Blog

Northern Maine Medical Center. Fort Kent, Maine.

Fort Kent is a town of just over 4,000 residents abutting the Canadian border in rural Aroostook County, Maine. Fort Kent is famous for being the northernmost terminus of U.S. Route One, and infamous for its long, harsh winters. It is also home to Northern Maine Medical Center (NMMC), a 10-bed hospital that has seen services cut in an effort to lower operating costs.

Maine Public Radio recently reported from a public forum held in Fort Kent’s town hall after the hospital announced plans to close its maternity ward. Residents fear NMMC will soon close; and if it does it will be part of a growing trend. The American Hospital Association (AHA) says that 136 rural hospitals have closed since 2010, and according to a recent report by the Center for Healthcare Quality and Payment Reform (CHQPR), there are more than 600 hospitals across the country in danger of closing due to financial pressures. Of those, more than 200 are in immediate danger of shutting down. That means that hospital mergers and acquisitions (M&A) are likely to continue as a trend identified by Chief Healthcare Executive magazine, which reported there were more than 50 hospital M&As in 2022, with more expected this year.

The Good and Bad of Healthcare M&A

When larger hospitals acquire smaller–and especially rural–hospitals, it can have a positive effect on access to quality of care for the communities they serve. The AHA said that nearly 40% of hospitals added services after being acquired, and that operating efficiencies helped to lower costs by an average of 3.3% after an acquisition. But along with the benefits associated with healthcare M&As come security risks. Security Magazine reported that ransomware attacks on healthcare organizations have doubled since 2016, and because rural hospitals struggle with financial and staffing constraints, they are often more easily breached by threat actors.

In her testimony to the Senate Homeland Security & Government Affairs Committee during a hearing on cybersecurity threats to rural healthcare organizations, former North Country Hospital (Vermont) CIO/CISO Kate Pierce said, “[An] alarming trend that escalated in 2022 was cyber attackers shifting focus to small and rural hospitals. While most larger health systems have implemented advanced cybersecurity hygiene to thwart attacks and are employing large cybersecurity teams with sophisticated defenses, small facilities continue to struggle.”

“[An] alarming trend that escalated in 2022 was cyber attackers shifting focus to small and rural hospitals. While most larger health systems have implemented advanced cybersecurity hygiene to thwart attacks and are employing large cybersecurity teams with sophisticated defenses, small facilities continue to struggle.” — Kate Pierce, former CIO/CISO, North Country Hospital

The Lurking Threat of Acquired Risks

The dynamic nature of connected devices operating in a network complicates security and IT management issues. In healthcare, these challenges are magnified because patient safety is affected when operations are compromised. Some findings from our most recent Rise of the Machines, Enterprise of Things Adoption and Risk Report (keep your eyes peeled for our 2023 edition soon), show the dangers present when Internet of Things (IoT), Internet of Medical Things (IoMT), and operational technologies (OT) proliferate in a healthcare environment.:

86% of IoT and IoMT deployments have 10 or more FDA recalls.
15%-19% of connected devices run on obsolete/unsupported operating systems.
10%-15% of devices connected to the network are unknown or unauthorized.

Compromised Medical Devices put Patient Safety at Risk

When a larger hospital makes an acquisition, it takes on the legacy cyber risks that previously beset the smaller one, including the technology assets used to run the facility and support staff in delivering care. In the best cases, hospitals and other healthcare delivery organizations (HDOs) rely on connected medical devices that are likely vulnerable to cyberattack. And once a piece of medical equipment is put in service, it may end up running with obsolete or unsupported software for years, or new vulnerabilities may be revealed that cannot be patched quickly due to patient safety concerns.

Even when a large hospital with “advanced cybersecurity hygiene” takes over the IT and security operations of a smaller hospital, it can take time to assess and mitigate the risks associated with integrating the new organization’s IT estate. And if any of the acquired systems were compromised prior to acquisition, a lurking, undetected threat actor may be able to use the smaller hospital’s IT infrastructure as a kind of Trojan horse from which to move laterally into the new owner’s systems, much like when hotelier Marriott was breached after acquiring Starwood Hotels in 2014.

Mitigate M&A Cybersecurity Risks

With these challenges in mind, a best practice approach to cybersecurity during an M&A event involves three critical steps:

1. Discover every asset in the network

You can’t protect what you can’t see, and so the key to addressing legacy threats and vulnerabilities inherited through the acquisition of other organizations’ technology estates is to be able to discover and classify every asset. That includes all the connected devices in operation: IoMT, IoT, OT, and more. This comprehensive asset inventory may also be useful to determine duplicate systems and reduce redundancies as both organizations in the M&A consolidate their assets.

The Ordr platform performs device discovery and classification quickly, and then monitors communications and tracks changes in real-time. Ordr goes beyond mere visibility to deliver deep, granular, classification of every device, from make, model, serial number, and operating system details. It also provides vital context about where a device is connected and what other systems it is communicating with. Ordr addresses one of the most common M&A challenges of overlapping IP schemas when two organizations are combined. This challenge prevents teams from easily establishing a single view of both environments and can slow risk assessment and integration efforts.

2. Identify your attack surface

The next step is identifying and measuring the attack surface from these assets. This can include devices with vulnerabilities, devices running outdated operating systems, or those with weak passwords. By baselining devices and their communications patterns, you can determine behavior that is outside of norm, that may be an indication of a compromised device.

From a deep, granular foundation of visibility, Ordr gives a complete view of the connected device attack surface and communications in real-time. Ordr identifies which devices are vulnerable or acting in a risky manner, and assigns a risk score based on the device’s known, determinative operational parameters.

3. Implement M&A cybersecurity best practices

Once you know what devices and risks you are inheriting as part of the acquisition, you can begin to implement M&A cybersecurity best practices. The most basic M&A cybersecurity best practices may be segmentation between the two networks, until access and convergence is complete. You will also want to identify or document key risks that need to be mitigated and addressed during or post acquisition.

Ordr dynamically automates the creation and enforcement of security policies. This means that organizations using the Ordr platform can quickly block attacks, quarantine compromised devices, segment vulnerable devices, and accelerate Zero Trust projects to proactively improve security.

Cybersecurity Due Diligence

Identify Risks Before Hospital Acquisition

Because hospitals and HDOs are under constant risk of attack from threat actors who care nothing of the danger their actions present to patients—and, in fact, use that danger to their advantage when carrying out ransomware attacks—there is no grace period when acquiring a smaller organization. It is imperative that the acquiring hospital include cybersecurity when conducting their due diligence. The network must be inventoried, assessed, and protected as quickly as possible, and Ordr helps get that done even before a contract is signed.

Furthermore, we operate on a philosophy of continuous improvement, expanding our integrations, leveraging the most up-to-date threat intelligence, and building our library of millions of device profiles to ensure Ordr is the most comprehensive, single source of connected device truth available. Check out our M&A solution brief for more details on how we help with cybersecurity due diligence.

A little background on why I’ve agreed to do this guest QA blog for Ordr:

In my role as CTO at CDW Healthcare, I talk to former healthcare peers, in an advisory capacity, to help them protect patient safety and resources with the best cybersecurity technology solutions. Prior to joining CDW, I was CIO of Halifax Health where we deployed Ordr for our medical device security needs

I’ve been at CDW for slightly more than two years, after more than two decades in the healthcare trenches, most recently as the former CIO of Halifax Health. I decided on a different role at CDW to bring best practices and cybersecurity technologies to my CIO colleagues who are on the forefront of fighting the cyber war. If the healthcare industry could more effectively collaborate and share security expertise to mitigate cyber-attacks, we would stand a much better chance against the cyberattacker army working together against us every day!

What is your primary goal as the CTO of CDW Healthcare Division?

To bring awareness to our healthcare customers on the importance of bringing modern IT tools into healthcare organizations to optimize patient safety and hospital resources. With Ordr’s cybersecurity solution there are many ways network visibility helps hospitals beyond, of course, ransomware, but also what’s happening with device utilization, what’s happening with compliance and what’s being communicated externally. There are several important use cases we want to advise our customers about to develop a proactive plan before something bad happens.

Why is IoT and connected device monitoring and enforcement so unique for hospitals?

There’s a problem with biomed devices and it’s not going away. There will always be biomed devices that have outdated and unsupported operating systems. In the beginning, when first purchased, they were of course running mainstream and perhaps even state of the art operating systems, but now these operating systems are no longer supported by the manufacturers. As a result, O/S patches are no longer available to address vulnerabilities, even though these devices are still within their useful lifecycle and are still viable, delivering strategic care for patients and revenue to healthcare organizations.

Why weren’t patches performed on outdated operating systems on biomed devices?

Unfortunately, this is due to the biomedical industry. As a medical device design engineer for ten years, I may have helped cause the problem, although we thought it made sense the way we did it back then. We would buy an off the shelf computer and put it in a cabinet or a device we were creating, and it would run it. The computer we installed ran whatever the latest operating system was at the time. The issue back then was per the FDA 510k rules for class two, and three medical devices once the device was tested, it could never be altered. This included the operating system on the off the shelf computer. So, the manufacturers never changed them or patch the OS because they could not!

Can you patch today?

In 2016, the FDA reversed their guidelines and said you can patch devices now because it is important to upgrade operating systems. But it was a guideline, it was not a mandate. Because it was a guideline and because it is hard for biomedical manufacturing companies to transition to have a global patch program for all the devices they sell, they do not do it. And they do not want to release the product to an IT team to open it up and obviously, upgrade the operating system or patch it due to inherent risk on their part, because it might make their system not work properly.

Bottom line, the problem is going to persist because biomed devices will continue to outlast the useful life of their operating systems and CFOs do not want to replace a $4M imaging device that makes the hospital money every day only because it has a security vulnerability.

If you don’t patch what can the CISOs and security leaders to do?

They are stuck, because now they have a known vulnerability in their system, and they must do something about it. This is the reason I was introduced to Ordr.

How did you select Ordr for addressing the patching issue?

“To get the security and network teams to completely agree on something was amazing.”

Our first step was to do a POC (proof of concept) by my IT security team. A few weeks later, my network and security team had a meeting with IT leadership to show the results of the POC. We were all blown away. I’ll never forget that moment because everyone was happy, even joyous which doesn’t normally happen with software in general.

To get the security and network team to completely agree on something was amazing, because normally, they have a little contention just due to their job functions where one wants data to flow, and the other one wants to control data.

Once deployed, did you meet your objective?

“One of the major tenants of cyber security is to understand your landscape. And that includes all devices connected to your network. Are they patched? Or are they outdated and unsupported?”

I was amazed. Ordr worked and it worked well. We purchased Ordr originally because I knew I had a problem with older biomed devices running Windows XP. Before Ordr, our vulnerability scans would find them but then they would disappear because of their dynamic nature of how they connected to the network. And if we didn’t find them that very minute and physically locate them, we would lose sight of them. It was a real problem. We could not see and didn’t know our full landscape. And that is scary, because to me, one of the major tenets of cyber security is to understand your landscape. And that includes all devices connected to your network and their patch status. Are they patched? Or are they unsupported? It is not just your IT devices, it is anything that is connected to your network. As you know, in the last five years, that’s grown greatly with so many other things connecting now, and you still have these legacy biomed devices that are out there too.

How did you manage all the outdated and unsupported biomed devices you found?

When we fully deployed Ordr, we noticed a couple of things right away. First, we not only found all the biomed devices, but we also now had an inventory of them. And we were able to understand what operating systems they were running and could have a plan of what to do about it. At that time, we had three choices.

Replace the device. But again, financially that might not be viable.
Get the manufacturer to patch it, or to upgrade the operating system so it was no longer vulnerable.
Bury it by micro segmentation. Through micro segments, you have controls around it from the internal firewall, Even though we have controls, you still need to monitor it and we used Ordr.

When I would talk to people, they understood Splunk monitors user behavior. Ordr monitors device behavior. I can now set upper or lower limits on the device itself. And if Ordr detects something odd, we can be alerted

What was the next step to managing these vulnerable devices?

“If the hacker gets in and gets to an XP device, that would be the biomed device, it takes about 20 minutes for them to own that device. If the device is connected to a server, then they can own the network.”

The roadmap was moving more towards enforcement and that sat well with me. The reason why is that hackers do not attack during the day, they tend to attack at night and on weekends. At those times, depending on what hospital you’re at, you might be relying on a managed Security Operations Center (SOC), which is pretty good. Or you might be relying on your on-call staff to fight any cyber problems in the middle of night. And there’s latency in that. If the hacker somehow gets in and gets to an XP device, it takes about 20 minutes for them to own that device. If there are any servers connected to that kind of device, then they have the opportunity to own the network. Now the world turns bad quickly. To have a system that has deep understanding of proper network communication related to strategic IoMT devices and can monitor those devices 24/7and alert us when something is wrong, is great.

Next, if I could actually enforce policy, or at least send API commands from Ordr to change the policy in my firewall or my NAC, these devices could shut down communication at 3 am in milliseconds. This is much better than the time it would take the team to figure out what the problem was, based on a calls to the service. IoT and connected device security enforcement can stop a virus from propagating

What else could you do now with full visibility of your network landscape?

Device utilization is a big deal. Ordr creates custom views per departmental stakeholders. For example, the Biomed and/or Operations team could go into their Ordr view and just look at medical device utilization. Their view doesn’t allow them to see the other aspects of cyber or network information Ordr was capturing.

I like to tell the story that if a clinician wants another ultrasound device in your hospital, but your ultrasound fleet is only being utilized 30% of the time, you do not need another ultrasound, you need to improve your processes to get better utilization of your devices. And when you do this, you save money by not buying another device while improving your processes. And so that is valuable.

For some devices, Ordr was monitoring down to the battery life level. Since we all know batteries go bad, to have an alert to the Clinical Engineering team for low batteries on biomed devices is cool and important.

The next important outcome we gained is forensic device data. Ordr collecting all device data in the cloud. When we have a potential security incident, we called the security team. The team uses Ordr to determine what device was bad and see who it was talking to and how it was talking, to see if it was doing things that it should not do. We always used Ordr during any security incident as part of our incident response toolbox. And it worked well. And even the network team liked it because Ordr does an incredibly good job of showing how everything communicates, and what it is trying to communicate and what is being blocked from communication.

To sum it up, first and foremost the outdated and unsupported biomed devices are a problem that is not going away, ever! Operating systems only have a life for so long, so you need something to address the issue. With Ordr though, you get more use cases including device utilization management, forensic data and the network team gets to see how things are communicating, outside of their regular forensic toolbox. So that’s why I like Ordr.

Please contact me if you’d like to learn more or to share stories that could benefit all of us in addressing outdated medical devices and cybersecurity resiliency in healthcare.

The Cyber & Infrastructure Security Agency (CISA) recently issued two security advisories highlighting vulnerabilities associated with connected devices made by medical technology firm Becton, Dickinson & Co. (BD). The advisories follow disclosures BD made to CISA, and describe security flaws in the company’s Pyxis and Synapsys product lines.

Among the vulnerabilities described in the advisories are the use of default and shared credentials in the Pyxis products and “insufficient” session expiration for the Synapsys informatics platform. Both flaws could leave the devices vulnerable to exploitation by threat actors who could then gain access to sensitive patient protected health information (PHI) or even affect the delivery of correct treatment.

Device Vulnerabilities Put Network and Patient Safety at Risk

The disclosure of these security flaws by BD, and the subsequent advisories issued by CISA, underscores the risk to both network and patient security when vulnerable internet of medical things (IoMT) devices are deployed within healthcare environments. Even when such devices must remain in service and cannot be patched, allowing them to continue operation without taking steps to mitigate their associated risks should be regarded as a dereliction of duty.

In this current case, BD recommends a number of steps to close the now-known security gaps, including:

Limit physical access to only authorized personnel;
Tightly control management of system passwords provided to authorized users;
Monitor and log network traffic attempting to reach the affected products for suspicious activity;
Isolate affected products in a secure VLAN or behind firewalls with restricted access that only permits communication with trusted hosts in other networks when needed; and,
Work with your local BD support team to ensure that patching and virus definitions are up to date. The BD Remote Support Services Solution for automated patching and virus definition management is an available solution for customer accounts.

From an IT and security operations standpoint, these steps may be difficult for hospitals and other healthcare delivery organizations (HDOs), especially in larger organizations with no means for effecting proper asset management. This leaves questions like: Does my organization have these devices in inventory and where are they located? What software versions are installed? Are they in use and unable to be taken out of service?

Ordr can answer these questions and easily address the recommendations by BD above.

See, Know, Secure, Every Connected Device

Our See, Know, Secure approach to connected device security means our customers can find and identify all the BD connected assets—as well as other connected devices operating in the network—within minutes of deployment. Once Ordr has discovered the devices, their specific make, model, and other operational data are identified, the BD products that are impacted by this vulnerability can be monitored for any anomalous behavior that could be an indicator of compromise (IOC).

Ordr can identify which BD devices are being accessed by which user, and track which users were logged into a specific device, at what time, duration and more.

Ordr also enables security teams to proactively segment the impacted BD devices, and to set Zero Trust security policies specific to each. In the event that a device is compromised, and we detect anomalies such as a suspicious communications pattern or other operations outside of defined parameters—our segmentation policies limit an attack’s potential “blast radius” by isolating affected devices and network segments, and allowing security teams to take mitigating actions within minutes of a breach.

Ordr Can Help Secure Your Devices and Environment

With studies suggesting that as many as three-quarters of all connected medical devices currently in service contain at least one security vulnerability, and that half may contain two or more, it is critically important for hospitals and HDOs to do what is necessary to gain the upper-hand on connected device inventory, management, and security. For more information about how the Ordr can assist in this endeavor, please visit our site to learn more about our security platform, or contact us with questions specific to your organization’s situation.

Ordr Knowledge Base

Become A Partner