April 28, 2025 3 Minute Read

• Understand the critical link between robust healthcare security, ransomware defense, and mandatory compliance (like HIPAA).
• See why ransomware remains a primary threat targeting healthcare, leading to significant data breaches and costly compliance failures.
• Explore essential strategies for healthcare organizations to achieve HIPAA compliance, manage risks effectively, and bolster security against ransomware attacks.

Neglecting regulatory compliance obligations, whether intentional or not, is not just a procedural error but a direct invitation for significant financial penalties, operational disruption, and, in the case of a healthcare organization, creating a potentially life-threatening situation.

These consequences were recently illustrated by the US Department of Health and Human Services (HHS), Office for Civil Rights (OCR). OCR settled a case with Guam Memorial Hospital Authority (GMHA) over a potential violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule, stemming from two separate cyber incidents.

In late 2018, a ransomware attack targeting GMHA allegedly exposed 5,000 electronic patient health information (ePHI). Then, in March 2023, two former GMHA employees allegedly gained unauthorized access to GMHA network systems.

"OCR's investigation determined that GMHA had failed to conduct an accurate and thorough risk analysis to determine the potential risks and vulnerabilities to ePHI held by GMHA", the report said.

Under the settlement with OCR, GMHA paid a $25,000 fine and will institute a corrective action plan to ensure compliance with the HIPAA Security Rule and protect the security of ePHI. OCR said this settlement marks OCR's 11th ransomware enforcement action.

Ransomware Remains the Top Danger to the Healthcare Sector

Trustwave SpiderLabs has actively tracked attacks against the healthcare industry, which can be seen in its latest research, Cybersecurity Challenges for Healthcare in 2025. The team notes in a supplemental report, Deep Dive on Ransomware Trends, that ransomware remains the primary threat facing the medical sector, with three threat actors – Ransomhub, Lockbit 3.0, and Dispossessor – accounting for 25% of all ransomware incidents.

According to the HIPAA Journal, the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) reported 725 healthcare-related data breaches in 2023, exposing 133 million records. HHS noted an almost continual upward trend in these numbers yearly since the data was first tracked 14 years ago. In 2023, OCR reported a 239% increase in hacking-related data breaches between January 1, 2018, and September 30, 2023, and a 278% increase in ransomware attacks over the same period.

OCR's corrective action plan included in the settlement requires GMHA to specifically follow the agency's basic security recommendations it has posted for all healthcare organizations.

Helping Alleviate Regulatory and Compliance Concerns

Navigating the labyrinth of healthcare and privacy regulatory issues impacting the healthcare industry is extremely difficult and requires personnel well-versed in what is required.

OCR required GMHA to make the following changes to its cybersecurity posture.

Conduct Comprehensive Risk Analysis

One of the foundational aspects of HIPAA compliance is conducting a thorough risk analysis. A proper risk analysis will look for potential vulnerabilities and threats to data, which provide a clear picture of an organization's security landscape. This initial step is crucial in understanding where improvements are needed and forms the basis for effective risk management strategies.

Implementing an Effective Risk Management Plan

Once risks are identified, the next step is to manage them effectively. Risk management plans should be tailored to an organization's unique needs, bring in outside help, like penetration test providers, when needed, and focus on mitigating identified risks while continuously monitoring systems to prevent potential breaches. The plan will also include understanding the risks associated with your supply chain. Ultimately, an effective risk management plan allows an organization to devise strategies that protect information and strengthen its overall security posture.

Reviewing Information System Activity

Regularly reviewing information system activity is essential in identifying unauthorized access and potential security threats through practices like database activity monitoring. These reviews enable organizations to monitor system activity continuously, providing insights into who is accessing data and how it is being used. This transparency is vital for detecting suspicious behavior early and maintaining compliance with HIPAA regulations.

Enhancing Security Training

Human error is often a significant factor in security breaches. This can be combated by offering comprehensive security training programs designed to educate staff about HIPAA regulations and best practices for protecting patient data. This should include:

• Defining PHI (e.g., names, medical records, billing information).
• Best practices should include handling, storing, transmitting, and disposing of PHI securely — including physical, administrative, and technical safeguards.
• Explain the internal reporting process and response protocols for suspected breaches and emphasize the importance of timely reporting.

Managing Access Credentials

Controlling access to patient information is critical in maintaining HIPAA compliance.

• Implementing role-based access controls that only grant access based on an employee's job role.
• Encrypt data in transit and at rest
• Assign each user a unique ID for system access.
• Require strong passwords and, ideally, multi-factor authentication (MFA)
• Regularly review who accesses PHI and when.
• Set up alerts for unusual or unauthorized access patterns.

Conducting Breach Risk Assessments

In the unfortunate event of a security incident, conducting a breach risk assessment is crucial to determine the impact and necessary response. Often, outside assistance, such as bringing in a digital forensics and incident response (DFIR) team, is needed to assess the severity of breaches, guide organizations in their response efforts, and implement measures to prevent future occurrences.

Trustwave's comprehensive suite of cybersecurity solutions can significantly aid healthcare organizations in meeting HIPAA requirements.

By partnering with Trustwave, you not only enhance your security measures but also gain peace of mind knowing that your patient data is protected. While HIPAA compliance may not be an easy journey, with the right tools and expertise, it becomes a manageable and rewarding endeavor.