Did you receive an email this morning informing you that your personal information was exposed in a data breach called Collection #1? You’re not alone, and it’s a reminder to take precautions like enabling two-factor authentication and signing up for a password manager. And it might also be time to reset your password.
Security researcher Troy Hunt, who runs breach notification site Have I Been Pwned (HIBP), first reported the Collection #1 exposure. The massive trove of leaked data, which was posted to a hacking forum, includes some 772,904,991 unique email addresses and 21,222,975 unique passwords, Hunt said.
“Collection #1 is a set of email addresses and passwords totaling 2,692,818,238 rows,” Hunt explained in a Thursday blog post. “It’s made up of many different individual data breaches from literally thousands of different sources.”
Hunt said he first caught wind of the breach last week when several people pointed him to a suspicious collection of files on the cloud service Mega. The 87GB collection, which contained more than 12,000 files, has since been removed from Mega, but found its way to a “popular hacking forum,” he wrote.
“My own personal data is in there and it’s accurate; right email address and a password I used many years ago,” Hunt wrote. “If you’re in this breach, one or more passwords you’ve previously used are floating around for others to see.”
That tool won’t tell you which, if any, of your passwords leaked, but Hunt does offer a feature that lets you manually check your current passwords against a list of known breached ones. On the HIBP site, click “Passwords” at the top, then enter the password you’re concerned about it (HIBP won’t see your actual password, according to Hunt).
Security experts have discovered what very well could be one of the largest data breach of all time, a collection of 772,904,991 unique emails and 21,222,975 unique passwords.
Called “Collection #1,” the breach was initially reported by Troy Hunt and seemingly comes from many different sources, not a single corporate entity. And it’s an especially dangerous one as he says it creates 1.16 billion “unique combinations of email addresses and passwords”.
People can check to see if their accounts and passwords were compromised at Hunt’s “Have I Been pwned?” Website.
The sheer volume of the data was contained in 12,000 separate files clocking in at 87 GB of data on hacking forums. What’s especially troubling to security experts is the files contain “dehashed” passwords, meaning hackers were able to circumvent methods used to scramble those passwords into unreadable strings and expose them.
After that, you’re on your own; you won’t get updates or security fixes.
If you still use Windows 7, it may be time to consider an upgrade.
Starting January 14, 2020, exactly one year from Monday, Microsoft will no longer support Windows 7. That means no more updates or security fixes for the operating system.
“Changes and upgrades in technology are inevitable,” said Brad Anderson, corporate vice president for Microsoft 365, in a blog. “And there’s never been a better time to start putting in motion the things you need to do to shift your organization to a modern desktop with Microsoft 365.”
Microsoft will continue to provide security updates for Windows 7 to business customers that pay for support, according to ZDNet, but not individual users.
Windows 7 was released in 2009 and is still one of the most widely used desktop operating systems. Windows 10 finally overtook Windows 7 in the desktop market at the end of last year, according to ZDNet. NetMarketShare’s December 2018 report showed that 39.2 percent of the machines they collect data from used Windows 10, while 36.9 percent used Windows 7, according to ZDNet.
In 2012, the software giant decided to extend five more years of support for all editions of Windows 7 for individual users.
A Risk Management Plan is the part of your compliance approach that plans, identifies, and analyzes risks.
Parts of a Risk Management Plan
Risk Response Plans
Risk is defined by the Project Management Institute as an uncertain event or condition that, if it occurs, has a positive or negative effect on one or more project objectives. Risk management is the process of identifying, analyzing, mitigating, and communicating risks.
All systems have vulnerabilities. The US Department of Health and Human Services defines a vulnerability as:
[a] flaw or weakness in system security procedures, design, implementation, or internal controls that could be exercised (accidentally triggered or intentionally exploited) and result in a security breach or a violation of the system’s security policy.
The US Department of Health and Human Services defines a risk as:
The net mission impact considering the probability that a particular [threat] will exercise (accidentally trigger or intentionally exploit) a particular vulnerability and the resulting impact if this should occur.
Risks arise from legal liability or mission loss due to:
Unauthorized (malicious or accidental) disclosure, modification, or destruction of information; Unintentional errors and omissions; IT disruptions due to natural or man-made disasters; Failure to exercise due care and diligence in the implementation and operation of the IT system.
When a risk event occurs, it is no longer uncertain. It becomes an issue.
Risk is a function of the likelihood of a given threat exercising a particular potential vulnerability, and the resulting impact of that adverse event on the organization, mitigated by controls. The relationship among these five concepts forms the basis of our risk assessment approach, which can be thought of as a formula:
The risk level is calculated using three underlying components:
Likelihood: The probability of the event happening. How likely is it that a threat acts on the vulnerability?
Impact: The consequences of the risk event. What happens if the threat acts on the vulnerability?
Effectiveness of Existing Controls: Existing controls and their effectiveness at mitigating risk. What is being actively done to mitigate the effects of a risk?
Likelihood × Impact − Controls ⇒ Risk Level
To illustrate, a plane crashing into your office has a high impact, but a low probability. In fact the probability is so low that the overall risk is probably insignificant. On the opposite end of the scale, a road construction project getting delayed due to rain is an event with a low impact but a high probability of occurrence. Thus, it is a significant risk.
What projects have been completed in the past and what unexpected issues occurred?
What was the response of the organization?
What permanent changes were made? Were they justified?
Did the response cause a corresponding loss of business?
Did the response cause a corresponding loss of future projects?
Another part of the risk planning portion of the Risk Management Plan is the definition of risk levels. Here is an example:
Very Low: The event is highly unlikely to occur under regular circumstances.
Low: The event is unlikely but should be noted by the project team.
Medium: The event has a normal chance of occurring and the project team should be aware of it.
High: The event has a reasonable chance of occurring. It should be regularly discussed and mitigation actions taken.
Very High: The occurrence of the event should be actively managed and mitigation actions taken.
Aligned Risk Management breaks down risk levels into four categories: Negligible, Marginal, Serious, and Critical.
Theoretical risk. Unlikely to be a serious concern.
Vulnerability is very unlikely to be exercised, OR
Existing controls are highly effective at mitigating the risk, OR
Potential impact on security, privacy and availability of ePHI is low
Unlikely to be an immediate concern, especially in light of other, more severe risks.
Some likelihood that vulnerability could be exercised
Existing controls provide some effective mitigation of risk
Potential for significant impact on operations. Effective Risk Management or reasonable plan for such recommended in near future.
Vulnerability is likely to be exercised
Existing controls provide inadequate mitigation of risk
Potential for significant impact on security, privacy or availability of ePHI
Failure to implement controls required by HIPAA. Potential liability and exposure to penalties. Potential for malicious exploitation. Exercise of vulnerability could cause mission-critical damage to business operations. Prompt intervention strongly recommended.
Vulnerability is very likely to be exercised or is currently being exercised
Existing controls provide little effective mitigation of risk
Potential for high or even catastrophic impact on security, privacy or availability of ePHI
A good brainstorming tool is to consider the assumptions made by the project. Most projects have disclaimers in their underlying contracts absolving the performing party of various obvious risks, but what about the next most obvious ones?
What assumptions has the project budget made?
What assumptions has the project schedule made (completion date, milestones, etc.)?
What expertise or prior experience does the company have in this work? How long ago was this experience? What areas require additional training?
Which relationships are being assumed to be strong that are not necessarily (owner, sponsor, client, contractor, consultant)?
How many previous projects with similar components have been completed successfully? What were the project issues?
Stay tuned for Part 2 of Aligned Risk Management’s series, Critical Parts of a Quality Risk Management Plan.
Aligned Risk Management helps healthcare organizations streamline and simplify HIPAA compliance efforts so that you can get back to providing the critical services your patients need. Our expert consulting staff works with you to ensure the privacy, security, and integrity of your systems. This specialized knowledge makes us the leading consulting firm for HIPAA compliance and healthcare risk management.
We’ll play defense so you don’t have to…
Defense of protected health information and the security of your systems is important to the safety of your patients. But it is also critical to the success of your practice. Data privacy concerns make headlines every day, and healthcare companies are especially vulnerable to the effects of unaddressed risk. Patient concern is growing. Regulations are poised to become more demanding. You want to concentrate on better serving your patients, and we make that possible.
…but our process doesn’t stop with just a risk assessment.
It doesn’t stop there. Risk management is a process, so our program includes regular follow-ups to make sure that you are successful. We assist in implementing recommendations and in documenting your efforts to ensure your success in case of an audit. Together, we’ll find high-value solutions that really matter, instead of wasting resources on unnecessary tools or time-consuming procedures that do not fit the way your organization operates.
Compliance with HIPAA can feel overwhelming. The most frequent question we hear is “Where do I start?” Start right here with Aligned Risk Management, and put yourself ahead of the curve.
HIPAA fines are up. Audits by the Department of Health and Human Services are up. 2019 is shaping up to be a rather tumultuous and dangerous year for healthcare providers as they ramp up to address their HIPAA privacy obligations.
And here are four steps to start out ahead this year….
1. Do SOMETHING.
There are so many different ways to start tackling another aspect of HIPAA. Are you wanting to make some headway in implementing technical safeguards? Great! Two-factor authentication. What about administrative safeguards? Awesome. Update your workforce sanctions policy and make sure it’s realistic. What about physical safeguards? Get those contingency operations plans updated. Whatever you decide to do, you’ll have to start somewhere.
“When eating an elephant take one bite at a time.”
Creighton Williams Abrams Jr.
I never said that eating the HIPAA elephant was going to be easy. But since you have to, you might as well start with one bite at a time. Approach HIPAA like you would an elephant and you’ll be surprised at just how much you can accomplish in a short period of time.
2. Business Associate Agreements
I’ve seen a lot of embarrassingly insufficient business associate agreements (BAA). As a recap, a “business associate” is likely a vendor to a healthcare provider, other than a member of the workforce of a covered entity, who provides certain services to a covered entity. Remember, this service directly involves access by the business associate to protected health information (PHI).
Among other confusing relationships that can exist between entities, a covered entity can be a business associate to another covered entity.
As part of your approach to HIPAA in 2019, perhaps it’s time to evaluate the relationship between yourself and your vendors, or between yourself and your clients. Are you a covered entity? Are you a business associate? Do you have business associates?
Once you’ve done some review of those relationships and you’ve identified all your vendors and business associates, it’s time to review those business associate agreements.
Cookie cutter policies aren’t going to cut it. In this industry, so highly regulated by HHS, it’s highly unlikely that you’ll get away with taking any shortcuts. Let’s tackle your policies and procedures and how they relate to the realistic operations of your organization.
Are they accurate? I mean, do your policies accurately reflect how your workforce carries out their day-to-day operations? If you’re documenting in your policies that your workforce implements rigorous access revocation procedures upon employee termination, but this isn’t being practiced regularly by your IT staff, that’s not good. You’re saying that you’re doing this, but if that can’t be proven and is likely to be disproved by the dozens of former employee accounts that haven’t been deactivated, HHS will certainly have a field day. At your expense.
Don’t let that happen. Get on top of your policies and procedures. Make sure they’re honest and truthful. Maybe it’s time to actually change some operations and procedures to better protect patient privacy. Maybe you’ll learn something about your own organization. It’s another bite you can take out of the HIPAA elephant. It’s getting smaller!
4. Risk Assessment
Calling in the experts can be totally nerve-racking. You’re inviting others into the sensitive operations of your organization, exposing your internal practices to a stranger. We’re not the bad guys. We’re here to help you.
Updating your risk assessment can give you invaluable insight into modern best-practices that you weren’t aware of. It can make you aware of problematic business operations that really ought to be corrected and streamlined.
And best of all, you’ll get a great plan for continuous improvement: a plan consisting of the best actionable steps you can take to make the most impact in mitigating risk at your organization.
The final version of the NIST Risk Management Framework 2.0 is now available, providing government agencies and commercial enterprises alike with new guidance that aligns risk, privacy and cyber-security controls.
The National Institute of Standards and Technology is out with the final version of its Risk Management Framework (RMF) 2.0 update, providing organizations with new detailed insight into how to define and manage risk.
RMF 2.0 was officially released on Dec. 20 and follows seven months of consultation and comments. RMF 2.0 is formally titled NIST Special Publication (SP) 800-37 Revision 2 and outlines how federal agencies and those that wish to align with the standard can address security and privacy risk management. Among the key additions in the RMF 2.0 updates is an alignment and integration with the NIST Cybersecurity Framework, which outlines controls and processes that should be used by U.S. government agencies.
“RMF 2.0 gives federal agencies a very powerful tool to manage both security and privacy risks from a single, unified framework,” NIST’s Ron Ross, one of the publication’s authors, wrote in a media advisory. “It ensures the term compliance means real cybersecurity and privacy risk management—not just satisfying a static set of controls in a checklist.”
RMF 2.0 itself is a lengthy report of 183 pages that is freely available. The report noted that organizations implementing the RMF will be able to maximize the use of automated tools to manage security categorization as well as control selection, assessment and monitoring.
“The RMF provides a dynamic and flexible approach to effectively manage security and privacy risks in diverse environments with complex and sophisticated threats, evolving missions and business functions, and changing system and organizational vulnerabilities,” the RMF states. “The framework is policy and technology neutral, which facilitates ongoing upgrades to IT resources and to IT modernization efforts—to support and help ensure essential missions and services are provided during such transition periods.”
The RMF 2.0 includes a long list of tasks that includes an outline of risk management roles within an organization as well as strategy. Identifying common controls as well as having a continuous monitoring strategy is another key component that is part of RMF. Risk itself is at the core of RMF 2.0, with the requirement that organizations execute a risk assessment that includes all assets that need to be protected.
“As a key part of the risk assessment, assets are prioritized based on the adverse impact or consequence of asset loss,” RMF 2.0 states. “The meaning of loss is defined for each asset type to enable a determination of the loss consequence (i.e., the adverse impact of the loss).”
NIST’s guidelines for cyber-security have become foundational elements in the product portfolios of multiple vendors that align their offerings to help enable organizations with governance, risk and compliance (GRC) needs. Multiple industry experts contacted by eWEEK were enthusiastic about the improvements made in the RMF and how it will help improve cyber-security overall.
“We view the NIST Risk Management Framework (RMF) as further refinement of NIST’s message around the practice of risk management and a bridge in the continuation of their guidance encompassing security of the organization, individual privacy, and organization-wide risk management,” Steve Schlarman, risk management strategist at RSA, told eWEEK. “We have long been committed to the belief that in order to effectively and efficiently manage information security, you have to take a risk-based approach.”
McAfee’s chief policy officer and head of government affairs, Tom Gann, is also supportive of RMF 2.0. He noted that the NIST Cybersecurity Framework presents a rational, step-by-step approach to identifying and managing an organization’s cyber-security risk.
Abdul Rahman, chief data scientist at Fidelis Cybersecurity, commented that from his perspective looking at the RMF 2.0 update, the focus is on enhancing the protection of individuals’ sensitive data.
“Organizations need to go beyond threat prevention—we’ve already seen that preventive tools alone don’t suffice against motivated and sophisticated attackers,” Rahman told eWEEK.
Istvan Molnar, product marketing manager and compliance specialist at One Identity, also sees as noteworthy the emphasis on privacy in RMF 2.0. Molnar said the RMF 2.0 document specifically calls out the need for organizations to “consider how to best promote and institutionalize collaboration between the two Privacy and Information Security programs to ensure that the objectives of both disciplines are met at every step of the process.”
“It’s also noteworthy that the report not only refers to access but also ‘system activity or behavior’ going a step further than simply focusing on controlling access to data,” Molnar told eWEEK. “Additionally, the framework promotes the notion of designing risk management into the security and privacy capabilities of information systems throughout the system development life cycle.”
For Meerah Rajavel, CIO at Forcepoint, there are three key takeaways from RMF 2.0. The first is that digital and cyber-security are becoming center seat in the boardroom.
“The RMF Revision 2.0 focusing on linkage and communication to the C-suite governance, and providing guidance on the synergy between Cybersecurity & Risk Management framework, can help elevate the CISO and CIO to be more powerful at the boardroom table,” Rajavel told eWEEK.
She added that the second aspect of interest is the focus on the IT/OT and supply chain, which are crucial to protect critical infrastructure that affects civilians and the economy.
“The third element, which is inspiring in lieu of many recent events, is linking privacy to risk, which helps other compliance and regulations like GDPR, CA Privacy Act, etc.,” she said.
Are medical device or pharmaceutical companies designated as a qualifying entity subject to HIPAA and HITECH?
Classifying the entity
Are medical device or pharmaceutical companies designated as a qualifying entity subject to HIPAA and the HITECH Act? Yes. In general, a provider that “transmits any health information in electronic form in connection with a transaction covered by this subchapter” is considered a covered entity. Moreover, according to the 45 CFR §160.103(2)(ii)(3), “a covered entity may be a business associate of another covered entity.” In fact, CMS recognized that as a government agency, it is subject to HIPAA, the HITECH Act and related rules in an October 2012 report issued by the Office of the Inspector General, “CMS Response to Breaches and Medical Identity Theft.”
In turn, a business associate, as defined by the HIPAA Rules, is “a person who performs functions or activitieson behalf of, or certain services for, a covered entity that involve the use or disclosure of protected health information” (emphasis added). A subcontractor is a person who contracts with a business associate and stores, handles or transmits PHI. Regardless, under Section 164.308(b) of the Security Rule and 164.502(e) of the Privacy Rule, a covered entity or business associate is required to enter into an arrangement known as a business associate agreement to provide parameters and some legal protection when a contracted entity is handling PHI.
Effective Feb. 18, 2010, Section 13408 of the HITECH Act provides that health information organizations, e-prescribing gateways, vendors of personal health records and other persons that facilitate data transmission and require access to PHI, regardless of their status as a covered entity, business associate or subcontractor, are subject to business associate agreements in accordance with the HIPAA Rules.
Therefore, medical device and pharmaceutical companies can be classified as a qualifying entity subject to HIPAA and the HITECH Act. As such, they are subject to handling, storing and transmitting in accordance with the requisite laws and regulations. The consequences from civil and criminal monetary penalties alone are significant. Since the HITECH Act expressly expanded HIPAA’s requirements to business associates and subcontractors, the same standards for access to medical records, business associate agreements and other provisions equally apply.
Patient access rights
The tension between patients wanting to have access to their health data from a medical device, which is implanted in them, and a medical device company is highlighted. According to a representative of a medical device maker quoted in the article, “Federal rules prohibit giving Ms. Hubbard’s data to anyone but her doctor and hospital. Our customers are physicians and hospitals.” In general, 45 C.F.R. §164.524, Access of Individuals to Protected Health Information, sets forth the parameters of the HIPAA Privacy Rule. Included in these standards are the circumstances for providing protected health information to a patient and exceptions. Nothing in the scenario of the PHI being transmitted from a patient’s implant to a medical device company, who would be classified as a business associate in this instance invokes an exception to deny the patient’s request.
Section 13410(d) of the Health Information Technology for Economic and Clinical Health Act authorizes penalties to be assessed for violations of the Privacy Rule. In February 2011, HHS issued a Final Notice of Determination and held Cignet Health, a business associate, liable for $4.3 million in civil monetary penalties when they denied 41 patients access to their medical records. As OCR Director Georgina Verdugo indicated, “covered entities and business associates must uphold their responsibility to provide patients with access to their medical records, and adhere closely to all of HIPAA’s requirements.” And, “The U.S. Department of Health and Human Services will continue to investigate and take action against those organizations that knowingly disregard their obligations under these rules.” This area should be considered in drafting business associate agreements. Therefore, business associates such as Medtronic are required to release the PHI to the patient requesting the information, unless one of the exceptions is met, and the patient is informed.
Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), issued a Request for Information (RFI) seeking input from the public on how the Health Insurance Portability and Accountability Act (HIPAA) Rules, especially the HIPAA Privacy Rule, could be modified to further the HHS Secretary’s goal of promoting coordinated, value-based healthcare. This RFI is a part of the Regulatory Sprint to Coordinated Care, an initiative led by Deputy Secretary Eric Hargan.
HHS developed the HIPAA Rules to protect individuals’ health information privacy and security interests, while permitting information sharing needed for important purposes. However, in recent years, OCR has heard calls to revisit aspects of the Rules that may limit or discourage information sharing needed for coordinated care or to facilitate the transformation to value-based health care. The RFI requests information on any provisions of the HIPAA Rules that may present obstacles to these goals without meaningfully contributing to the privacy and security of protected health information (PHI) and/or patients’ ability to exercise their rights with respect to their PHI.
“This RFI is another crucial step in our Regulatory Sprint to Coordinated Care, which is taking a close look at how regulations like HIPAA can be fine-tuned to incentivize care coordination and improve patient care, while ensuring that we fulfill HIPAA’s promise to protect privacy and security,” said Deputy Secretary Hargan. “In addressing the opioid crisis, we’ve heard stories about how the Privacy Rule can get in the way of patients and families getting the help they need. We’ve also heard how the Rule may impede other forms of care coordination that can drive value. I look forward to hearing from the public on potential improvements to HIPAA, while maintaining the important safeguards for patients’ health information.”
“We are looking for candid feedback about how the existing HIPAA regulations are working in the real world and how we can improve them,” said OCR Director Roger Severino. “We are committed to pursuing the changes needed to improve quality of care and eliminate undue burdens on covered entities while maintaining robust privacy and security protections for individuals’ health information.”
In addition to requesting broad input on the HIPAA Rules, the RFI also seeks comments on specific areas of the HIPAA Privacy Rule, including:
Encouraging information-sharing for treatment and care coordination
Facilitating parental involvement in care
Addressing the opioid crisis and serious mental illness
Accounting for disclosures of PHI for treatment, payment, and health care operations as required by the HITECH Act
Changing the current requirement for certain providers to make a good faith effort to obtain an acknowledgment of receipt of the Notice of Privacy Practices
A Vancouver surgery center notified more than 2,000 patients of a recent email-based cyberattack and data breach that targeted Social Security, credit card numbers and other personal information.
The Southwest Washington Regional Surgery Center in Vancouver has been hit by a data breach, which may have revealed personal information from 2,393 patients including names, Social Security numbers, driver license numbers, medical information and some credit card numbers.
Not all patients were affected. A notice posted on the center’s website says the office notified the 2,393 affected patients last week, on Nov. 6.
The breach involved a phishing attack that allowed hackers to gain access to one employee’s email, according to the notice. The list of affected patients and compromised data was determined by reviewing the emails on the employee’s account.
The notice says that the email box was compromised between May 27 and [August] 13. After learning of the breach, the center hired external cybersecurity professionals and launched a forensic investigation, which concluded [September] 25.
The center is offering free enrollment in a credit monitoring and identity theft restoration service for impacted patients, and the company also notified patients about ways to protect their information including monitoring their bank statements and placing a security freeze on their credit files.
The website notice says the company has found no evidence the compromised information has been misused.
The company has set up a response hotline for affected patients: 888-891-8399. The center has also updated its passwords and enhanced its email access protocols to prevent further breaches.
A representative at the hotline and an employee at the company’s office said they would forward questions about the breach to center officials. Those officials did not return the calls on Tuesday.
The Southwest Washington Regional Surgery Center is an outpatient surgery center that performs general surgery and also features a variety of specializations including orthopedic, spine, podiatry, pain management and plastic surgery. The center handles almost 8,500 cases per year, according to its website.
News of the center breach comes just a month after a similar breach was publicly reported by Vancouver-based Rebound Orthopedics and Neurosurgery, which operates offices in the same building where the center is located: the Physician’s Pavilion building at PeaceHealth Southwest Medical Center.
Rebound and the center appear to be primarily owned by the same group of physicians, according to the center’s website and business registration records at the Washington State Department of Revenue.
The two breaches also share some characteristics; the Rebound breach was reported to have taken place on May 22 — just a week before the center breach — and also involved a successful phishing attack that gained access through a single employee’s email account.
However, a Rebound official named Todd Carpenter, reached by email on Tuesday, said the two data breaches were unrelated.
Rebound executive director John Bauman told The Columbian in October that the company’s employees are trained to scrutinize suspicious emails, but the phishing email appeared to have been sent by a known representative of the company’s landlord.
According to PeaceHealth spokeswoman Debra Carnes, the Pavilion building is physically connected to the adjacent PeaceHealth hospital and PeaceHealth leases some of the Pavilion’s offices, but the building itself is not owned or operated by PeaceHealth.
The Physicians Pavilion building appears to be owned by Pacific Medical Buildings, a California-based real estate company. The company’s website advertises vacant office suites in the Pavilion. Pacific Medical Buildings did not return calls requesting comment when the Rebound breach was reported in October, and again did not return calls on Tuesday.