As an example of the magnitude of the outdated equipment problem, the Food and Drug Administration issued an emergency alert last year warning that Medtronic MiniMed insulin pumps are vulnerable to potentially life-threatening cyberattacks. The flaw, which has since been patched, could have enabled cybercriminals to connect wirelessly to a MiniMed insulin pump and change its settings, allowing them to either deliver too much insulin, or not enough – with potentially fatal results for patients. Another existing issue is the ongoing digitization of patient data and a growing reliance on connected medical devices. In general, this has created a massively expanded threat landscape for the healthcare industry.
Then there’s the fact that there are millions of decentralized endpoints associated with telehealth – including patient facing portals, new COVID related and existing mobile apps and wearables – all providing new ways to gather and process health-related data. As such, they crack open wide the attack vector for adversaries.
With COVID-19, all of the existing issues that make healthcare cybersecurity difficult have become magnified, say experts.
For instance, telehealth adoption by primary caregivers jumped by 50 percent between January and June of 2020. That required new investment in technology, when facilities are already paying a premium for testing, additional staff, PPE and ventilators.
“The biggest challenge with COVID-19 and healthcare security in my view is the significant strain on available resources,” Jeff Tully, a pediatrician and anesthesiologist at the University of California at Davis, said. “With a precipitous decrease in elective surgical procedures and routine outpatient visits, hospitals and other healthcare facilities already facing razor-thin margins pre-pandemic are now forced to make increasingly difficult decisions about how to prioritize limited funds.”
He points out that elective surgeries are a significant money-maker for hospitals, in normal times. Reuters news agency reported in March that the New York-Presbyterian Hospital postponed all elective surgeries, impacting 10 New York area hospitals.
These realities make it hard to advocate for something like a newly segmented network or increased IT security staffing, when healthcare workers may be furloughed or patient-care programs underfunded, he said.
While hospitals, doctors’ offices and other healthcare stakeholders wrestle with a morass of cybersecurity challenges, threat actors have been paying attention – as evidenced by a cresting cybercriminal offensive on the healthcare industry.
A recent study by SecurityScorecard and DarkOwl found that attacks have increased 16 percent on web applications since the coronavirus pandemic hit states hard in March, while attacks on endpoints are up 56 percent and attacks targeting IP addresses have climbed 117 percent (PDF).
For hackers, COVID-19-related attack vectors remain low-hanging fruit. Patient data represents a lucrative store of goods to sell on the criminal underground. And ransomware attacks are all too easy, thanks to a lack of patching and user awareness/distraction – according to SonicWall, ransomware attack volumes have grown 109 percent annually in the U.S., in part due to the pandemic. Espionage meanwhile continues as attackers strive to get their hands on valuable coronavirus treatment and vaccine research.
Real-world examples abound of cybercriminals taking advantage of the weaknesses. As an example, in 2019 a breach of AMCA impacted the data of 25 million patients – including their names, addresses, dates of birth and payment data.
Ransomware examples are readily available too. For instance, Hammersmith Medicines Research, a London-based healthcare provider that was working with the British government to test COVID-19 vaccines, was recently hit by a ransomware attack. A ransomware attack in October also hit eResearchTechnology, a medical software company that supplies pharma companies with tools for conducting clinical trials – including trials for COVID-19 vaccines.
And on the espionage front, APT29, a Russia-based advanced persistent threat (APT) group also known as Cozy Bear, reportedly targeted academic and pharmaceutical research institutions in various countries around the world in July – just one of several such incidents.
With medical cybersecurity in a state of perpetual disruption – and ongoing attacks – there’s a darker side to consider. Researchers and healthcare professionals alike worry that the heightened security threats are evolving from impacting technology availability and patient data privacy to actually threatening patients’ physical safety.
The Atlantic Council’s Woods cited academic research that examined the impact of re-routing ambulances around marathon race routes versus ambulances that did not face any obstructions. That study determined that delays of just five minutes in care can impact patient outcomes.
A cyberattack’s effect is no different, said Woods: A system-crippling incident can freeze access to care for hours, and sometimes days, he pointed out.
There’s precedent for the concern. The WannaCry cyberattacks of 2017, which spread to more than 300,000 computers in 150 countries, not only brought down computer systems, but paralyzed hospitals’ ability to keep customers’ appointments, preventing patients’ access to care.
“During WannaCry, in some areas many hospitals shut down, with at least 30 to 40 percent shutting down for a day to a week,” said Woods. “If you think about someone with a stroke, with a 90-minute timeline of being treated, no one got the care needed during that time, which leads me to believe people have died because of these things before.”
More recently, a ransomware attack on the Duesseldorf University Hospital in Germany led to the hospital turning away emergency patients. During this attack, a woman who had to be sent to a different healthcare facility, around 20 miles away, died. German prosecutors suspect it’s because of delayed treatment after the cyberattack. Later, the cause of death was determined unrelated to the delay in care.
While the Duesseldorf University Hospital incident might be the first to sound an alarm, Woods said, the incident is not the first death that’s been caused – or at least partly influenced – by ransomware.
UC-Davis’ Tully knows the potential human consequences of poor IT security in healthcare facilities first-hand. At a Black Hat USA session in 2018, Tully demonstrated a proof-of-concept attack against a computerized Health Level 7 lab-results system. He was able to tamper with lab results coming from blood gas machines and urinalysis machines, which could lead to a lethal dosage of the wrong medication to treat an already sick patient.
“Certainly, sentinel events like WannaCry and, more recently, attacks explicitly directed at hospitals caring for COVID patients raise the specter that the quality of care, particularly for time-critical conditions like heart attacks, strokes or sepsis, may be affected enough to result in increased morbidity and mortality,” Tully said.
The Future of Healthcare Security
Against this bleak backdrop, the prognosis isn’t all bad. There are several steps that healthcare organizations can take in order to secure patient data and critical infrastructure.
For one, in order to secure systems across the board, healthcare providers need to incorporate a patching cadence as an integral part of their vendor due diligence. In a report published in August, analyst firm McKinsey identifies patching as the first in a list of required controls (PDF) that healthcare organizations need to put into place.
Beyond that, hospital networks can bolster security by adopting proactive monitoring programs to weed out risks of breaches, conduct risk analyses to keep tabs on their connected devices and follow cybersecurity frameworks – like the National Institute of Technology (NIST) cybersecurity framework – to further understand new threats.
And, as is the case in many industries, prioritizing staff training and awareness across the organization is crucial — awareness can prevent spear-phishing and close other attack vectors. Building relationships between the IT teams and the hospital staff should also be at the top of the to-do list, Dan Costantino, CISO at Penn Medicine, said, stressing that hospital CISOs shouldn’t “run programs in a vacuum.”
He also urged IT teams to bring other business leaders to the table and give them “skin in the game.” Doing so, he said, would help build strong security advocates within the business. This is particularly important during the ongoing pandemic, where security teams need the extra support of the healthcare leadership.
“The COVID-19 pandemic has been challenging for everyone, both personally and professionally,” said Costantino. “Cybersecurity teams have found themselves in a position where business operations are changing at warp speed. COVID-19 presents the need to turn that known state of operations sideways as the business scrambles to adjust, and implement a model capable of responding to our communities’ needs while maintaining employee safety.”
Download our exclusive FREE Threatpost Insider eBook Healthcare Security Woes Balloon in a Covid-Era World , sponsored by ZeroNorth, to learn more about what these security risks mean for hospitals at the day-to-day level and how healthcare security teams can implement best practices to protect providers and patients. Get the whole story and DOWNLOAD the eBook now.