1. Security & Privacy of
Health Data
Nawanan Theera‐Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospital
Mahidol University
August 7, 2013
http://www.SlideShare.net/Nawanan

2.  Introduction to Information Privacy & Security
 Privacy Laws
 Protecting Information Privacy & Security
 User Security
 Malware
Outline

3. Introduction to
Information Privacy &
Security

4. Malware
Threats to Information Security

5. Sources of the Threats
 Hackers
 Viruses & Malware
 Poorly‐designed systems
 Insiders (Employees)
 People’s ignorance & lack of knowledge
 Disasters & other incidents affecting
information systems

6.  Disclosure of patient’s confidential information
 Unauthorized modification of patient
information
 Patient care disrupted
 Patient’s health risks
 Organization’s financial losses
 Damage to reputation & trust
Consequences of Attacks on
Health Data & Systems

7.  Privacy: “The ability of an individual or group
to seclude themselves or information about
themselves and thereby reveal themselves
selectively.” (Wikipedia)
 Security: “The degree of protection to safeguard
... person against danger, damage, loss, and
crime.” (Wikipedia)
 Information Security: “Protecting information
and information systems from unauthorized
access, use, disclosure, disruption, modification,
perusal, inspection, recording or destruction”
(Wikipedia)
Privacy & Security

8. Health Information
Privacy Laws

9. http://www.aclu.org/ordering‐pizza
Privacy Protections: Why?

10.  Respect for Persons (Autonomy)
 Beneficence
 Justice
 Non‐maleficence
Ethical Principles in Bioethics

11. Hippocratic Oath
...
What I may see or hear in the course of
treatment or even outside of the
treatment in regard to the life of men,
which on no account one must spread
abroad, I will keep myself holding such
things shameful to be spoken about.
...
http://en.wikipedia.org/wiki/Hippocratic_Oath

12. Thailand’s Health
Information Privacy
Law

13. 7. ผู้ป่วยมีสิทธิที่จะได้รับการปกปิดข้อมูลเกี่ยวกับ
ตนเอง จากผู้ประกอบวิชาชีพด้านสุขภาพโดย
เคร่งครัด เว้นแต่จะได้รับความยินยอมจากผู้ป่วย
หรือการปฏิบัติหน้าที่ตามกฎหมาย ผู้ป่วยมีสิทธิที่
จะได้รับทราบข้อมูลอย่างครบถ้วน
คําประกาศสิทธิผู้ป่วย

14.  “มาตรา 7 ข้อมูลด้านสุขภาพของบุคคล เป็นความลับส่วน
บุคคล ผู้ใดจะนําไปเปิดเผยในประการที่น่าจะทําให้บุคคลนั้น
เสียหายไม่ได้ เว้นแต่การเปิดเผยนั้นเป็นไปตามความประสงค์
ของบุคคลนั้นโดยตรง หรือมีกฎหมายเฉพาะบัญญัติให้ต้อง
เปิดเผย แต่ไม่ว่าในกรณีใด ๆ ผู้ใดจะอาศัยอํานาจหรือสิทธิ
ตามกฎหมายว่าด้วยข้อมูลข่าวสารของราชการหรือกฎหมาย
อื่นเพื่อขอเอกสารเกี่ยวกับข้อมูลด้านสุขภาพของบุคคลที่ไม่ใช่
ของตนไม่ได้”
พรบ.สุขภาพแห่งชาติ พ.ศ. 2550

15. Privacy Safeguards
Image: http://www.nurseweek.com/news/images/privacy.jpg
 Security safeguards
 Informed consent
 Privacy culture
 User awareness building & education
 Organizational policy & regulations
 Enforcement
 Ongoing privacy & security assessments, monitoring,
and protection

16. Protecting Security

17. Information Security
 Confidentiality
 Integrity
 Availability

18. Examples of Confidentiality Risks
http://usatoday30.usatoday.com/life/people/2007‐10‐10‐clooney_N.htm

19. Examples of Integrity Risks
http://www.wired.com/threatlevel/2010/03/source‐code‐hacks/
http://en.wikipedia.org/wiki/Operation_Aurora
“Operation Aurora”
Alleged Targets: Google, Adobe, Juniper Networks,
Yahoo!, Symantec, Northrop Grumman, Morgan Stanley,
Dow Chemical
Goal: To gain access to and potentially modify source
code repositories at high tech, security & defense
contractor companies

20. Examples of Integrity Risks
http://news.softpedia.com/news/700‐000‐InMotion‐Websites‐Hacked‐by‐TiGER‐M‐TE‐223607.shtml
Web Defacements

21. Examples of Availability Risks
http://en.wikipedia.org/wiki/Blaster_worm
Viruses/worms that led to instability &
system restart (e.g. Blaster worm)

22. Alice
Simplified Attack Scenarios
Server Bob
Eve/Mallory

23. Alice
Simplified Attack Scenarios
Server Bob
‐ Physical access to client computer
‐ Electronic access (password)
‐ Tricking user into doing something
(malware, phishing & social
engineering)
Eve/Mallory

24. Alice
Simplified Attack Scenarios
Server Bob
‐ Intercepting (eavesdropping or
“sniffing”) data in transit
‐ Modifying data (“Man‐in‐the‐
middle” attacks)
Eve/Mallory

25. Alice
Simplified Attack Scenarios
Server Bob
‐ Unauthorized access to servers through
‐ Physical means
‐ User accounts & privileges
‐ Attacks through software vulnerabilities
‐ Attacks using protocol weaknesses
‐ DoS / DDoS attacks Eve/Mallory

26. Alice
Simplified Attack Scenarios
Server Bob
Other & newer forms of
attacks possible
Eve/Mallory

27. Alice
Safeguarding Against Attacks
Server Bob
Administrative Security
‐ Security & privacy policy
‐ Governance of security risk management & response
‐ Uniform enforcement of policy & monitoring
‐ Disaster recovery planning (DRP) & Business continuity
planning/management (BCP/BCM)
‐ Legal obligations, requirements & disclaimers

28. Alice
Safeguarding Against Attacks
Server Bob
Physical Security
‐ Protecting physical access of clients & servers
‐ Locks & chains, locked rooms, security cameras
‐ Mobile device security
‐ Secure storage & secure disposition of storage devices

29. Alice
Safeguarding Against Attacks
Server Bob
User Security
‐ User account management
‐ Strong p/w policy (length, complexity, expiry, no meaning)
‐ Principle of Least Privilege
‐ “Clear desk, clear screen policy”
‐ Audit trails
‐ Education, awareness building & policy enforcement
‐ Alerts & education about phishing & social engineering

30. Alice
Safeguarding Against Attacks
Server Bob
System Security
‐ Antivirus, antispyware, personal firewall, intrusion
detection/prevention system (IDS/IPS), log files, monitoring
‐ Updates, patches, fixes of operating system vulnerabilities &
application vulnerabilities
‐ Redundancy (avoid “Single Point of Failure”)

31. Alice
Safeguarding Against Attacks
Server Bob
Software Security
‐ Software (clients & servers) that is secure by design
‐ Software testing against failures, bugs, invalid inputs,
performance issues & attacks
‐ Updates to patch vulnerabilities

32. Alice
Safeguarding Against Attacks
Server Bob
Network Security
‐ Access control (physical & electronic) to network devices
‐ Use of secure network protocols if possible
‐ Data encryption during transit if possible
‐ Bandwidth monitoring & control

33. Alice
Safeguarding Against Attacks
Server Bob
Database Security
‐ Access control to databases & storage devices
‐ Encryption of data stored in databases if necessary
‐ Secure destruction of data after use
‐ Access control to queries/reports

34. User Security

35. Need for Strong Password Policy
So, two informaticians
walk into a bar...
The bouncer says,
ʺWhatʹs the password.ʺ
One says, ʺPassword?ʺ
The bouncer lets them
in.
Credits: @RossMartin & AMIA (2012)

36.  Access control
 Selective restriction of access to the system
 Role‐based access control
 Access control based on the person’s role
(rather than identity)
 Audit trails
 Logs/records that provide evidence of
sequence of activities
User Security

37.  Identification
 Identifying who you are
 Usually done by user IDs or some other unique codes
 Authentication
 Confirming that you truly are who you identify
 Usually done by keys, PIN, passwords or biometrics
 Authorization
 Specifying/verifying how much you have access
 Determined based on system owner’s policy & system
configurations
 “Principle of Least Privilege”
User Security

38.  Multiple‐Factor Authentication
 Two‐Factor Authentication
 Use of multiple means (“factors”) for authentication
 Types of Authentication Factors
 Something you know
 Password, PIN, etc.
 Something you have
 Keys, cards, tokens, devices (e.g. mobile phones)
 Something you are
 Biometrics
User Security

39. Recommended Password Policy
 Length
 8 characters or more (to slow down brute‐force attacks)
 Complexity (to slow down brute‐force attacks)
 Consists of 3 of 4 categories of characters
 Uppercase letters
 Lowercase letters
 Numbers
 Symbols (except symbols that have special uses by the
system or that can be used to hack system, e.g. SQL Injection)
 No meaning (“Dictionary Attacks”)
 Not simple patterns (12345678, 11111111) (to slow down brute‐
force attacks & prevent dictionary attacks)
 Not easy to guess (birthday, family names, etc.) (to prevent
unknown & known persons from guessing)
Personal opinion. No legal responsibility assumed.

40. Recommended Password Policy
 Expiration (to make brute‐force attacks not possible)
 6‐8 months
 Decreasing over time because of increasing computer’s
speed
 But be careful! Too short duration will force users to write
passwords down
 Secure password storage in database or system
(encrypted or store only password hashes)
 Secure password confirmation
 Secure “forget password” policy
 Different password for each account. Create variations
to help remember. If not possible, have different sets of
accounts for differing security needs (e.g., bank
accounts vs. social media sites) Personal opinion. No legal responsibility assumed.

41. Techniques to Remember Passwords
 One easy & secure way: password
mnemonic
 Think of a full sentence that you can
remember
 Ideally the sentence should have 8 or more
words, with numbers and symbols
 Use first character of each word as password
 Sentence: I love reading all 7 Harry Potter
books!
 Password: Ilra7HPb!
 Voila!
Personal opinion. No legal responsibility assumed.

42. Dear mail.mahidol.ac.th Email Account User,
We wrote to you on 11th January 2010 advising that you change the password on
your account in order to prevent any unauthorised account access following
the network instruction we previously communicated.
all Mailhub systems will undergo regularly scheduled maintenance. Access
to your e‐mail via the Webmail client will be unavailable for some time
during this maintenance period. We are currently upgrading our data base
and e‐mail account center i.e homepage view. We shall be deleting old
[https://mail.mahidol.ac.th/l accounts which are no longer active to create
more space for new accountsusers. we have also investigated a system wide
security audit to improve and enhance
our current security.
In order to continue using our services you are require to update and
re‐comfirmed your email account details as requested below. To complete
your account re‐comfirmation,you must reply to this email immediately and
enter your account
details as requested below.
Username :
Password :
Date of Birth:
Future Password :
Social Engineering Examples
Real social‐engineering e‐mail received by Speaker

43. Phishing
Real phishing e‐mail received by Speaker

44.  Poor grammar
 Lots of typos
 Trying very hard to convince you to open
attachment, click on link, or reply without
enough detail
 May appear to be from known person (rely on
trust & innocence)
Signs of a Phishing Attack

45.  Don’t be too trusting of people
 Always be suspicious & alert
 An e‐mail with your friend’s name & info doesn’t have
to come from him/her
 Look for signs of phishing attacks
 Don’t open attachments unless you expect them
 Scan for viruses before opening attachments
 Don’t click links in e‐mail. Directly type in browser
using known & trusted URLs
 Especially cautioned if ask for passwords, bank
accounts, credit card numbers, social security numbers,
etc.
Ways to Protect against Phishing

46. Malware

47.  Virus
 Propagating malware that requires user action
to propagate
 Infects executable files, data files with
executable contents (e.g. Macro), boot sectors
 Worm
 Self‐propagating malware
 Trojan
 A legitimate program with additional, hidden
functionality
Malware

48.  Spyware
 Trojan that spies for & steals personal
information
 Backdoor/Trapdoor
 A hole left behind by malware for future access
Malware

49.  Rogue Antispyware (Ransomware)
 Software that tricks or forces users to pay before fixing
(real or hoax) spyware detected
 Botnet
 A collection of Internet‐connected computers that have
been compromised (bots) which controller of the
botnet can use to do something (e.g. do DDoS attacks)
Malware

50.  Installed & updated antivirus, antispyware, &
personal firewall
 Check for known signatures
 Check for improper file changes (integrity failures)
 Check for generic patterns of malware (for unknown
malware): “Heuristics scan”
 Firewall: Block certain network traffic in and out
 Sandboxing
 Network monitoring & containment
 User education
 Software patches, more secure protocols
Defense Against Malware

51.  Social media spams/scams/clickjacking
 Social media privacy issues
 User privacy settings
 Location services
 Mobile device malware & other privacy risks
 Stuxnet (advanced malware targeting certain
countries)
 Advanced persistent threats (APT) by
governments & corporations against specific
targets
Newer Threats

52. Q & A