Most health system CIOs have heard about the 2014 attack on Boston Children’s Hospital by a member or members of the activist hacker group Anonymous. The hospital was forced to deal with a distributed denial of service (DDoS) attack as well as a spear phishing campaign. Yesterday, as part of the Harvard Medical School Clinical Informatics Lecture Series, the hospital’s senior vice president and CIO Daniel Nigrin, M.D., discussed six lessons learned from the attack.
Although the cyber-attack took place four years ago, there have been some recent developments. The attack was undertaken to protest the treatment of a teenager, Justina Pelletier, in a dispute over her diagnosis and custody between her parents and the hospital. In August 2018 Martin Gottesfeld, 32, was convicted of one count of conspiracy to damage protected computers and one count of damaging protected computers. U.S. District Court Judge Nathaniel Gorton scheduled sentencing for Nov. 14, 2018. Gottesfeld was charged in February 2016.
According the U.S. Department of Justice, Gottesfeld launched a massive DDOS attack against the computer network of the Boston Children’s Hospital. He customized malicious software that he installed on 40,000 network routers that he was then able to control from his home computer. After spending more than a week preparing his methods, on April 19, 2014, he unleashed a DDOS attack that directed so much hostile traffic at the Children’s Hospital computer network that he temporarily knocked Boston Children’s Hospital off the Internet.
In his Oct. 17 talk, Nigrin said cyber criminals still see healthcare as a soft target compared to other industries. “The bottom line is that in healthcare, we have not paid attention to cybersecurity,” he said. “In the years since this attack, we have seen ransomware attacks that have brought hospital systems to their knees. We have to pay more attention and invest more in terms of dollars and technical people, but it really does extend to entire organizations — educating people about what a phishing attack is, what a social engineering attack is. These need to be made a priority.”
He offered six lessons learned from Boston Children’s experience:
1. DDoS countermeasures are critical. No longer can healthcare organizations assume that a DDoS attacks are things that only occur against corporate entities, he said. “Prior to this event, I had never thought about the need to protect our organization against a DDoS attack,” he said. “I will submit that the vast majority of my CIO colleagues were in the same boat. And that was wrong. I think now we have gotten this understanding.”
2. Know what depends on the internet. Having a really detailed understanding of what systems and processes in your organization depend on internet access is critical, Nigrin stressed. You also mush have good mitigation strategies in place to know what to do if you lose internet access — whether it is because you have a network outage due to a technical issue or a malicious issue. “As healthcare has become more automated and dependent on technology, these things are crippling events. You have got to know how you are going to deal with it ahead of time. Figuring it out on the fly is not going to work.”
3. Recognize the importance of email. Email may be seen as old-school, Nigrin noted, but it is still the primary method to communicate, so you have to think about how you can communicate and get the word out in scenarios where you don’t have email or lose voice communication. “In our case, we were super-lucky because we had just deployed a secure texting platform, so we could do HIPAA-compliant texting, and when our email was down, that was how we communicated, and it was very effective,” he explained.
4. Push through security initiatives – no excuses anymore. Because he is a doctor himself, Nigrin feels OK picking on doctors about security. Historically they have always pushed back on security measures such as dual-factor authentication. He paraphrases them saying “Come on, Dan, that is an extra 10 seconds; I have to carry a secure ID, or you have to send me a text message on my phone. It is a pain. I don’t want to do it. I am the highest-paid employee in your organization and that is time better spend on something else.” But Nigrin argues that we can’t afford to think like that anymore. He used the Anonymous attack as an opportunity to push through four or five security initiatives within the next two to three months when he had everyone’s attention. “The platform was burning, and the board of trustees was willing to expend the money to pay for it all. They all of a sudden recognized the risk.”
5. Securing audio- and teleconference meetings. Nigrin said this topic wouldn’t have occurred to Boston Children’s until they were warned by the FBI. “The FBI told us about an attack that affected them when they were dealing with Anonymous. When Anonymous was attacking the FBI, the FBI convened internal conference calls on how to deal with it. Anonymous had already breached their messaging platform and intercepted the calendar invites that invited everyone to dial in. Anonymous basically was called into the meeting. Within 30 minutes of one of those meetings, the entire audio transcript of the conference call was posted to YouTube. “So we took heed of that and made sure that when we had conference calls, we sent out PINs over our secure texting platform,” he said.
6. Separating signal from noise. During the attack, Boston Children’s set up a command center and told employees: if you see something, say something. “We didn’t know what attack was coming next. We were flying blind,” Nigrin said. “We started to get lots of calls into our command center with reports of things that seemed somewhat suspicious,” he remembers. People got calls on their cell phone with a recorded message saying your bank account has been compromised. Press 1 to talk to someone to deal with it. “Today we would recognize this as some type of phishing scam and hang up,” he said, “but at the time it was sort of new. People started calling us and we didn’t know if this was Anonymous trying to get into the bank accounts of our senior clinicians. Was it part of the attack? It was tough for us to detect signal from noise.”
In the Q&A after his presentation, listeners were curious about how much the incident cost the hospital. Nigrin said there two big costs incurred: One was the technology it had to deploy in an emergent way to do DDOS protection and penetration testing. The other was revenue lost from philanthropic donations. Together they were close to $1 million.
Another person asked if the hospital had cyber insurance. Nigrin said they did, but when they read the fine print it said they were covered only if they were breached and technically they were never breached, so the insurance company was reluctant to pay. Although they eventually got compensated for a good share of it, the hospital also made sure to update its policy.
Still another attendee asked Nigrin if ransomware attacks were still targeting hospitals. He said they definitely were. “Think about community hospitals just squeaking by on their budgets,” he said. “They don’t have millions to spend, yet their data is valuable on the black market. Attackers recognize we are dead in the water as entities if we don't have these systems. We have important data and will do anything to get our systems back up and running.”
Nigrin said even large health systems can be vulnerable because some technology they deploy is run by third-party vendors who haven’t upgraded their systems. An example, he said, might be technology to record videos in the operating room setting. Some vendors, he said, are not accustomed to thinking about security. They are unable to update their software so it works on more modern operating systems. That leaves CIOs with a tough choice. “We can shut off the functionality or take the risk of continuing to use outdated and unpatched operating systems. Those vendors now have woken up and realize they have to pay more attention.”
