Navigating the “Ascension” and “Change Healthcare” Breaches – Guidance for Healthcare Cybersecurity Teams

Ascension – one of the largest healthcare entities in the United States with over 140 hospitals and over 40 care facilities – has confirmed it has experienced a ransomware attack resulting in the need to take down systems. Operations have been severely disrupted, affecting care capacity and causing multiple clinical systems, including the Electronic Health Records (EHR) system, infrastructure, and communication systems, to be impacted. Staff are resorting to manual procedures due to the lack of electronic system support, and some hospital sites are diverting emergency care. Ascension has even advised its business partners to disconnect systems to prevent further propagation of the attack. They have also engaged third-party cybersecurity firms to investigate and restore systems, but the timeline for restoration is uncertain and could take weeks or months.

In light of this attack, the Federal Bureau of Investigation (FBI), Cybersecurity and Infrastructure Security Agency (CISA), the U.S. Department of Health and Human Services (HHS), and Multi-State Information Sharing and Analysis Center (MS-ISAC) had outlined the technical exploit details and preventative measures organizations can take to protect against the Black Basta ransomware variant believed to be the culprit.

This latest cyber incident comes just a couple of weeks after the Change Healthcare attack in which attackers were able to leverage stolen credentials to gain access through an external-facing Citrix platform which lacked Multi-Factor Authentication (MFA). The costs associated with the Change Healthcare attack amount to over $870 million, $600 million of which is directly linked to the cyber incident and restoration costs and an additional $250 million in revenue loss, including an undisclosed amount of ransom payment. The breach costs are expected to continue rising to over $1billion.

With the industry experiencing back-to-back attacks of some of the largest organizations in the United States, the disruption and backlog created to patient care is unprecedented. The reported ransom paid during Change Healthcare’s breach, reinforces malicious attacker motivations who then continue to target not only the healthcare industry, but the largest organizations. Extended downtimes, widespread care impact, and mounting pressure can force Healthcare Delivery Organizations (HDOs) to give in to ransom demands, sometimes seen as a necessary evil in order to restore operations, but a double edged sword which continues ransomware proliferation through the industry.

The (C)Rippling Effects of a Healthcare Cyberattack

The cascading effects of cyberattacks on healthcare systems leave a long lasting impact on patient care delivery.

Hospitals redirecting and diverting patients creates additional pressures on healthcare systems, clinics, and other hospitals in the surrounding areas, even those not directly impacted or involved in the cyber incident, thereby further impacting healthcare delivery on a grander scale. For example, a regional hospital which may serve 1,000 patients in a day now having to cope with an unexpected surge of an additional 1,000-2,000 patients as overflow from the impacted hospital creates its own challenges from resource and patient care management.

It’s important to understand as well that medical devices, and application infrastructures aren’t the only elements to consider. A single compromise or failure of an Heating, Ventilation, and Air Conditioning (HVAC) in an operating room can result in canceled surgery should humidity levels not fall within specified standards. Of course, this is only further amplified should multiple systems be affected requiring lengthy re-certification processes.

In the life after a breach, and once restoration has been accomplished, the detrimental effects of the incident continue to linger for months. Rescheduling of patients, getting billing back on track, and other administrative and operational elements of care delivery take months to catch up. Furthermore, there are then regulatory reporting requirements and external investigation and audits that will be mandatory.

The Growing Healthcare Attack Surface

At the core of this issue is the need for healthcare organizations to anchor themselves in a security program and measure maturation at regular intervals. What we have seen is rapidly evolving care models and the accelerated adoption of technologies in an industry that used to be change adverse. This has led to uncontrollable growth of the industry’s attack surface, providing attackers multiple entry points into the organizations along with plenty of blindspots for them to set up camp.

Telehealth care models, smart medical devices and entire smart hospitals, cloud infrastructure, innovative solutions from the research department, cloud workloads, and remote workforces are some examples of how much more complex it is to get a true understanding of the healthcare environment and corresponding risk. And while technology adoption has sped up, security teams are having an extremely difficult time as the growing number of risks continue to outpace their mitigation efforts.

Security teams are now responsible for securing unknown devices, with unknown workflows, and unknown impacts – many of which do not support nor adhere to traditional security tools and methodologies. Without a grasp on all the assets and unable to leverage traditional controls deployed in the environment, it is virtually impossible to measure compliance to information security programs and best practices.

What this means for security teams is the need to monitor well beyond their enterprise IT assets – cloud infrastructure and workloads including those that have ephemeral footprints, IoT, IoMT, OT/BMS devices along with Identity and Access Management (IAM) and vendor risks – are all elements that must be scrutinized. Many of these remain outside the purview of teams. This is only further exacerbated by the velocity of vulnerabilities being released along with more complex and evolved threats including those that come from nation state attackers.

Healthcare Cybersecurity Best Practices

While the root cause of Ascension’s cyber incident is currently under investigation, Change Healthcare’s was attributed to a number of contributing factors including network blindspots, misconfigured or absent security controls, and detection gaps in anomalous behaviors and other indicators of compromise (IOCs). Attackers have a plethora of areas they can target, while cybersecurity teams have a growing number of blindspots and attack vectors they must immediately get a handle on.

Healthcare organizations are strongly encouraged to review and implement the following security best practices:

• Updated Information Security Policies – Ensure the tone is set at the top and Information Security Policies are reviewed and updated to encompass the appropriate scope
• Asset Inventory – At the most foundational level, a complete and holistic asset inventory is the basis for your security program. This needs to include enterprise assets, but also IoT, medical/IoMT, BMS/OT, cloud, remote, and virtual assets. Keep in mind, the inventory should be at a hardware, software, and system level inventory. Overlaying the business context and its role in the care journey can help with prioritization efforts down the road.
• Endpoint Security – Ensure Endpoint Detection and Response (EDR) agents are configured and deployed across your entire device fleet. Disabled, misconfigured, or out-of-date agents as well as coverage gaps can be easily exploited. Ensure all images are deployed pre-installed with endpoint protection, patches and hardening measures.
• Vulnerability and Patch Management – Vulnerability assessments require a combination of active discovery, passive analysis for sensitive equipment, prioritization mechanisms, threat intelligence, and process management to ensure optimal risk reduction and efficient remediation. Ensure your vulnerability management scope encompasses every asset in the environment. Prioritization should also include business context so ensure the most critical patient care impacting vulnerabilities are addressed first. Keep in mind code repositories and ephemeral assets should also be monitored, requiring a dynamic approach.
• Third-Party Risk Management – Ensure a dedicated effort to catalog vendor managed assets, footprints, and connections into your environment. Areas to be specifically reviewed include vendor credentials, site-to-site tunnels, and the presence of remote access software (both sanctioned and unsanctioned). Vendors may have security hardening documents and procedures available to assist this effort.
• Network and Threat Monitoring – Ensure all traffic in your environment is traversing a network monitoring and IDS/IPS platform. Many attackers are able to live off the land and proliferate through the network due to blindspots in traffic movement and patterns. While North-South traffic is usually well protected, East-West traffic often goes unmonitored. Monitoring policies should not only be for known threats, but include zero-day exploits and anomalous behaviors – spikes in data access and exfiltration, lateral movement between unrelated zones, authentication behaviors never before seen, etc. Threat intelligence partnerships are important to ensure continuous updates and detection of Indicators of Compromise (IOCs).
• Network Segmentation – While a complex project, this is one of the strongest controls an organization can have. A network segmentation project is a journey comprising multiple phases including those mentioned above – asset inventory, communication mapping, policy creation, and enforcement automation. It is imperative to include this in the security strategy to achieve proactive risk reduction and help prevent ransomware. Starting off at a macro-segmentation first, and then further micro-segmentation will at the very least contain cyber attacks from bringing down entire hospital networks.
• IAM Security – Including complex passwords, expiring passwords, privileged access management around admin accounts, service accounts and vendor accounts. Review the transmission of unencrypted credentials and the use of default credentials on IoT devices including their cloud platforms. Enforce Role-Based Access Control (RBAC) and restrict access where possible.
• Enable MFA Across the Organization – Include all mail systems, external facing systems, internal critical applications and where possible enforcing it as a standard security control requirement across the entire environment. Regular review and validation of both applications and users is recommended to ensure there are no gaps in MFA.
• Email Security – As phishing remains one of the top vectors, it is important to review email security controls and apply additional measures as they become available. Often organizations do not enable new capabilities and refine email security controls in a continuous manner.
• Automated Security Enforcements – One of the key areas healthcare organizations struggle with and the need to double down is automated enforcements. Through leveraging connected platform approaches and integrations, automation can greatly help reduce the time-to-response for security teams helping contain and prevent malware attacks. Automation between Network Access Control (NAC) solutions, firewalls, endpoint security, and other security platforms is how security teams will be able to augment and alleviate resource constraints.
• Continuous Risk and Gap Assessments – Dynamic and real-time risk assessments are key to a continuous security improvement model. By staying on top of your changing environment, teams can quickly address weaknesses and zero-day exploits. Also, be your own bad guy. Conduct penetration tests for much deeper visibility into threat paths than a standard vulnerability scan. Investing in regular penetration testing is much cheaper than dealing with the cost of a breach. Quarterly mapping of your organization’s controls back to your security framework results in systematic program maturity.
• Regular Executive Reporting – Regular reporting to executives and the board are important to support the cybersecurity initiatives. The key here is security posture reporting should be broken down into multiple categories and corresponding scores for better transparency and focus. For example, endpoint security, IoT security, medical device security, cloud security, IAM security, etc. all feed into the overall security posture of the organization.
• Collaboration Is Key – Security teams must work in collaboration with all other teams in the organization for a successful cybersecurity program. Going beyond phishing training, this includes working directly with clinical engineers to secure medical devices, facilities management for BMS and HVAC security, physical security for IoT cameras and various security elements. While the security of these assets fall under the purview of the security team, the management and hardening of them will rely on the device owners. Collaboration does not have to be extremely complex either – weekly calls, or creation of steering committees is a great way to start.
• Incident Response Processes & Simulations – WIth healthcare attacks compromising the largest and most complex organizations, HDOs should prepare for the worst, ensuring backups, testing of backups, conducting simulations and tabletop exercises to ensure organizational preparedness and continuity in the face of an attack.

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