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Vol. 13
ADVANCING THE BIOMEDICAL / HTM PROFESSIONAL
DIGITAL SUPPLEMENT
Securing the Modern HTM Environment PAGE 2
Secure Network: HTM, IT Collaboration Vital for Hospitals PAGE 4
Helping HTM Teams Overcome Top 5 IoMT Challenges PAGE 8
Introducing Ordr Clinical Defender PAGE 11
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Securing the Modern HTM Environment
An Interview With Ben Stock, Director Healthcare Product Management, Ordr
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he explosion of connected devices in healthcare is revolutionizing hospital systems and patient care. Hospitals can now automate clinical workflows, improve patient care, enable better efficiencies. The pandemic accelerated digital transformation, which is expected to triple connected medical device spending over the next few years.
However, the connected nature of medical devices poses a challenge in cybersecurity risks. Internet of medical things (IoMT) are not always designed with security in mind, often run outdated operating systems, and frequently have risks such as weak, default passwords. In addition to the risk of patient data being exfiltrated, a compromised IoMT system may act as a springboard for an attacker to access the rest of the network. Kevin Fu, the former top US Food and Drug Adminstration (FDA) cybersecurity expert has said that “it’s only a matter of time before disaster strikes in the form of a medical device exploit that could harm patients.” Risks notwithstanding, HTM and clinical engineering teams need to embrace the connected healthcare future, and more efficiently scale the management of medical IoT devices. Ben Stock spent more than 17 years managing and leading clinical engineering operations at SSM Health, before joining Ordr to work on healthcare product development. We spoke to Ben about Ordr, the importance of clinical asset and risk management, and why he made the transition from managing them to helping develop them. CAN YOU TELL US MORE ABOUT ORDR? Ordr is a three-time KLAS healthcare IoT security leader. We discover and secure connected devices, and are deployed in the top healthcare systems and hospitals in the world. 2
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Our connected device security platform can be used by cybersecurity and IT, as well as HTM teams. We recently launched the Ordr Clinical Defender, built on Ordr’s foundational asset and risk management features, to enable HTM teams to more efficiently and accurately manage their connected medical devices. YOU DECIDED TO JOIN ORDR TO WORK ON HEALTHCARE PRODUCT DEVELOPMENT. CAN YOU SHARE YOUR STORY BEHIND WHAT DROVE YOU DOWN THIS CAREER PATH? Healthcare is a key focus for Ordr, and with Wannacry as a catalyst in 2019, Ordr was already discovering and securing medical devices in many healthcare environments. I wanted to build on this foundation to simplify clinical asset and vulnerability management for HTM and clinical engineering teams. For product management teams, some of the most exciting projects to work on are breakthrough products that solve real problems people didn’t even realize they had. That’s what I’m doing here. I have a very unique perspective from decades spent as a practitioner, where I can put myself in our customers’ shoes. Connected devices in healthcare is changing the world, and HTM teams need to more effectively manage them and secure them from malicious actors and others looking to do harm. The ability to enable clinical engineering teams to see every medical device at a granular level, identify their vulnerabilities, gain utilization insights, and automate their lifecycle management is extremely rewarding. AS A FORMER HTM AND CLINICAL ENGINEERING LEADER, WHAT ARE SOME OF THE CHALLENGES WITH MANAGING CONNECTED MEDICAL DEVICES? There are a number of challenges when it comes to managing connected medical devices. First, you can’t secure what you don’t know about. But CMMS systems are often not up to date, or cannot provide
real-time insights. That makes it very hard to understand your risks, and to locate missing or misplaced devices. You can spend 30-60 minutes per person per shift looking for devices. Additionally, medical devices go through a very vigorous FDA approval process before they are deployed, so by the time they are deployed, they may be running older operating systems. When there are hundreds of thousands of medical devices in the network, how do you identify the ones with critical vulnerabilities, and where do you focus patching efforts? The traditional vulnerability management solutions can impact medical device operations. Finally, HTM and clinical engineering teams want to understand whether devices are being used efficiently. This is important for clinical asset efficiencies. WHAT IS UNIQUE ABOUT THE ORDR CLINICAL DEFENDER PLATFORM? Ordr Clinical Defender addresses the unique and critical use cases for HTM teams. As part of our design and development efforts, we worked very closely with HTM users across the Ordr customer base to ensure Ordr Clinical Defender is optimized for every one of their needs. These include: • Real-time visibility of every connected device in healthcare – Ordr discovers and automatically classifies every device at a granular level, from make, model, serial number, to where they are located and what they are communicating with in the network. • Automated lifecycle management – Manual CMMS processes are inefficient. It can be challenging to understand if there are new devices, devices that are missing or stolen, which ones are connected, and where they are in real-time. Ordr can integrate with CMMS Sponsored by ordr
“When it comes to developing a medical device security strategy it’s a team sport.”
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and deliver insights about every device to free teams from manual, time consuming processes. We can automate the device lifecycle management, from when a device is first onboarded to when it is end of life. Vulnerability and risk management – There is no need to hunt for devices that are vulnerable as Ordr will discover them using a passive scanning method without impacting their operations. Ordr will identify and alert on devices with critical CVEs, devices with weak passwords and outdated certificates. Risk levels are provided so that clinical engineering teams can prioritize which devices to patch first. Ordr can also integrate with existing vulnerability management solutions to provide a complete view of which devices to scan and which not to scan. Device utilization – Ordr enables device insights so that HTM teams can make better decisions about over and under-used devices, schedule maintenance, and support procurement decisions.
YOU’VE SPOKEN AT CONFERENCES AND WEBINARS ABOUT THE IMPORTANCE OF CYBERSECURITY, IT AND HTM TEAMS WORKING TOGETHER. CAN YOU ELABORATE ON THIS? When it comes to developing a medical device security strategy it’s a team sport. Despite clinical engineering, cybersecurity, and networking teams sharing the same objectives, in many organizations they are siloed. It’s important that these three teams work together. For example, if there are devices running outdated operating systems that cannot be patched, clinical engineering teams need to work with their networking teams to segment them. Additionally, you must think about the “people, process, technology” considerations. If you decide that clinical asset management is important, and you purchase a product like Ordr, that’s the “technology” piece. You want to ensure you have support from your cybersecurity and IT leaders. You also need to have proper training to take advantage of the rich functionality of the product. Finally, you need to define appropriate clinical asset management processes, such as the owners and appropriate policies when high-risk devices or those running outdated operating systems are identified on the network. Sponsored by ordr
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SECURE NETWORK HTM, IT COLL ABOR ATION V ITAL FOR HOSPITAL S
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BY K. RICHARD DOUGLAS
W
hile there has been an evolution in the HTM/IT/IS ecosystem that has produced hybrid and specialist positions, the challenges that overlap the professions remain abundant.
The focus of these departments intertwines frequently and the goals of each group – to protect the integrity of the network, patient safety and hardening the ever-increasing surface of modern-day health care systems – unites all parties under a common umbrella. The roles of HTM and IT/IS require something of a balancing act. Both are critical to the facilities they serve, but often they have methods or protocols that conflict. As the universe of IoMT and IoT continues to expand, and devices containing patient protected health information (PHI) evolves, the need for collaboration across the groups is critical to workflows and cybersecurity. Today, it’s not enough to maintain the hardware and software of devices on the network. The perils posed by threat actors exploiting any possible vulnerability is continuously growing. That threat can target any medical device that has an operating system as well as any device that may connect to the Internet through the facility’s access points. For this reason, mitigation of threats is paramount and awareness of the entire surface that is vulnerable must be known to HTM and IT/IS and written protocols must be followed precisely. The methods used by cyber threat actors continue to grow as well. Collaboration between departments is key and any tips or insights to enhance and bolster that effort should be pursued. But what happens when circumstances outside of HTM’s control prevent the biomed department from being able to complete a project, or install a device on the network, because IT/IS will not approve it?
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THE HTM PERSPECTIVE While many goals and objectives of IT and biomed are closely aligned and many procedures are more standardized across both groups, the safety protocols that IT requires can often be frustrating when it encroaches on areas outside of biomed’s control. Other times, availability might hold up projects. Obsolete legacy platforms, that no longer receive security updates, have caused many problems. There have been several operating systems that have faced this inevitability in recent years. There was a time, not long ago, when most ATMs still ran Windows 7. Before that, many ATMs ran on Windows XP. These systems were in place even after they were considered obsolete. So, it comes as no surprise that this scenario may also impact biomeds who have the best intentions. Hosameldin “Sam” Elsemany, CCE, CBET, a clinical engineer in the department of clinical engineering with UConn Health has dealt with a related issue in the NICU area. “We are scheduled to go live with integrating our NICU bedside monitors with Epic and our network security team is refusing to connect the Philips server to the hospital since it has Windows 2008 OS,” Elsemany says. He says that there were a couple of options to connect the bedside monitors to Epic. “One option was to connect each bedside monitor to the network via HL7 middleware, but we couldn’t use that option because our bedside monitors are end-of-life and the serial port, needed to connect to the middleware, was not available to order,” Elsemany says. He says that the second option was to connect to the network via the Philips gateway server, and as mentioned, the server has W2008 and was never patched in the past. “Now we are exploring the possibility of patching the server, putting it behind a
firewall, and segmenting it on the network until the whole bedside monitor system is replaced/upgraded,” Elsemany says. He says that although it is very expensive to upgrade the NICU monitors and it was not on the hospital’s radar to purchase this year, due to supply chain issues, Philips has a lead time of 10 months to deliver the new monitors/server if they were purchased in May of this year. “That limits our options to connecting the outdated server to the network with all associated cybersecurity risks,” Elsemany says. “One tool we found very useful in mitigating and monitoring medical device cybersecurity risks is to use a healthcare security platform software application. The application monitors all devices connected to the hospital network, provides detailed reports of the risk level associated with each device and recommends how to mitigate those risks,” Elsemany adds. He says that it is then up to the CE team to work with the hospital network security team and vendors to patch the device or make network changes to alleviate the risks. “We invested in that software last year and it was a great step in the right direction towards creating a CE device cybersecurity program,” Elsemany adds. Elsemany says that regardless of the efforts taken by in-house CE/IT to minimize cybersecurity risks with medical devices, there will always be medical devices that received 510K clearance with now outdated operating systems such as Windows 7 and XP. “The vendor won’t have patches for those systems and CE must work with the IT team to find ways to reduce risks with those systems. CE must also have a plan to replace those systems in the near future to eliminate the risks,” he says. Aged operating systems provide a perfect illustration of when all parties want to do what is right, but collaboration is needed to explore all options.
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“Concerning some of the frustrations, it is important for HTM professionals to have a basic understanding of the job requirements of the IT/IS cybersecurity department. In my experience, they are not intentionally making things difficult in the installation, implementation or security management of medical equipment. It is extremely important for HTM departments to understand the ‘why’ behind IT/IS requirements for connected medical devices,” says Mike Busdicker, MBA, CHTM, FACHE, system director of clinical engineering at Intermountain Healthcare. He says that once biomed understands the requirements, it becomes imperative to be imbedded in the process and work collaboratively toward solutions. “There cannot be an ‘us and them’ mentality or we will hinder the ability to implement a program that benefits the patients we serve and the overall health care environment. There are a lot of bad players out there and we need to be on the same page in order to protect our organizations, caregivers and patients,” Busdicker says. He says that recently, their HTM department was struggling with the disabling of ports on their laptops because of cybersecurity risks. “This hindered the ability to download service software and connect to medical devices for calibration and troubleshooting. Our HTM medical equipment security team worked with the IT/IS cybersecurity team to establish an exemption process that would meet the requirements of both departments. This is an example of both departments working together to develop a solution to meet the needs of the health care system,” Busdicker adds.
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THE IT/IS PERSPECTIVE Some IT/IS security professionals clearly recognize the challenges placed before HTM because of the extraordinary advances in technology during the past decade. “The HTM field is changing as more and more medical devices are relying on microchips, an underlying off-the-shelf operating system and network/EMR integration. There is so much more to the HTM field than there used to be 10 years ago. Preventative maintenance is still critical, but there are so many more elements that can impact the clinical efficacy and the safety of devices on the network,” says Ali K. Youssef, director of medical device and IOT security, information privacy and security office at Henry Ford Health in Detroit. He says that IT team members have had years to hone their skills and mature frameworks and processes for dealing with cybersecurity. “Institutions like ISO, NIST and others have helped pave the way. IT teams are generally not mature in dealing with IOT and medical device security issues, or even understanding the medical device life cycle,” Youssef says. He says that some of the most common gaps in IT systems are: • Poor IOT/medical device identification and classification. The traditional tools do well with identifying servers and workstations, but do not address IOT/medical devices very well. • There is not an automated mechanism to sift through the thousands of ever-growing known vulnerabilities and correlate them to the IOT
and medical device inventory connected to the network. • There is not a clear automated way to gauge the risk associated with each vulnerability and boil down the most important devices to focus on. He says that in order to deal with these challenges, people and processes alone are not sufficient. “We need to rely on technology, and more specifically medical device and IOT security management tools,” Youssef says.“Without these tools, the task of understanding and remediating risks associated with medical devices is extremely difficult and time consuming. Understanding and sifting through the volume of vulnerabilities coming out on a daily basis manually is a poor use of time and resources,” Youssef says. Youssef adds that from an healthcare delivery organization (HDO) standpoint, medical device and IOT security can be aligned around existing cybersecurity programs. “There are some key things to be aware of when we’re dealing with medical devices on the network. Passive security scanning is as far as one can go in order to avoid impacting the functionality of a given medical device. The devices often do not integrate with active directory and do not support AV or EDR. Minor changes can be made to existing HTM policies to include a security focus. For example, requesting security documents like the MDS2 and SBOM from the medical device manufacturers, prior to procurement, ensuring that there is a focus on cybersecurity as a part of the
The HTM field is changing as more and more medical devices are relying on microchips, an underlying off-the-shelf operating system and network/EMR integration. There is so much more to the HTM field than there used to be 10 years ago. - Ali K. Youssef
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COVER STORY preventative maintenance and ultimately ensuring the devices are wiped appropriately during the decommissioning process,” he says. Youssef points out that scenarios will arise where a medical device may require a firmware patch due to a known vulnerability. Assuming a patch is available from the manufacturer, in many cases HTM departments have to quickly find the devices and install the patch on a device per device basis. “Some of the newer medical devices allow for centralized management, but unfortunately the majority of medical devices in use throughout health systems are anywhere between 10 to 20 years old. Having the ability to bring in staff augmentation to help quickly for these types of scenarios is important and can help to prevent staff burnout,” he says. Youssef says that as HDOs focus on medical device security, it is becoming increasingly important to have dedicated teams focused on this area that can speak the language of IT and HTM. “The trend toward cross training HTM on IT principals and vice versa continues to be critical. The Configuration Management Database (CMDB) and CMMS need to have some level of integration in order for each to enrich the data of the other. The goal of both departments is to improve patient safety and promote the confidentiality, integrity and availability of medical devices which requires cooperation from both teams,” he says. CHALLENGES AND REALITIES There are some challenges that are likely to frustrate HTM when either timing or technology limitations are obstacles to repairs or maintenance. “It is hard for the standard IT desktop/application team to understand that medical devices using common operating systems cannot just be ‘patched.’ A patch could have an ill-effect on the medical device application side of the device. If there is a vulnerability with the OS, the device should be segmented or placed behind a dedicated firewall. Both sound easy when you read and think
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about it, but configuration, testing and deployment all need to then occur. Time, money and other resources are required. However, segmenting and firewalling could be a faster solution than a patch that needs to go through FDA validation,” says David Soffer, manager of the medical device IS specialist team at WellSpan Health. Occasionally, HTM will also face challenges because of storage trends when adding new equipment to the network or making replacements. “The cloud is here, and devices are sending data up ‘there.’ We have devices that send to the vendor’s cloud space. Data is collected and then available for review and analytics. Our IT security team reviewed the cloud server connections from the vendor documentation and allowed the IP and port for communication. As we acquire equipment, it goes through a very large technology assessment. That way all technical teams involved, along with the customer and vendor, can discuss options, challenges and solutions that are available,” Soffer says. He says that in the IT world, a great defense comes with a great offense. “If we set up the device accordingly, to make it as secure as possible, there should be minimal issues with connectivity. Unfortunately, it always seems the dark side of hacking and finding OS holes is faster than our defense,” Soffer says. Is there any way to streamline the permissions required by IT when new equipment is placed on the network? “As mentioned above, we perform a technology assessment with the vendor pre-purchase for new medical equipment being requested. The vendor is provided the form in advance so their appropriate teams can answer the questions,” Soffer says. He says that the questions focus on network connectivity, server requirements, application deployment for workstations and so on. “There are also questions about special power, ventilation, fluids such as steam or water, consumables, user training, etc. There is even more to the form which provides information needed
in advance to provide a successful purchase, installation and user deployment. The days of devices just showing up because someone was able to sneak a PO through the purchasing system are long over. Working together provides a successful outcome,” Soffer adds. What if the system is down and the part being replaced needs to be re-registered on the network and it is off-hours? “This is your worst-case scenario question. Like a CT reconstruction computer goes down and the vendor is working with the local hospital on-call imaging technician. But then the on-call tech realizes the new computer will not plug right into the network because it is DHCP reserved IP. Now the network team needs to be called so someone can update the switch port with the new MAC address of the reconstruction computer. Am I far off from a real-world situation?” Soffer asks. He says that luckily, he does have on-call procedures, escalation trees and IT managers that rotate on-call. “Everyone likes to think they have the worst of the worst figured out for afterhours coverage, but it doesn’t always go the way it has been planned. If we have a system outage, we have an escalation process that brings teams and leaders together on a live call. This is like a verbal incident command where staff are reporting in, leaders are making decisions and work is being tasked. Having the live communication with real-time decision making and feedback is a seamless way to work through and eventually solve issues,” Soffer says. Busdicker says that within his health care system, they have an IT/IS team dedicated to the cybersecurity of the organization and there are caregivers within the HTM department focusing on medical equipment. “These two teams meet routinely, communicate constantly and work collaboratively to ensure we are fulfilling the requirements associated with medical equipment security and data protection. To bridge the requirements, and ensure a safe environment, these teams need to be on the same page with the same end goal in mind,” he says.
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Helping HTM Teams Overcome Top 5 IoMT Challenges I
oMT devices have introduced unique challenges for HTM teams and come with new responsibilities that extend beyond daily management and maintenance tasks. Challenges and complexity increase as more devices are introduced at a rapid rate to keep pace with growth plans, meet electronic health records (EHR) requirements, and support other modernization efforts. Approaching IoMT device management with the appropriate strategy and leveraging tools with the right capabilities can help reduce complexity and improve efficiency. The following are five common challenges HTM teams face when managing and securing IoMT devices with insights to overcome each one. MAINTAINING AN ACCURATE INVENTORY OF IOMT DEVICES CHALLENGE: An accurate inventory of all devices under management is a foundational resource for anyone in the HTM role. Maintaining that inventory to ensure it’s up to date with comprehensive and accurate details for each device is an overwhelming task if left to manual efforts. Each device has unique characteristics, and the constant addition of newly connected IoMT devices can cause an inventory to drift out of sync with the reality of your environment. SOLUTION: Leveraging automation to discover IoMT devices can help ensure your inventory is always up to date even as new devices are connected. Automation can also help with the task of collecting essential device information that includes
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details such as manufacturer, model, serial number, and OS version. Any tool that enables automation should also integrate with your existing CMMS, CMDB, or other inventory management platforms to ensure you have a centralized view of all devices under management. Since agents are not compatible with many IoMT devices and network scanning can have an adverse impact on operations, look for tools that passively analyze network traffic to meet your device discovery and inventory management requirements. IDENTIFYING IOMT DEVICES WITH VULNERABILITIES AND RECALLS CHALLENGE: New vulnerabilities and recalls are constantly emerging. Keeping up with the latest insights requires continuous monitoring of multiple sources such as threat feeds, manufacturer websites, and FDA or other agency alerts. When a new threat is discovered, quick action is essential to ensure devices, your environment, and patients are kept safe. Manual efforts to monitor multiple sources often results in a delayed response to critical insights or missing them altogether. SOLUTION: Aggregation of vulnerability and recall details from multiple sources can ensure threat insights are not missed. Combining this aggregated data with an inventory management tool, as mentioned above, will help you identify impacted devices in your environment so threats can be quickly addressed. The ability to assess overall device
risk is also essential to prioritizing remediation efforts. In addition to vulnerabilities and risk, it’s critical to also consider device characteristics such as OS version, patch levels, strength of passwords, and status of certificates when assessing risk. LOCATING MISSING DEVICES CHALLENGE: Many IoMT devices move throughout healthcare environments to meet demand or to ensure continuation of care. More devices might be needed in an emergency room to meet an influx of new patients and devices move as a patient is transferred to other parts of the hospital or even another facility. Devices might even be taken offline by staff in an attempt to “reserve” devices that are in high demand and short supply. All these factors impact your ability to properly manage and align a fleet of devices to meet demand. SOLUTION: Analyzing network traffic addresses inventory requirements as mentioned above and can also help keep track of device location. By analyzing network traffic, you gain details for each device, such as the network location (switch port or wireless access point) and connection status (connected, disconnected, and when last connected) to help pinpoint where devices are in the environment. Using a tool that analyzes network traffic can also help you pinpoint devices containing protected health information (PHI) or other sensitive data to help focus location efforts on
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high-risk devices to meet compliance requirements.
are in place to ensure devices and data are protected.
ENSURING DEVICES MEET COMPLIANCE REQUIREMENTS CHALLENGE: A major focus of compliance in healthcare is on the protection of sensitive data such as PHI. Devices with sensitive data connecting to the network introduce new challenges for teams that need to be mindful of requirements. Factors such as at-risk devices, a device deployed on the wrong area of the network, and device mobility can impact the ability to successfully meet compliance requirements. Keeping track of all devices and providing details required for compliance reporting can be a complex and time-consuming endeavor. SOLUTION: An up-to-date and accurate inventory is essential to assessing the compliance status of all your IoMT devices. From this inventory you can identify devices with potential violations such as outdated operating systems or misconfigurations. By combining external feeds, you can also identify devices with known vulnerabilities and recalls. A tool that analyzes network data can provide both these capabilities as well as provide insights into potential network violations such as a medical device deployed on a guest VLAN. Having all these insights centralized can also simplify reporting to help auditors understand device risk, how remediation has been applied, and what protections
GAINING INSIGHTS TO INFORM MAINTENANCE AND PROCUREMENT EFFORTS CHALLENGE: Understanding device utilization helps HTM teams align resources, plan maintenance tasks, and determine when new equipment should be purchased. Collecting these insights from individual devices is tedious. Without this information, teams risk impacting patient care when performing maintenance. They might also purchase new equipment when a better balance of utilization across a device fleet would address demand. SOLUTION: Leveraging a tool that provides insights into how and when devices are utilized can help teams plan maintenance at a time that will minimize impact to care. A tool that aggregates this insight from multiple devices can provide an accurate understanding of fleet level utilization to better balance patient load and avoid unneeded budget spending. When a determination is made that new devices are required, device utilization insights provide needed justification to management and procurement teams so budget can be spent with confidence.
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to continuously discover and classify all IoMT devices. The Ordr solution uses an agentless, passive approach for discovery that does not impact the performance of IoMT devices or the networks they are connected to. Through analysis Ordr automatically provides granular details for every device, understands how each device is behaving, and provides a visual map of your devices on the network. With Ordr you can: • Automate and ensure accuracy of the device inventory in your CMMS, CMDB, or another tool. • Gain a comprehensive understanding of threats with aggregated threat feeds and recall data. • Locate each device in your environment by network or physical location. • Simplify compliance with insights into violations and comprehensive reporting. • Optimize device usage and improve maintenance and procurement efforts with utilization insights. To learn more about the Ordr solution see the whitepaper Optimizing Medical Device Management and Security for
CONCLUSION Leveraging the right tools and automation is critical to keeping up with the constantly increasing demands of the HTM role. Ordr is a solution that helps HTM teams meet these demands by analyzing network traffic
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