Clinical laboratories and anatomic pathology groups should consider these cyberattacks on major healthcare entities as reminders that they should tighten their cybersecurity protections
Hackers continue to gain access to public health records—including clinical laboratory testing data—putting thousands of patients’ protected health information (PHI) at risk of being exposed. The latest important healthcare entity to become the victim of a ransomware attack is American Associated Pharmacies (AAP). According to The Register, AAP announced a ransomware operation called Embargo had stolen over 1.4 terabytes (TB) of data, encrypted those files, and demanded $1.3 million to decrypt the data.
Embargo claims that Scottsboro, Ala.-based AAP paid $1.3 million to have its systems restored. They are now demanding an additional $1.3 million to keep the stolen data private, the HIPAA Journal reported, adding, “The attack follows ransomware attacks on Memorial Hospital and Manor, an 80-bed community hospital and 107 long-term care facility in Georgia, and Weiser Memorial Hospital, a critical access hospital in Idaho.”
AAP has not publicly confirmed the ransomware attack, nor has it made an official statement regarding the breach. But it did post an “Important Notice” on its website reporting, “limited ordering capabilities for API Warehouse have been restored at APIRx.com.”
API Warehouse is a subsidiary of AAP that helps subscribers save on brand name and generic prescriptions via wholesale purchasing plans. It oversees more than 2,000 independent pharmacies across the US and has over 2,500 stock keeping units (SKUs) in its inventory.
The message further states “All user passwords associated with both APIRx.com and RxAAP.com have been reset, so existing credentials will no longer be valid to access the sites. Please click ‘forgot password’ on the log in screen and follow the prompts accordingly to reset your password.”
“Embargo seems to have international and multi-sector victims and is not focusing on a specific victim profile. They seem opportunistic,” Mike Hamilton (above), founder and chief information security officer (CISO) of cybersecurity firm Critical Insight, told HealthcareInfoSecurity. “However, as they do have multiple victims in healthcare, and their tooling to disable detection is sophisticated, they should not be discounted. If indeed they operate through affiliates, we can expect others to use their infrastructure and tools, and Embargo may emerge as a top threat to healthcare.” Since 80% of all medical records are made up of clinical laboratory testing data, laboratory patients are particularly vulnerable. (Photo copyright: Critical Insight.)
Embargo on the Hunt for PHI
Due to the large amount of data Embargo stole from the AAP servers, it’s likely the hackers were able to procure medical records and account details from all customers of the pharmacies involved in the attack.
Researchers at ESET, an internet security company, first noticed the ransomware organization known as Embargo in June of this year. In a news release, ESET stated that Embargo used an endpoint detection and response (EDR) killer toolkit to steal AAP’s data.
“Based on its modus operandi, Embargo seems to be a well-resourced group. It sets up its own infrastructure to communicate with victims. Moreover, the group pressures victims into paying by using double extortion: the operators exfiltrate victims’ sensitive data and threaten to publish it on a leak site, in addition to encrypting it,” ESET wrote in a news release.
Embargo recently attacked other organizations within the healthcare industry as well. In November, it claimed responsibility for breaching the security of Memorial Hospital and Manor in Bainbridge, Ga. The cyberattack affected Memorial’s email and electronic medical record (EHR) systems, which caused the facility to pivot to a paper-based system, The Cyber Express reported.
Embargo’s attack on Weiser Memorial Hospital in Weiser, Idaho, involved the theft of approximately 200 gigabytes (GB) of sensitive data and caused a four-week-long outage of its computer systems.
Other Cyberattacks on Healthcare Organizations
Dark Daily has covered many cyberattacks on hospital health systems in multiple ebriefs over the past few years.
Safeguarding patient data is critical, and more healthcare organizations are discovering the hard way that they are vulnerable to hackers. This situation serves as another reminder to clinical laboratory and pathology group managers that they need to be proactive and serious about protecting their information systems, and in upgrading their digital security at regular intervals.
Hackers are working hard to obtain access to protected health information, which puts patients at continuous risk of having their private records stolen.
Inability to access clinical laboratory test results forced hospitals to suspend critical procedures and surgeries causing major disruptions to healthcare
Cyberattacks continue to shut down the ability of hospitals to process orders for clinical laboratory tests, medical imaging, and prescriptions. One such cyberattack recently took place against Ascension, the largest nonprofit Catholic health system in the United States. It took more than a month for the health network’s electronic health record (EHR) system to be fully restored, according to a cybersecurity event press release.
Immediately following the event, Ascension announced it had hired a third party company to resolve the fallout from the cyberattack.
“On Wednesday, May 8, we detected unusual activity on select technology network systems, which we now believe is due to a cybersecurity event. … Access to some systems have been interrupted … We have engaged Mandiant, a third party expert, to assist in the investigation and remediation process, and we have notified the appropriate authorities,” a press release states.
Based in Reston, Va., Mandiant is an American cybersecurity firm and a subsidiary of Google.
Cyberattacks are happening more frequently and medical professionals need to be aware that patient care can be severely disrupted by such attacks. The Ascension attack locked its employees out of the healthcare provider’s computer databases, rendering medical personnel unable to track and coordinate patient care. The health network’s EHR, phones, and databases used to order certain clinical laboratory tests, imaging services, procedures, and medications were all affected.
Hospital employees, including two doctors and a registered nurse, spoke anonymously to the Detroit Free Press regarding the issues at their facilities resulting from the cyberattack.
“It’s so, so dangerous,” said the nurse, describing the immediate aftermath of the cyberattack. “We are waiting four hours for head CT [computed tomography scan] results on somebody having a stroke or a brain bleed. We are just waiting. I don’t know why they haven’t at least paused the ambulances and accepting transfers because we physically … don’t have the capacity to care for them right now.”
“In some cases, what are supposed to be unique medical record numbers assigned to patients when they register in the emergency department at Ascension St. John [Detroit, Mich.] have been given to more than one patient at a time,” Detroit Free Press reported. “Because of that, the nurse told the Free Press she couldn’t be confident that a patient’s blood test results actually were his own.”
“We’ve started to think about these as public health issues and disasters on the scale of earthquakes or hurricanes,” Jeff Tully, MD (above), Associate Clinical Professor, Anesthesiology, and co-director of the Center for Healthcare Cybersecurity at the University of California-San Diego, told NPR. “These types of cybersecurity incidents should be thought of as a matter of when and not if,” he added. Inability to verify clinical laboratory test results or access patients’ electronic medical records endangers patients and undermines the confidence of critical healthcare workers. (Photo copyright: UC San Diego.)
Losing Track of Patients and Their Records
According to the HIPAA Journal’sH1, 2024 Healthcare Data Breach Report, “In H1 [first half of the fiscal year], 2024, 387 data breaches of 500 or more [healthcare] records were reported to OCR, which represents an 8.4% increase from H1, 2023, and a 9.3% increase from H1, 2022.”
After the Ascension cyberattack, the healthcare organization’s computer systems were inoperable, and its pharmacy services were temporarily closed. Medical orders for clinical laboratory testing, imaging tests, and prescriptions had to be handwritten on paper and faxed to appropriate departments, which led to long wait times for patients.
There were cases where singular medical record numbers were assigned to multiple patients. Staff resorted to Google documents, paper charting, and text messaging to communicate with one another. But they still lost track of some patients.
“For a lot of our nurses, they’ve never paper charted at all,” said Connie Smith, a charge capture coordinator and head of the Wisconsin Federation of Nurses and Health Professionals, in a ThinkStack blog post. “We were using forms that we pulled out of drawers that hadn’t seen the light of day in a long, long time.”
“They are texting me to find out where the patient went,” a St. John Hospital Emergency Room physician anonymously told the Free Press immediately following the Ascension cyberattack. “They don’t even know where the patient is going or if they’ve been admitted. People are getting lost.
“The pharmacy is getting requests for patient medications, and they have no idea where the patient is in the hospital,” the doctor continued. “Some of the attending physicians are putting in orders for medications, somewhat dangerous medications, and we have no idea if the medications are actually being administered. It’s a scary thing when your medical license is tied to this. If medication mistakes become lawsuits, they will follow us throughout our entire careers and that is not fair to us. It’s not fair to patients.”
According to online updates provided by Ascension, the cyberattack began when an employee downloaded a malicious file thinking it was a legitimate document. That allowed hackers to access seven of Ascension’s 25,000 servers. The resulting cyberattack stifled operations across the organization’s facilities and among its healthcare providers for weeks.
A June 12 update read, “we are pleased to announce that electronic health record (EHR) access has been restored across our ministries. This means that clinical workflow in our hospitals and clinics will function similarly to the way it did prior to the ransomware attack.” The updates did not mention how the attack was resolved or if a ransom was paid to restore the hospitals’ systems.
Preparing for System Disruptions
According to its website, St. Louis-based Ascension has 134,000 associates, 35,000 affiliated providers, and 140 hospitals serving communities in 18 states and the District of Columbia.
“Despite the challenges posed by the recent ransomware incident, patient safety continues to be our utmost priority. Our dedicated doctors, nurses, and care teams are demonstrating incredible thoughtfulness and resilience as we utilize manual and paper based systems during the ongoing disruption to normal systems,” Ascension noted in a Michigan Cybersecurity Event Update.
Clinical laboratory managers and anatomic pathology practice administrators may want to learn from Ascension’s experience and make advanced preparations that will secure patient information and enable their lab to continue functioning during a cyberattack. The Ascension cyberattack illustrates how easily computer systems containing critical information can be hacked and affect patient care.
Recent attacks illustrate how costly a security breach can be and why clinical laboratories and pathology groups must work to protect their information systems from ransomware attacks
Therefore, it is crucial clinical laboratories and pathology groups have a cybersecurity strategy in place for dealing with ransomware attacks. Running security drills may need to be part of that strategy. Managers and employees should undergo specific training and vendors must be vetted carefully. Without such a strategy, the question is not if an attack will happen, but rather when an attack will succeed.
Ransomware Attackers are Getting Better
“Ransomware is increasing in sophistication; it’s increasing in prevalence. The purveyors of ransomware are generally reinvesting the fees that they collect from the entities they extort to acquire more capabilities,” Beau Woods, Senior Advisor at the federal Cybersecurity and Infrastructure Security Agency (CISA), told The San Diego Tribune.
“They’re getting better, they’re getting more frequent, particularly during the pandemic where we’ve opened up more connectivity to allow more remote work,” he added.
The Scripps Health attack is notable for several reasons, with one being the length of the outage it caused. The attack was first detected on May 1 of this year. It took four weeks before Scripps could restore most of its network and get its Epic EHR back online, Health IT Security reported.
However, the ransomware attack on Universal Health Services (NYSE:UHS) may be the biggest attack so far. It took place on September 27, 2020, and caused a three-week outage. The company told The San Diego Tribune the incident had a $67 million impact on operations.
According to HIPAA Journal, “The phone system was taken out of action, and without access to computers and electronic health records, employees had to resort to pen and paper to record patient information. In the early hours after the attack occurred, the health system diverted ambulances to alternative facilities and some elective procedures were either postponed or diverted to competitors. Patients reported delays receiving test results while UHS recovered from the attack.”
At Utah Pathology Services, an employee e-mail hack resulted in the potential exposure of patient data. The malicious actors attempted to divert funds intended for a physician but failed to do so. However, the information of 112,000 patients was accessible to the hacker during the attempt.
“The compromised data varied by patient but could include names, contact information, insurance details such as ID and group numbers, medical and health information like internal records numbers and clinical and diagnostic information, and some Social Security numbers,” Health IT Security reported.
“We are seeing adversaries that are targeting our pharmaceutical companies, pharmaceutical research, laboratory companies, testing and really even out into the future manufacturing of the vaccine systems,” Bryan S. Ware (above left) Assistant Director for Cybersecurity for the Department of Homeland Security’s (DHS) Cybersecurity and Infrastructure Security Agency (CISA) told CyberScoop. CISA Director Christopher Krebs (above right) added, “At the onset of the COVID-19 pandemic, we recognized just how vital the healthcare sector was to the response and we established Project Taken to bring to bear the government’s particular set of skills to protect those organizations.” (Photo copyrights: CyberScoop/Business Insider.)
Value of Patient Data on the Dark Web is Increasing
In the case of the Utah Pathology Services attack, the hackers were specifically after money. However, according to cybersecurity company SecureLink, patient records are “the new prize” for hackers. Healthcare data carries a value of its own on the digital black market. In fact, healthcare data is more valuable than credit card or banking data.
“Healthcare data is valuable on the black market because it often contains all of an individual’s personally identifiable information, as opposed to a single marker that may be found in a financial breach,” SecureLink wrote in a blog post.
A 2018 Trustwave Global Security Report estimated that a healthcare record is worth about $250. Trustwave, however, estimated the value of a banking record at less than $5. That strongly suggests health records are increasing in value.
And even after a healthcare entity has regained control of its IT infrastructure, the hacker still has possession of the stolen patient information. It may take weeks or years for the hacker to sell that information, meaning the breach represents a continuing threat to the healthcare organization and its patients.
Clinical Laboratories Must Prepare for an Attack
Simply understanding the threat is not enough. Clinical laboratory and pathology group managers must have robust plans in place for both protecting patient information and for dealing with a security breach should one occur.
According to a Health IT Security report, “The ransomware attack that struck all 400 UHS care sites and caused three weeks of EHR downtime in September, cost the health system $67 million in recovery costs and lost revenue.”
The report added, “Security researchers have long-recommended the need for providers to shift into a proactive security model, like zero trust. Recent reports show successful cyberattacks on healthcare providers doubled in the last year, with at least 560 providers falling victim to ransomware.”
To deal with the ransomware attacks, we wrote, “CISA, FBI, and HHS advise against paying ransoms. ‘Payment does not guarantee files will be recovered,’ the advisory states. ‘It may also embolden adversaries to target additional organizations, encourage other criminal actors to engage in the distribution of ransomware, and/or fund illicit activities.’ The federal agencies advise organizations to take preventive measures and adopt plans for coping with attacks.
“The advisory suggests:
Training programs for employees, including raising awareness about ransomware and phishing scams. Organizations should ‘ensure that employees know who to contact when they see suspicious activity or when they believe they have been a victim of a cyberattack.’
Regular backups of data and software. These should be ‘maintained offline or in separated networks as many ransomware variants attempt to find and delete any accessible backups.’ Personnel should also test the backups.
Continuity plans in case information systems are not accessible. For example, organizations should maintain ‘hard copies of digital information that would be required for critical patient healthcare.’”
Given the enormous amounts of money hackers can earn from selling protected health information on the Dark Web, it is a near certainty these attacks will continue. Clinical laboratory and anatomic pathology group managers would be well advised to plan for the inevitability that their health system will be targeted.
