Mitigations for the Digital Health Era

 By Shahid N. Shah MS

There has been a tremendous explosion of information technology (IT) in healthcare caused by billions of dollars of government incentives for usage of digital healthcare tools. But, IT systems face threats with significant adverse impacts on institutional assets, patients, and partners if sensitive data is ever compromised. Every health enterprise is required to confidentiality, integrity and availability of its information assets (this is called “information assurance” or IA). Confidentiality means private or confidential information must not be disclosed to unauthorized persons. Integrity means that the information can be changed only in an authorized manner so as to maintain the correctness of the information. Availability defines the characteristic that information systems work as intended and all services are available to its users whenever necessary.

It is well known that healthcare organizations face and have been mitigating many risks such as investment risk, budgetary risk, program management risk, safety risk, and inventory risk for many years. What’s new in the last decade or so is that organizations must now manage risks related to information systems because  operating systems [OSs] are also at risk. IT is now just as a critical an asset as most other infrastructure managed by health systems. It is important that information security risks are given the same or more importance and priority as given to other organizational risks.

As health records move from paper native to digital native, it’s vital that organizations have information risk management programs and security procedures that woven into the culture of the organization. For this to happen, basic requirements of information security must be defined and implemented as part of both the operational and management processes. A framework that provides guidance on how to perform these activities, and the co-ordination required between these activities is needed.


The Risk Management Framework (RMF), supported by the National Institute of Standards and Technology (NIST) provides this framework. The NIST 800 series publications provide a structured approach to achieve risk management. It provides broad guidance and not necessarily all the prescriptions, which means it can be tailored to meet the organization’s specific needs and providing the flexibility needed for the different organizations. Using the NIST RMF helps organizations with risk management not only in a repeatable manner, but also with greater efficiency and effectiveness. Healthcare information assurance is complex and without a framework that takes into account a broad risk management approach, it is difficult to consider all the intricacies involved.

NIST Risk Management Framework

The NIST Risk Management Framework consists of a six step process designed to guide organizations in managing the risks in their information systems. The various steps as defined in the NIST specifications are the following:

  • Categorize the information system and the information processed, stored, and transmitted by that system based on an impact analysis.
  • Select an initial set of baseline security controls for the information system based on the security categorization; tailoring and supplementing the security control baseline as needed based on an organizational assessment of risk and local conditions
  • Implement the security controls and describe how the controls are employed within the information system and its environment of operation.
  • Assess the security controls using appropriate assessment procedures to determine the extent to which the controls are implemented correctly, operating as intended, and producing the desired outcome with respect to meeting the security requirements for the system.
  • Authorize information system operation based on a determination of the risk to organizational operations and assets, individuals, other organizations, and the Nation resulting from the operation of the information system and the decision that this risk is acceptable.
  • Monitor the security controls in the information system on an ongoing basis including assessing control effectiveness, documenting changes to the system or its environment of operation, conducting security impact analyses of the associated changes, and reporting the security state of the system to designated organizational officials.



Worst case scenario

All information systems process, store and transmit information. What is the possible impact if a worst case scenario occurs that causes endangers this information? A structured way to find out the potential impact on the confidentiality, integrity and availability of information can be done through the first step of NIST RMP, the categorization of information systems. The NIST SP 800-60  provides such guidance. The potential impact is assigned qualitative values – low, moderate, or high. Based on these impact levels for each of the information type contained in the system, the high water mark level is calculated, that helps in selecting the appropriate controls in the subsequent steps.

Organizations need to mitigate risks adequately by selecting an appropriate set of controls that would work effectively. In the selection of security controls step, the set of controls are chosen based on the categorization of the information system, the high water mark and the goals of the organizations. These baseline controls are selected from NIST SP 800-53  specification, one of three sets of baseline controls, corresponding to low, moderate, high impact rating of the information system. These baseline controls can be modified to meet specific business needs and organization goals. These tailored controls can be supplemented with additional controls, if needed, to meet unique organizational policies and environment factors and its security requirements and its risk appetite. The minimum assurance requirements need to be specified here.

All the activities necessary for having the selected controls in place, is done in the implementation of security controls step. The implementation of the selected security controls will have an impact on the organization risks and its effects. NIST SP 800-70 can be used as guidance for the implementation. An implementation strategy has to be planned and the actions have to be defined and the implementation plan needs to be reviewed and approved, before the implementation is done.

Once the controls are implemented, then the assessment of security controls is done to find out whether the controls have been correctly implemented, working as intended, and giving the desired output with respect to the security requirements. In short, whether the applied security controls are indeed the right ones, done in the right way, giving the right outcome. NIST SP 800-53,, NIST 800-53A, NIST 800-115 can provide the necessary guidance, here.

IS authorization

The authorization of information systems is an official management decision, authorizing that the information system can be made operational, with the identified risks mitigated and the residual risks accepted, and is accountable for any adverse impacts on the confidentiality, integrity and availability of information systems. If the authorizing personnel find that the risks are not mitigated and hence can compromise the sensitive information, they can deny authorizing the information system. NIST SP 800-37 provides guidance on authorization. The authorizing personnel are to be involved actively throughout the risk management process.

Risk management is not one-time process, that once it is done, it is forgotten. It is a continuous process, to be integrated with day-to-day activities. One of the key aspects of any risk management is the monitoring of security controls to check whether the controls are performing as intended. The main focus of monitoring security controls is to know whether the controls are still effective over a period time, given the changes that occur in the information systems — the changes in hardware, software and firmware, the changes in environment factors, operating conditions etc. NIST SP 800-37  provides guidance about this. And if the security controls are found to be ineffective, the cycle starts again, with either re-categorization or selecting another set of baseline controls, or assessing the effectiveness of the controls once more etc.

And, in all the steps in risk management framework, one of the important aspects is communication. Appropriate documents needed to be generated in all the steps, reviewed and kept up-to-date.


Organizational risk management provides great benefits to the organization because it helps to prioritize the resources, increase interoperability, and reduce costs incurred due to the adverse effects. It helps to prevent unauthorized access to personally identifiable information which will lead to security breaches.


Your thoughts are appreciated.


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6 Responses

  1. Where have all the dental EHR salespeople gone?

    A decade ago, giddy stakeholders, cheerleaders and hangers-on for electronic dental records believed the ADA-supported rumor that digital records were to be mandated and there was nothing dentists could do to stop it. Nobody considered dental EHRs would become so dangerous and costly that promoters would have to censor, ignore or otherwise hide from customers with concerns about cost and safety.

    Well, nobody but me!

    Darrell K. Pruitt DDS

    Liked by 3 people

  2. The value of stolen medical records

    “Can The Health Care Industry Protect Itself from Cyberattacks? – While data breaches in the banking and retail space are well documented, breaches in the health care industry have not received the considerable media attention they deserve.”

    By Seyfarth Shaw LLP for JD
    Supra, October 22, 2018


    Medical data is big business and is worth top dollar on the black market—up to $1000 per patient. The going rate for Social Security numbers on the black market is 10 cents and credit card numbers can fetch upwards of 25 cents.

    But electronic medical health records—which consist of demographic information and data about past medical history, including doctor’s visits and diagnoses—could be worth hundreds or even thousands of dollars.

    That’s because medical records are the most comprehensive records about the identity of a person that exist today. If stolen, medical records can be used to buy medical equipment or drugs—either of which can be resold—or to file fraudulent insurance claims. If that isn’t frightening enough, because medical records cannot be canceled, they lack the kinds of protection that credit cards and other financial information provide.

    Darrell Pruitt DDS


  3. Healthcare Cybersecurity in Intensive Care

    “Despite regulatory mandates and years of costly data breaches in the healthcare industry, a recent survey found that less than one-third of healthcare organizations say they have a comprehensive cybersecurity programin place.”

    George V. Hulme for Security Boulevard
    December 21, 2018


    Darrell Pruitt DDS


  4. Jussie Smollett Medical Records

    Dozens Of Northwestern Hospital Workers Fired For Improperly Reviewing Jussie Smollett Records, Sources Say – OR Not so!


    Dr. David E. Marcinko MBA


  5. Who Do Consumers Trust to Keep Digital Healthcare Information Secure?

    1. Hospitals I visit: 84%
    2. My doctor(s) or other healthcare providers: 83%
    3. My pharmacy: 82%
    4. Labs that process my medical tests: 80%
    5. My health insurance company: 75%
    6. Urgent care or walk-in retail clinic I visit: 74%
    7. Non-medical staff at my doctor’s or health provider’s office: 63%
    8. Tech companies: 45%
    9. Government: 38%

    Notes: Survey data is from November to December 2019

    Source: Accenture


  6. The dangers of a quantum computer and health and financial records

    In the near future, quantum computers will be so advanced that they will have the capability to simulate very complicated systems. This could be used for simulations in physics, aerospace engineering, cybersecurity, HIPAA, bank, block-chain and financial data, and much more.

    However, once this computer is built, it has the potential to unravel data encryption protocols. It could also potentially compromise air gaps due to its ability to scan vast distances for nearby networked devices or applications that are open.

    This means that it can become even simpler for external hackers. They may already have access to your computer or computer system via other avenues, like vulnerabilities in web browsers. They could find it much easier because you’re not locking up all the doors.

    Dr. David E. Marcinko MBA


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