Comments on the Cybersecurity in the healthcare and public health sector

Form Approved
OMB No. 0990-0379
Exp. Date 09/30/2020

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Volume 1: Cybersecurity Best
Practices for Small Healthcare
Organizations

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Table of Contents

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Introduction ................................................................................................................................. 3

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Document Guide - Cybersecurity Best Practices ......................................................................... 5

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Cybersecurity Best Practice #1: Email Protection Systems......................................................... 7

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Cybersecurity Best Practice #2: Endpoint Protection Systems ................................................. 10

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Cybersecurity Best Practice #3: Access Management .............................................................. 12

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Cybersecurity Best Practice #4: Data Protection and Loss Prevention .................................... 14

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Cybersecurity Best Practice #5: Asset Management ................................................................ 17

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Cybersecurity Best Practice #6: Network Management ........................................................... 19

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Cybersecurity Best Practice #7: Vulnerability Management .................................................... 21

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Cybersecurity Best Practice #8: Incident Response .................................................................. 22

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Cybersecurity Best Practice #9: Medical Device Security ......................................................... 24

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Cybersecurity Best Practice #10: Cybersecurity Policies .......................................................... 25

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Appendix A: Acronyms and Abbreviations ............................................................................... 27

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Introduction

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Technical Volume I provides healthcare cybersecurity best practices for small organizations. For the
purpose of this volume, small organizations generally do not have dedicated Information Technology (IT)
and security staff to implement cybersecurity practices due to limited resources. Without this focus,
personnel may have limited awareness of the consequences of cyber threats to patients and the
organization and, subsequently, the importance of implementing basic cybersecurity practices.

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The primary mission of small healthcare organizations is to provide healthcare to their constituents in
the most cost-effective way. Cost-effectiveness enables small organizations to sustain operations,
maintain financial viability, justify future investments such as grants and, in the case of for-profit
organizations, generate an acceptable profit. Conducting day-to-day business usually involves the
electronic sharing of clinical and financial information with patients, providers, vendors, and other
players to manage the practice and maintain business operations. For example, small organizations
transmit financial information to submit invoices and insurance claims paid by Medicare, Medicaid,
Health Maintenance Organizations (HMOs), and credit card companies.

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In general, small organizations perform the following functions:

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Clinical care, which includes but is not limited to the sharing of information for clinical care,
the transitioning of care (both Social and Clinical), electronic or “E-prescribing” and patient
communication through direct secure messaging, and the operation of diagnostic
equipment that is connected to a computer network, such as Ultrasound and Pictures
Archiving and Communication Systems (PACS).

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Provider practice management, which includes patient access/registration, patient
accounting, patient scheduling systems, claims management, and bill processing.

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Business operations, which includes accounts payable, supply ordering, human resource
vendors, information technology (IT) operations, staff education, providing protection for
patient information, and business continuity and/or disaster recovery in the case of
emergencies such as fire, flood or storm damage.

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Just as healthcare professionals must wash their hands before caring for patients, healthcare
organizations must practice good cyber hygiene in today’s digital world by including it as part of everyday, universal precautions. Like hand-washing, a culture of cyber awareness does not have to be
complicated or expensive. In fact, simple cybersecurity practices, such as always logging off a computer
when finished, are very effective at protecting information that is sensitive and private.

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This volume takes into consideration recommendations made by HHS divisions including, but not limited
to, the Office for Civil Rights (OCR), Food and Drug Administration (FDA), the Assistant Secretary for
Preparedness and Response (ASPR), the Office of the Chief Information Officer (OCIO), the Centers for
Medicare and Medicaid (CMS), and the Office of the National Coordinator for Health Information
Technology (ONC), as well as guidelines and best practices from the National Institute of Standards and
Technology (NIST) and the Department of Homeland Security (DHS).

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Small organizations must comply with multiple legal and regulatory guidelines and requirements. To
ensure compliance, they often create an internal infrastructure of personnel and procedures,
transmitting sensitive data as needed internally and with authorized external resources. Examples of
the issuing entities and/or directives are:

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Electronic Health Records (EHR) interoperability guidelines

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Medicare Access and the Children’s Health Insurance Program (CHIP) Reauthorization Act of
2015 (MACRA)/Meaningful Use

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Health Insurance Portability and Accountability Act (HIPAA)/Health Information Technology
Economic and Clinical Health Act (HITECH)

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Payment Card Industry Data Security Standard (PCI-DSS)

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Substance Abuse and Mental Health Services Administration (SAMHSA)

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The Stark Law as it relates to using the services of an affiliated organization

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Many small practices and organizations use third-party IT support and cloud service providers to
maintain operations that leverage current technologies. Given the complicated nature of IT and
cybersecurity, these third-party IT organizations can be helpful in identifying, assessing and
implementing cybersecurity best practices. Your IT support providers should be capable of reviewing
the best practices in this publication to determine which are most applicable to your organization.

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While the best practices in this volume are tailored to small organizations, it is important to note that
small organizations may also benefit from selected best practices in Technical Volume 2, which is
tailored to medium and large organizations. Technical Volume 2 is included with this publication and
small organizations are encourage to review it as well.

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Document Guide - Cybersecurity Best Practices

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This volume provides small organizations with a series of best practices to reduce the impact of the five
cybersecurity threats identified in Table 1 and discussed in the main document, Cybersecurity for the
Healthcare and Public Health Sector.
Threat Description
Email Phishing Attack
Ransomware Attack

Loss or Theft of Equipment
or Data
Accidental or Intentional
Data Loss
Attack Against Connected
Medical Devices that May
Affect Patient Safety

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Impact of Attack
Potential to deliver malware or conduct credential attacks.
Both attacks lead to further compromise of the organization.
Potential to lock up assets (extort) and hold them for
monetary ransom. This may result in the permanent loss of
patient records.
Potential for equipment to be lost or stolen, leading to a
breach of sensitive information. This may lead to patient
identity theft.
Potential for data to be intentionally or unintentionally
removed from the organization. This may lead to a breach of
sensitive information.
Potential for patient safety, treatment and well-being to be
impacted by a cyber attack.

Table 1. Five Prevailing Cybersecurity Threats to Healthcare Organizations

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For the five cybersecurity threats identified in Table 1, a series of best practices, sub-practices, and
baseline practices are presented in this document, as listed in Table 2.

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Table 2. Best Practices, Sub-Practices and Baseline Practices are Presented for Small Organizations
Best Practice
Email Protection Systems

Endpoint Protection Systems
Access Management
Data Protection and Loss Prevention
Asset Management

Network Management

Vulnerability Management
Incident Response

Sub Practice
1.A
1.B
1.C
2.A
3.A
4.A
4.B
5.A
5.B
5.C
6.A
6.B
6.C
7.A
8.A
8.B

Baseline Practice
Email System Configuration
Education
Phishing Simulation
Basic Endpoint Protection
Basic Access Management
Policy
Procedures
Inventory
Procurement
Decommissioning
Network Segmentation
Physical Security and Guest Access
Intrusion Prevention
Vulnerability Management
Incident Response
ISAC/ISAO Participation

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Medical Device Security
Cybersecurity Policies

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10.A

Medical Device Security
Policies

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Cybersecurity Best Practice #1: Email Protection Systems

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Most small practices leverage outsourced email providers, rather than establishing a dedicated internal
email infrastructure. The best practices discussed below are presented in three parts:

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Email System Configuration: the components and capabilities that should be included within
your email system

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Education: how to increase understanding and awareness across your staff on ways to
protect your organization against email-based cyberattacks such as phishing and
ransomware

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Phishing Simulations: ways to provide training and awareness to your staff on phishing
emails

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Baseline Practices

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A. Email System Configuration

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Consider the following controls to enhance the security posture of your email system. Check with
your email service provider to ensure these are in place and enabled.

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Avoid “free” or “consumer” based email systems for your business: these systems are not
approved to store, process, or transmit protected health information (PHI). We recommend
contracting with a server provider that caters to the Healthcare or Public Health Sector.

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Ensure that Basic Spam/Antivirus software solutions are installed, active, and automatically
updated wherever possible. Many spam filters can be configured to recognize and block
suspicious emails before they reach employee inboxes.

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Deploy multi-factor authentication before enabling access to your email system. This
prevents hackers who have obtained a legitimate user's credentials from accessing your
system.

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Optimize security settings within your authorized Internet browser(s) to minimize the
likelihood that an employee will open a malicious website link, including blocking specific
websites or types of websites. Most browsers assess the possibility that the site is
malicious, and will send a warning message to the user about the potential danger of
accessing a specific site.

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Configure your email system to tag messages as “EXTERNAL” that are sent from outside of
your organization. Consider implementing a tag that advises the user to be cautious when
opening such emails, for example, “Stop. Read. Think. This is an External Email.”

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Implement an email encryption module that enables users to send emails securely to
external recipients or to protect information that should only be seen by authorized
individuals.

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B. Education

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Implement the following education and awareness activities to assist your employees and partners in
protecting your organization against phishing attacks.

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Establish and maintain a training program for your workforce that includes a section on phishing
attacks. All users in your organization should be able to recognize the phishing techniques in Table 3.

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Phishing Technique

Check Embedded Links

Validate that the URL of the link is the same as the link itself. This
can be achieved by hovering (but not clicking) your cursor over the
email link and reading the website to be accessed.

Look for Suspicious From:
Addresses

Check received emails for spoofed or misspelled From: addresses.
For example, if your organization is “ACME” and you receive an email
from user@AMCE.com, do not open the email without verifying that
it is legitimate.

Be cautious with “Urgent”
messages

If the email message requires immediate action, especially if it
includes a request to access your email or any other account, do not
open the email or take any action without verifying that it is
legitimate.

Be cautious with “Too
Good to be True”
messages

If you receive an unexpected message about winning money, or gift
cards (such as Amazon gift cards), do not open the email or take any
action without verifying that it is legitimate.

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Best Practice

Table 3. Train Users to Recognize Phishing Techniques
Be extra careful when sending and receiving emails that contain sensitive and private data, especially
patient information. Use of an encryption module minimizes your organization’s vulnerability to this
information being intercepted by hackers.

C. Phishing Simulations

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Implement regular (e.g., monthly or quarterly) anti-phishing campaigns with real-time training for your
staff. Many third parties provide low cost, cloud based, phishing simulation tools to train and test your
workforce. These tools often include pre-configured training that is easy to distribute for your
workforce to complete independently.

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Steps for an effective anti-phishing campaign include:

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Direct your IT specialist to send a phishing email to everyone on your staff. Track how many
of your employees “bite” or open the email. This enables you to target training to those
who demonstrate need as well as to monitor staff and provide opportunities for
improvement. It will set the baseline for you to understand how susceptible your
organization is and allow you to measure awareness over time.

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While an anti-phishing campaign cannot stop the inbound flow of phishing emails, it will
help your organization to identify attacks that bypassed your established email security
protections. Your workforce can become “human sensors” to inform you when a real
phishing attack is occurring.

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Start your anti-phishing campaigns with easy-to-spot emails that your workforce learns to
recognize. Slowly raise the level of sophistication of these simulations to increase the
awareness capability of your workforce.

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Threats Mitigated

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Email Phishing Attack

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Ransomware Attack

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Accidental or Intentional Data Loss

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Cybersecurity Best Practice #2: Endpoint Protection Systems

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A small organization’s endpoints must be protected. Endpoints include desktops, laptops, mobile
devices or other connected hardware devices (e.g., printers, medical equipment). Because technology is
highly mobile, computers often are connected and disconnected from an organization’s enterprise
network. Although attacks against endpoints tend to be delivered via email, as described above, they
can be caused by “client-side attacks.” Client-side attacks occur when vulnerabilities within the
endpoint are exploited. Recommended security controls to protect endpoints are presented in Table 4.

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Baseline Practice

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A. Basic Endpoint Protection Controls
Security Control

Description

Remove
administrative
accounts

Most users in an organization do not need to be authorized as system
administrators with expanded system access and capabilities. Remove
administrative access on endpoints to mitigate the damage that can be caused
by an attacker who compromises that endpoint. Only authorized personnel
within an organization should be allowed to install software applications.
Every organization should audit software applications on each endpoint,
maintaining a list of approved software applications and removing any
unauthorized software as soon as it is detected.

Keep your
endpoints
patched

Patching (i.e., regularly updating) systems removes vulnerabilities that can be
exploited by attackers. Each patch modifies a software application, rendering
it more difficult for hackers to maintain programs that are aligned with the
most current version of that software application. Configure endpoints to
patch automatically and ensure that third-party applications (e.g., Adobe
Flash) are patched as soon as possible.

Implement
Antivirus
software

Like maintaining a safe and infection free operating room for surgery, it is
essential to maintain safe and infection free endpoints for your organization to
function smoothly. Antivirus software is readily available at low cost and
effective at protecting endpoints from computer viruses, malware, spam and
ransomware threats. Each endpoint in your organization should be equipped
with antivirus software that is configured to update automatically.

Turn on
endpoint
encryption

Install encryption software on every endpoint that connects to your Electronic
Health Records (EHR), especially mobile devices such as laptops. Maintain
audit trails of this encryption in case the device is ever lost or stolen. This
simple and inexpensive precaution may prevent a complicated and expensive
breach.
For devices that cannot be encrypted or that are managed by a third-party,
implement physical security controls to minimize theft or unauthorized
removal. Examples include installation of anti-theft cables, locks on rooms
where the devices are located, and the use of badge readers to monitor access
to rooms where devices are located.

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Enable firewalls

Enable local firewalls for your endpoint device. This is especially important for
mobile devices that may be connected to unsecured networks, for example,
Wi-Fi networks at coffee shops or hotels.

Enable 2Factor
Authentication
for remote
access

For devices that are accessed off site, leverage technologies that use 2Factor
Authentication before permitting the user to access data or applications on
the device. Logon with a username and password is often compromised
through phishing emails.

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Table 4. Effective Security Controls Protect Organization Endpoints.

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If your organization leverages an EHR system, or accesses sensitive data through application systems
(either on the cloud or on premise), encrypt network access to these applications. Contracts with EHR
vendors should include language that requires medical/PHI data to be encrypted both at rest and during
transmission between systems. Encryption applications prevent hackers from accessing sensitive data,
usually by requiring a “key” to encrypt and/or decrypt data.

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Threats Mitigated

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Ransomware Attack

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Theft or Loss of Equipment or Data

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Cybersecurity Best Practice #3: Access Management

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Healthcare organizations of any size need to clearly identify all users and maintain audit trails that
monitor each user’s access to data, applications, systems and endpoints. Just as you may use a name
badge at work, proper identification and appropriate access should always be obtained and maintained
for proper cybersecurity hygiene.

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Baseline Practice

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User accounts enable organizations to control and monitor each user’s access to and activities on
devices, EHRs, email and other third-party software systems. It is essential to protect user accounts and
mitigate the risk of cyber threats. Your IT specialist should implement the security controls in Table 5 to
manage user access of data, applications and devices.

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A. Basic Access Management
Security Control

Description

Establish a unique
account for each
user

Assign a separate user account to each user in your organization. Train and
continuously communicate to users that they must never share their
passwords. Require each user to create an account password that is
different from the ones used for personal internet or email access (e.g.,
Gmail, Yahoo, Facebook).

Limit the use of
shared or generic
accounts

Tailor access to the
needs of each user

Terminate user
access as soon as
the user leaves the
organization

The use of shared or generic accounts should be avoided. If required, train
and continuously communicate to users that they must “sign out” upon
completion of activity or whenever they leave the device, even for a
moment. Passwords should be changed after each use.
Sharing accounts exposes an organization to greater vulnerabilities. For
example, the complexity of updating passwords for multiple users on a
shared account may result in a compromised password remaining active
and allowing unauthorized access over an extended period of time.
Tailor access for each user based on the user’s specific workplace
requirements. Most users require access to select common systems, such
as email and file servers. This is usually called provisioning.
When an employee leaves your organization, ensure that procedures are
executed to terminate the employee’s access immediately. This is very
important for organizations that use cloud-based systems where access is
based on credentials. You don’t want former employees to access your
patient data and other sensitive information after they have left the
organization!
If an employee changes jobs within the organization, it’s important to
terminate access required for the employee’s former position before
granting access based on the requirements for the new position.

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Role based access

As user accounts are established, the appropriate authorization must be
granted to access the organization’s various computers and programs.
Consider leveraging the principle of Minimum Necessary associated with
the HIPAA Privacy Rule. Allow each user access only to the computers and
programs required to accomplish the user’s job or role in the organization.
This limits the organization’s exposure to unauthorized access and loss or
theft of data if the user’s identity or access is compromised.

Configure systems
and endpoints
with automatic
lock and log-off

Configure systems and endpoints to automatically lock and log off users
after a predetermined period of inactivity, such as 15 minutes.

Implement SingleSign On

Implement Single-Sign On systems that allow a user to sign onto the
network once with subsequent access properly managed. This allows the
organization to maintain access centrally.

Implement MultiFactor
Authentication for
the Cloud

Implement Multi-Factor Authentication for cloud-based systems used by
your organization to store or process sensitive data, such as EHRs. This
mitigates the risk of access by unauthorized users.

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Table 5. Security Controls Enable Organizations to Manage User Access to Data

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To monitor compliance with these practices, implement access management procedures to track and
monitor user access to computers and programs. These procedures will ensure the consistent
provisioning and control of access throughout your organization. Examples of these standard operating
procedures can be found in Appendix I of the main document.

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Threats Mitigated

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Ransomware Attack

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Accidental or Intentional Data Loss

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Attack Against Connected Medical Devices that May Affect Patient Safety

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Cybersecurity Best Practice #4: Data Protection and Loss Prevention

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A security breach is the loss or exposure of sensitive data – information that is relevant to the
organization’s business or patient’s PHI. Impacts to the organization can be profound if data are
corrupted, lost or stolen. This includes the inability of users to complete work accurately or on a timely
basis and the potentially devastating consequences to patient treatment and well-being. Establishing
good cybersecurity practices to protect data and prevent data loss protects the organization and its
patients.

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Baseline Practice

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Preventing the loss of sensitive data can be accomplished in several ways. It is based on understanding
where data resides, where it is accessed, and how it is shared. Throughout this document, there are
many tips to protect data and prevent loss. Information in this section is organized by policy,
procedures and education.

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A. Policy

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First and foremost, set the expectation for how your workforce is expected to manage the sensitive data
at their fingertips. Most healthcare employees work with sensitive data on a daily basis and it’s easy to
forget the importance of being vigilant with its protection. Organizational policies should address all
user interactions with sensitive data and reinforce the consequences of data that is lost or
compromised.

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Establish a data classification policy that segments data types into Sensitive, Internal Use, and Public Use
categories. For each category, identify the types of records. For example, the Sensitive data category
should include PHI, social security numbers, credit card numbers, and other information that must
comply with regulations, may be used to commit fraud, or may damage the organization’s reputation.
Table 6 suggests data classifications with descriptions.
Classification

Description

Highly
Sensitive

Data that can be used easily to commit financial fraud or cause
significant damage to the organization’s reputation. Examples of such
data for patients include Social Security Numbers (SSN), credit card
numbers, mental health information, substance abuse information, and
sexually transmitted infections/disease information. Access to this data
should be restricted to users who require access and demonstrate
proper authentication at logon. This data must be managed in
compliance with applicable regulatory requirements.

Sensitive

All other PHI, especially data associated with the Designated Record
Set, Clinical Research data, Insurance information, human/employee
data, and organizational board materials.

Internal

Data that should be protected yet is not considered sensitive. Examples
include organization policies and procedures, contracts, business plans,
corporate strategy and business development plans, and internal
business communications.

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All other data that has been sanitized and approved for distribution to
the public with no restrictions on use.

Public

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Prohibit the use of unencrypted storage, such as thumb drives, mobile phones, or computers. Require
encryption of these mobile storage mediums before use.

B. Procedures
In addition to implementing policies to define expected workforce behaviors, it’s important to establish
procedures to manage sensitive data. These procedures facilitate data management by instilling
consistency, reducing errors, and providing clear and explicit instructions. The following methods may
be used to develop and implement data management procedures:

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

Use the classifications in Table 6 to establish data usage procedures. Identify authorized
users of sensitive data, and the circumstances under which this data may be disclosed.

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

Train your workforce to comply with organizational procedures and ONC guidance when
transmitting PHI through email. Encrypt PHI that is sent using email or text, unless patients
expressly authorize their PHI to be emailed or texted to them.

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

When emailing PHI, use a secure messaging application such as Direct Secure Messaging
(DSM), which is a nationally adopted secure email protocol and network to transmit PHI.
DSM can be obtained from EHR vendors and other HIE systems. It was developed and
adopted through the Meaningful Use program, and a significant number of medical
organizations now participate in these trusted networks. When texting PHI, use a secure
texting system.

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

Implement Data Loss Prevention Technologies to mitigate the risk of unauthorized access to
PHI. Check with your IT provider to determine if this is feasible for your organization, or
reference Cybersecurity Best Practice #4: Data Protection and Prevention in Technical
Volume 2, for details on the applicability of these technologies to your organization.

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

Train your staff to never back up data on non-controlled storage devices or personal cloud
services. For example, do not permit employees to configure any workplace mobile device
to back up to a personal computer unless that computer has been configured to comply
with your organization’s encryption and data security standards.
o

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Note: Leveraging the cloud for backup purposes is fine if you have established a
business associate agreement with the cloud vendor and verified the security of
their systems.

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

Remember to protect archived data, such as records for previous patients. It is important to
monitor access to this data, which may be used infrequently, so that a cyberattack is
detected immediately.

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Ensure that obsolete data are removed or destroyed properly and cannot be accessed by
cyber-thieves. Much like fully shredding paper, medical records, or burning paper financial
paperwork, digital data must be properly disposed of to ensure it cannot be inappropriately
recovered. Discuss options for properly disposing outdated or unneeded data with your IT
support. Do not assume that deleting or erasing data means that it is destroyed. See
Appendix I of the main document for a sample data destruction form that can be used to
ensure data are disposed of appropriately.

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C. Education

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It is important to train your workforce to comply with your organization’s policies. At minimum,
provide annual training on the most salient policy considerations, such as the use of encryption and
PHI transmission restrictions.

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Retain and maintain only data that is required by your organization to complete work or
comply with records storage requirements. Minimize your organization’s risk footprint by
removing unnecessary data regularly.

Threats Mitigated

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Ransomware Attack

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Loss or Theft of Equipment or Data

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Accidental or Intentional Data Loss

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Cybersecurity Best Practice #5: Asset Management

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Organizations manage IT assets using processes referred to collectively as IT Asset Management (ITAM).
ITAM is critically important to understanding and ensuring that cyber hygiene controls are maintained
across all assets in your organization.

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ITAM processes should be conducted for endpoints, servers, and networking equipment. ITAM
processes enable organizations to understand their devices, and the best options to secure them.
Additionally, the best practices described in this section may be used to support many of the best
practices described in other sections of this volume. It can be difficult to implement and sustain best
practices for asset management. ITAM processes should be part of daily IT operations and encompass
the lifecycle of each IT asset from procurement to deployment and maintenance and, finally, to the
decommissioning (i.e., replacement or disposal) of the device.

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Baseline Practice

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A. Inventory

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A complete and accurate inventory of the IT assets in your organization facilitates the implementation of
optimal security controls. This inventory can be conducted and maintained using a well-designed
spreadsheet. The following fields should be captured for each device:

315



Asset ID (primary key)

316



Host Name

317



Purchase Order

318



Operating System

319



Media Access Control (MAC) Address

320



IP Address

321



Deployed to (User)

322



User Last Logged On

323



Purchase Date

324



Cost

325



Physical Location

326
327

Remember to include all devices owned by your organization, including workstations, laptops, servers,
portable drives, mobile devices, tablets and smart phones.

328

B. Procurement

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330
331
332

Once you have established your ITAM spreadsheet, it is important to record the acquisition of each
new IT asset when it is acquired. This requires establishing standard operating procedures. Generally,
it’s advisable to assign the responsibility of collecting information on new assets to the purchaser
within your organization.

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333

C. Decommissioning

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337

IT assets that are no longer functional or required should be decommissioned in accordance with your
organization’s procedures. Small organizations often contract with an outside service provider that
specializes in secure destruction processes. This ensures that all data, especially sensitive data, are
properly removed from a device before it is turned over to other parties.

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339
340

Additionally, your standard operating procedures should ensure that you record the decommissioning
of each device. If you use a service provider to decommission or destroy devices, record the
certification of destruction so there is never a question about what happened with it!

341

Threats Mitigated

342

Ransomware Attack

343

Loss or Theft of Equipment or Data

344

Accidental or Intentional Data Loss

345

Attack Against Connected Medical Devices that May Affect Patient Safety

346
347

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348

Cybersecurity Best Practice #6: Network Management

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351
352

Computers communicate with other computers through networks. These networks are connected
through a connection that is wireless or a wired (e.g., a network cable) and must be established before
systems can interoperate. Networks that are established in an insecure manner increase an
organization’s exposure to cyberattack.

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354
355
356

Proper cybersecurity hygiene ensures that the network is secure and that all devices access the network
in a safe and secure manner. If network management is provided by an IT support vendor, the
organization must understand key aspects of proper network management and ensure that they are
included in contracts for these services.

357

Baseline Practice

358
359
360

A. Network Segmentation
Configure networks to restrict access between devices to that which is required to successfully complete
work. This will limit the spread of any cyberattack on your network.

361
362
363



Disallow all Internet bound access into your organization’s network. If you host servers that
interface with the Internet, consider using a third-party vendor to provide security as part of
the hosting service.

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365
366



Restrict access to assets with potentially high impact in the event of compromise. This
includes medical devices and Internet of Things (IoT) items (e.g., security cameras, badge
readers, temperature sensors, building management systems).

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368
369
370
371



Just as you might restrict physical access to different parts of your medical office, it’s
important to restrict the access of third-party entities, including vendors, to separate
networks. Allow them to connect only through tightly controlled interfaces. This limits the
exposure to and impact of a cyberattack on your organization as well as the third-party
entity.

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373
374
375



Establish and enforce network traffic restrictions. These restrictions may apply to
applications and websites as well as to users in the form of role-based controls. Restricting
access to personal websites (e.g., social media, couponing, online shopping) limits exposure
to browser add-ons or extensions, reducing the risk of cyberattacks.

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377
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379

B. Physical Security and Guest Access
Just as network devices need to be secured, physical access to the network equipment should be
secured and restricted to IT professionals. Configure physical rooms and wireless networks to allow
Internet access only.

380
381



Keep data and network closets locked always. Grant access using badge readers rather than
traditional key locks.

382
383
384



Disable network ports that are not in use. Maintain network ports as inactive until an
activation request is authorized. This minimizes the risk of an unauthorized user “plugging
in” to an empty port to access to your network.

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386
387



Establish guest networks in conference rooms or waiting areas that separate the
organizational data and systems. Validate that guest networks are configured to access
authorized guest services only.

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388

C. Intrusion Prevention

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390
391
392
393
394

Implement intrusion prevention systems as part of your network protection plan to provide ongoing
protection for your organization’s network. Most modern firewall technologies that are used to
segment your network include an Internet Partner Services (IPS) component. Implementing this
component and configuring these systems to update automatically reduces your organization’s
vulnerability to known cyberattacks. Configure your intrusion prevention systems to stop well-known
attacks and to automatically update their signatures.

395
396

Intrusion prevention systems are available as part of a next generation technology/network suite of
applications, or as a stand-alone product that may be added to existing networks.

397

Threats Mitigated

398

Ransomware Attack

399

Loss or Theft of Equipment or Data

400

Accidental or Intentional Loss of Data

401

Attack Against Medical Device that May Affect Patient Safety

402

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403

Cybersecurity Best Practice #7: Vulnerability Management

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406

Vulnerability management is the process used by organizations to detect technology flaws that may be
exploited by hackers. This process uses a scanning capability, often provided by an EHR or IT support
vendor, to proactively scan devices and systems in your organization.

407

Baseline Practice

408

A. Vulnerability Management

409
410
411
412
413

As discussed in the introduction to this document, weak passwords, default passwords, outdated
software, and other technology flaws identified by these scans are commonly referred to as
vulnerabilities. During the process of conducting a scan, organizations may be presented with large
amounts of data. The urgent need to classify, evaluate, and prioritize remediation of these flaws before
an attacker can exploit them may require significant time and resources.

414

Vulnerability management best practices include:

415
416



Schedule and conduct scans on servers and systems within your control/inventory to
proactively identify technology flaws.

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418
419
420
421



Remediate flaws based on the severity of the identified vulnerability. This method is
considered an “unauthenticated scan.” The scanner has no extra sets of privileges to the
server. It queries a server based on ports that are active and present for network
connectivity. Each server is queried for vulnerabilities based upon the level of sophistication
of the software scanner.

422
423
424



Conduct web application scanning for Internet-facing webservers, such as a web-based
patient portal. Specialized vulnerability scanners can interrogate a running web application
to identify vulnerabilities within the application design.

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426
427
428
429



Conduct routine patching of security flaws within servers, applications (including web
applications), and third-party software. Maintain software at least monthly, implementing
patches distributed by the vendor community, if this isn’t done automatically. A robust
patch management mitigates vulnerabilities associated with obsolete software versions,
which are often easier for hackers to exploit.

430

Threats Mitigated

431

Ransomware Attack

432

Accidental or Intentional Data Loss

433

Attack Against Connected Medical Devices that May Affect Patient Safety

434

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435

Cybersecurity Best Practice #8: Incident Response

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442

Incident response is the ability to discover cyberattacks on the network and prevent them from causing
data breaches or loss. This is often referred to as the standard “blocking and tackling” of Information
Security. Many types of security incidents occur on a regular basis across organizations of all sizes. Two
common incidents are 1) the installation and detection of malware, and 2) the influx of phishing attacks
that include malicious payloads (via attachments and links). Though neither of these incidents directly
results in a data breach or loss, each event enables data breaches or loss to occur through subsequent
events.

443

Baseline Practice

444

A. Incident Response

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449
450
451

Small organizations are often challenged by incident response management. Incident response
procedures may not be established. Employees who rarely encounter cyberattacks may not remember
what to do. Members of the management team may not know who must be contacted to obtain or
provide information about the incident. In many cases, there are no dedicated Information Security
professionals within the small organization, and the reliance on the IT department becomes even more
important. A common concern is the fear of penalties if the organization contacts someone to rectify a
security incident.

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454

Cyberattacks may have severe consequences for healthcare organizations. Patient safety, treatment,
well-being and privacy may be comprised. Financial and credibility impacts to the organization may
cause irreparable damage.

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461

Establish and implement an Incident Response Plan. Before an incident occurs, make sure you
understand who will lead your incident investigation. Additionally, make sure you understand which
personnel will support the leader during each phase of the investigation. At minimum, you should
identify the top security expert who will provide direction to the supporting personnel. Ensure the
leader is fully authorized to execute all tasks and activities required to complete the investigation. A
sample Incident Response plan is provided in Appendix I of the main document. Examples of actions to
respond to incidents are described in Table 7.

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463
464

Incident Response Execution: Once your Incident Response Plan is implemented, ensure compliance
with the plan elements. At minimum, your plan should describe steps to be followed in the event of
malware downloaded on a computer or upon receipt of a phishing attack.
Incident

Malware

Phishing

Response Recommendation


Re-image, rebuild, or reset computer to a known good state.



Do not trust “malware cleaning” tools until they are verified to function as
described.



Identify malicious email messages and delete from mailboxes.



Proactively block websites (URLs) referenced in “click attacks.”



Identify malware that might have been installed on computers. Execute
malware play if run.

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465

Table 7. Implementing Incident Response Recommendations Mitigates Risk of a Data Breach or Loss

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467
468
469
470
471
472
473

B. ISAC/ISAO Participation
Establish a method to receive notifications about cyber threats that are actively targeting other
organizations. The most effective way to do this is to join an Information Sharing and Analysis
Organization (ISAO) or Information Sharing and Analysis Center (ISAC). Participating in an appropriate
ISAO or ISAC is a great way to manage incident response. As directed by Executive Order 13691, when a
member organization provides an ISAO with information about cyber-related breaches, interference,
compromise or incapacitation, the ISAO must:

474



Protect the individuals’ privacy and civil liberties,

475



Preserve business confidentiality, and

476



Safeguard the information being shared.

477
478
479
480
481
482

ISAOs and ISACs establish a community of professionals who are prepared to respond to the same cyber
threats. By joining this community, security and IT professionals bridge knowledge gaps with
information provided by their peers via the ISAC/ISAO. ISACs and ISAOs tend to focus on a specific
vertical (such as the National Healthcare Information Sharing and Analysis (NH-ISAC) within Healthcare)
or community (such as the Population Health ISAO). In all cases, the primary function of these
associations is to establish and maintain a channel for the purpose of sharing cyber intelligence.

483

Threats Mitigated

484

Phishing Attack

485

Ransomware Attack

486

Loss or Theft of Equipment

487

Accidental or Intentional Data Loss

488

Attack Against Connected Medical Devices that May Affect Patient Safety

489
490
491

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492

Cybersecurity Best Practice #9: Medical Device Security

493
494

Medical devices are essential to diagnostic, therapeutic and treatment practices. These devices deliver
significant benefits and are successful in the treatment of many diseases.

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502

As technology advances and healthcare environments migrate to digitized systems, so do medical
devices. For many reasons, it is highly desirable to interface medical devices directly with clinical
systems. Automating data collection from these devices reduces the labor burden and exposure to
human error that results from manual input of data. Automatic data interfacing also reduces errors that
can occur when transcribing data from the medical device to the clinical system. Automated control of
device instrumentation delivers the most accurate treatment possible to the patient. For example,
bedside vital signs monitors are networked to centralized nursing station displays and alarms, and
infusion pumps are networked to servers to distribute pump drug libraries and download usage data.

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506
507

As with all technologies, medical device benefits are accompanied by cybersecurity challenges.
Increasingly, new threats include “hacking” medical devices to cause harm by operating them in an
unintended manner. For example, the 2015 document “How to Hack an Infusion Pump” describes how
an infusion pump can be controlled remotely to modify the dosage of drugs, threatening patient safety
and well-being.

508
509
510

Cybersecurity vulnerabilities are introduced when medical devices are connected to a network or
computer to process required updates. Many medical devices are managed remotely by third-party
vendors, which increases the attack footprint.

511

Baseline Practice

512

A. Medical Device Security

513
514

If your organization connects medical devices to a network, consider the best practices recommended in
Cybersecurity Best Practice #9: Medical Device Security in Technical Volume 2.

515

Threats Mitigated

516

Attacks Against Connected Medical Devices that May Affect Patient Safety

517

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518

Cybersecurity Best Practice #10: Cybersecurity Policies

519
520
521
522
523

Establishing and implementing cybersecurity policies, procedures, and processes is one of the most
effective means of preventing cyberattacks. They set expectations and foster a consistent adoption of
behaviors by your workforce. With clearly articulated cybersecurity policies, your employees,
contractors and third-party vendors know which data, applications, systems and devices they are
authorized to access and the consequences of unauthorized access attempts.

524

Baseline Practice

525

A. Policies

526
527

Policies are established first and supplemented with procedures that enable the policy to be fulfilled.
Policies describe what is expected, procedures describe how that expectation is met.

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530
531
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For example, a policy is established that privacy and security training will be completed by all users. The
policy specifies that training courses will be developed and maintained for these two topics, that all
users will complete this training, that a particular method will be used to conduct the training, and that
specific actions will be taken to address non-compliance with the policy. The policy does not describe
how your workforce will complete the training, nor does it identify who will develop the courses. Your
procedures section provides these details, for example, clearly stating that your privacy and security
professionals will develop and release the courses. Additionally, the procedures describe the process to
access the training.

536

Examples of policy templates are provided in Appendix I of the main document.

537

Policy examples with descriptions and recommended users are provided in Table 8.
Policy Name

Description

User Base

Roles and
Responsibilities

Describe cybersecurity roles and responsibilities
throughout the organization, including who is
responsible for conducting security practices,
setting and establishing policy, and implementing
security practices.

Education and
Awareness

Describe the mechanisms by which the
organizational workforce will be trained on
cybersecurity practices, threats and mitigations.

Acceptable Use /
Email Use

Describe what actions users are permitted and not
permitted to execute, including detailed

descriptions of how email will be used to complete
work.

All users

Data Classification

Describe how data will be classified with usage
parameters for each classification.



All users

Personal Devices

Describe the organization’s position on usage of
personal devices – also referred to as Bring Your



All users



All users



All users



Cybersecurity
Department

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Own Device (BYOD). If usage of personal devices is
permitted, describe the expectations for how the
devices will be managed.
Laptop, Portable
Device, and Remote
Use

Describe the policies that relate to mobile device
security and how these devices may be used in a
remote setting.



All users



IT Departments

Incident Reporting
and Checklist

Describe requirements for users to report
suspicious activities in the organization and for the
cybersecurity department to manage incident
response.



All Users



Cybersecurity
Department

538

Table 8. Effective Policies Mitigate the Risk of Cyberattacks

539
540

Threats Mitigated

541

Email Phishing Attack

542

Ransomware Attack

543

Loss or Theft of Equipment or Data

544

Accidental or Intentional Data Loss

545

Attacks Against Connected Medical Devices that May Affect Patient Safety

546

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Appendix A: Acronyms and Abbreviations

547
548

Acronym/Abbreviation

Definition

AHIP

America’s Health Insurance Plans

ASL

Assistant Secretary for Legislation

ASPR

Assistant Secretary for Preparedness and Response

BYOD

Bring Your Own Device

CEO

Chief Executive Officer

CHIO

Chief Health Information Officer

CHIP

Children’s Health Insurance Program

CIO

Chief Information Officer

CISO

Chief Information Security Officer

CISSP

Certified Information Security Systems Professional

CMS

Centers for Medicare and Medicaid

CNSSI

Committee on National Security Systems Instruction

COO

Chief Operations Officer

CSA

Cybersecurity Act

DHS

Department of Homeland Security

DoD

Department of Defense

DOS

Denial of Service

DRP

Disaster Recovery Plan

DSM

Direct Secure Messaging

EHR

Electronic Health Record

EMR

Electronic Medical Record

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EPHI

Electronic Private Health Information

FDA

Food and Drug Administration

FIPS

Federal Information Processing Standards

HCIC

Health Care Industry Cybersecurity

HHS

Department of Health and Human Services

HIMSS

Health Information Management and Systems Society

HIPAA

Health Insurance Portability and Accountability Act

HIT

Health Information Technology

HITECH

Health Information Technology Economic and Clinical
Health Act

HMO

Health Maintenance Organization

HPH

Healthcare and Public Health

HRSA

Health Resources and Services Administration

IA

Information Assurance

IBM

International Business Machines

ICU

Intensive Care Unit

INFOSEC

Information Security

IoT

Internet of Things

IP

Intellectual Property or Internet Protocol

IPS

Internet Partner Services

ISAC

Information Sharing and Analysis Center

ISAO

Information Sharing and Analysis Organization

IT

Information Technology

ITAM

Information Technology Asset Management

LAN

Local Area Network

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LLC

Limited Liability Corporation

MAC

Media Access Control

MACRA

Medicare access and the Children’s Health Insurance
Program Reauthorization Act

MFA

Multi-Factor Authentication

NCCIC

National Cybersecurity and Communications
Integration Center

NH-ISAC

National Healthcare – Information Sharing and
Analysis Centers

NIST

National Institute of Standards and Technology

NVD

National Vulnerability Database

OCIO

Office of the Chief Information Officer

OCR

Office for Civil Rights

ONC

Office of the National Coordinator (for Healthcare
Technology)

PACS

Pictures Archiving and Communication Systems

PCI-DSS

Payment Card Industry Data Security Standard

PHI

Personal Health Information

PII

Personal Identifiable Information

ROM

Read Only Memory

SAMHSA

Substance Abuse and Mental Health Services
Administration

SOC/IR

Security Operations Center / Incident Response

SSN

Social Security Number

SVP

Senior Vice President

URL

Uniform Resource Locator

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US-CERT

United States Computer Emergency Readiness Team

USB

Universal Serial Bus

VP

Vice President

VPN

Virtual Private Network

549

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