Vulnerability to Cyberattacks and Sociotechnical Solutions for Health Care Systems: Systematic Review.

BACKGROUND: Health care organizations worldwide are faced with an increasing number of cyberattacks and threats to their critical infrastructure. These cyberattacks cause significant data breaches in digital health information systems, which threaten patient safety and privacy. OBJECTIVE: From a sociotechnical perspective, this paper explores why digital health care systems are vulnerable to cyberattacks and provides sociotechnical solutions through a systematic literature review (SLR). METHODS: An SLR using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was conducted by searching 6 databases (PubMed, Web of Science, ScienceDirect, Scopus, Institute of Electrical and Electronics Engineers, and Springer) and a journal (Management Information Systems Quarterly) for articles published between 2012 and 2022 and indexed using the following keywords: "(cybersecurity OR cybercrime OR ransomware) AND (healthcare) OR (cybersecurity in healthcare)." Reports, review articles, and industry white papers that focused on cybersecurity and health care challenges and solutions were included. Only articles published in English were selected for the review. RESULTS: In total, 5 themes were identified: human error, lack of investment, complex network-connected end-point devices, old legacy systems, and technology advancement (digitalization). We also found that knowledge applications for solving vulnerabilities in health care systems between 2012 to 2022 were inconsistent. CONCLUSIONS: This SLR provides a clear understanding of why health care systems are vulnerable to cyberattacks and proposes interventions from a new sociotechnical perspective. These solutions can serve as a guide for health care organizations in their efforts to prevent breaches and address vulnerabilities. To bridge the gap, we recommend that health care organizations, in partnership with educational institutions, develop and implement a cybersecurity curriculum for health care and intelligence information sharing through collaborations; training; awareness campaigns; and knowledge application areas such as secure design processes, phase-out of legacy systems, and improved investment. Additional studies are needed to create a sociotechnical framework that will support cybersecurity in health care systems and connect technology, people, and processes in an integrated manner.

Lightweight Crypto-Ransomware Detection in Android Based on Reactive Honeyfile Monitoring.

Given the high relevance and impact of ransomware in companies, organizations, and individuals around the world, coupled with the widespread adoption of mobile and IoT-related devices for both personal and professional use, the development of effective and efficient ransomware mitigation schemes is a necessity nowadays. Although a number of proposals are available in the literature in this line, most of them rely on machine-learning schemes that usually involve high computational cost and resource consumption. Since current personal devices are small and limited in capacities and resources, the mentioned schemes are generally not feasible and usable in practical environments. Based on a honeyfile detection solution previously introduced by the authors for Linux and Window OSs, this paper presents a ransomware detection tool for Android platforms where the use of trap files is combined with a reactive monitoring scheme, with three main characteristics: (i) the trap files are properly deployed around the target file system, (ii) the FileObserver service is used to early alert events that access the traps following certain suspicious sequences, and (iii) the experimental results show high performance of the solution in terms of detection accuracy and efficiency.

Combatting ransomware in ZephyrOS-activated industrial IoT environments.

The rapid growth of the Industrial Internet of Things (IIoT) has opened up new avenues for cyber threats, with ransomware being a primary area of concern. In response to this, proposed study introduces an innovative approach that combines the strength of the Gradient Boosting Machine (GBM) and the precision of Lasso Regression to effectively identify ransomware threats in IIoT settings. Functioning on the Zephyr operating system, the GBM's ability to handle large-scale datasets and traverse complex data dimensions is complemented by Lasso Regression's skill in curbing overfitting and extracting critical features. This combined ML technique is specifically designed to address the diverse data challenges of IIoT, providing a solid line of defense. Comprehensive tests on updated ransomware tools and the established RanSAP & IoT-23 datasets validated our model's capabilities, achieving an impressive 92 percent detection rate while keeping false positives to a minimum. When compared to existing strategies, projected solution showcased superior performance, highlighting its pivotal role in bolstering IIoT security against ransomware attacks. These results shed light on the next steps for ensuring a safer IIoT landscape, emphasizing the need for advanced, flexible cybersecurity measures in our ever-evolving industrial ecosystem.

Ransomware Cyberattack Associated With Cardiac Arrest Incidence and Outcomes at Untargeted, Adjacent Hospitals.

OBJECTIVES: Healthcare ransomware cyberattacks have been associated with major regional hospital disruptions, but data reporting patient-oriented outcomes in critical conditions such as cardiac arrest (CA) are limited. This study examined the CA incidence and outcomes of untargeted hospitals adjacent to a ransomware-infected healthcare delivery organization (HDO). DESIGN SETTING AND PATIENTS: This cohort study compared the CA incidence and outcomes of two untargeted academic hospitals adjacent to an HDO under a ransomware cyberattack during the pre-attack (April 3-30, 2021), attack (May 1-28, 2021), and post-attack (May 29, 2021-June 25, 2021) phases. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Emergency department and hospital mean daily census, number of CAs, mean daily CA incidence per 1,000 admissions, return of spontaneous circulation, survival to discharge, and survival with favorable neurologic outcome were measured. The study evaluated 78 total CAs: 44 out-of-hospital CAs (OHCAs) and 34 in-hospital CAs. The number of total CAs increased from the pre-attack to attack phase (21 vs. 38; p = 0.03), followed by a decrease in the post-attack phase (38 vs. 19; p = 0.01). The number of total CAs exceeded the cyberattack month forecast (May 2021: 41 observed vs. 27 forecasted cases; 95% CI, 17.0-37.4). OHCA cases also exceeded the forecast (May 2021: 24 observed vs. 12 forecasted cases; 95% CI, 6.0-18.8). Survival with favorable neurologic outcome rates for all CAs decreased, driven by increases in OHCA mortality: survival with favorable neurologic rates for OHCAs decreased from the pre-attack phase to attack phase (40.0% vs. 4.5%; p = 0.02) followed by an increase in the post-attack phase (4.5% vs. 41.2%; p = 0.01). CONCLUSIONS: Untargeted hospitals adjacent to ransomware-infected HDOs may see worse outcomes for patients suffering from OHCA. These findings highlight the critical need for cybersecurity disaster planning and resiliency.

Design and Pilot Study of a High-Fidelity Medical Simulation of a Hospital-Wide Cybersecurity Attack.

Background: Cybersecurity incidents affecting hospitals have grown in prevalence and consequence over the last two decades, increasing the importance of cybersecurity preparedness and response training to minimize clinical disruptions. This work describes the development, execution, and post-exercise assessment of a novel simulation scenario consisting of four interlocking intensive care unit (ICU) patient scenarios. This simulation was designed to demonstrate the management of acute pathologies without access to conventional treatment methods during a cybersecurity incident in order to raise clinician awareness of the increasing incidence and patient safety implications of such events. Methods: The simulation was developed by a multidisciplinary team of physicians, simulation experts, and medical education experts at UCSD School of Medicine. The simulation involves the treatment of four patients, respectively experiencing postoperative hemorrhage, end stage renal disease, diabetic ketoacidosis, and hypoxic respiratory failure, all without access to networked medical resources. The simulation was first executed as part of the proceedings of CyberMed Summit, a healthcare cybersecurity conference in La Jolla, California, on November 19th, 2022. Following the simulation, a debrief session was held with the learner in front of conference attendees, with additional questioning and discussion prompted by attendee input. Results: Though limited to a single subject by the pilot-study nature of this research, the physician learner successfully identified the acute etiologies and managed the patients' acute decompensations while lacking access to the hospital's electronic medical records (EMRs), laboratory results, imaging, and communication systems. Review of footage of the event and post-experience interviews yielded numerous insights on the specific physician-focused challenges and possible solutions to a hospital-infrastructure-crippling cyber attack. Conclusion: Healthcare cybersecurity incidents are known to result in significant disruption of clinical activities and can be viewed through a patient-safety oriented perspective. Simulation training may be a particularly effective method for raising clinician awareness of and preparedness for these events, though further research is required.

eMIFS: A Normalized Hyperbolic Ransomware Deterrence Model Yielding Greater Accuracy and Overall Performance.

Early detection of ransomware attacks is critical for minimizing the potential damage caused by these malicious attacks. Feature selection plays a significant role in the development of an efficient and accurate ransomware early detection model. In this paper, we propose an enhanced Mutual Information Feature Selection (eMIFS) technique that incorporates a normalized hyperbolic function for ransomware early detection models. The normalized hyperbolic function is utilized to address the challenge of perceiving common characteristics among features, particularly when there are insufficient attack patterns contained in the dataset. The Term Frequency-Inverse Document Frequency (TF-IDF) was used to represent the features in numerical form, making it ready for the feature selection and modeling. By integrating the normalized hyperbolic function, we improve the estimation of redundancy coefficients and effectively adapt the MIFS technique for early ransomware detection, i.e., before encryption takes place. Our proposed method, eMIFS, involves evaluating candidate features individually using the hyperbolic tangent function (tanh), which provides a suitable representation of the features' relevance and redundancy. Our approach enhances the performance of existing MIFS techniques by considering the individual characteristics of features rather than relying solely on their collective properties. The experimental evaluation of the eMIFS method demonstrates its efficacy in detecting ransomware attacks at an early stage, providing a more robust and accurate ransomware detection model compared to traditional MIFS techniques. Moreover, our results indicate that the integration of the normalized hyperbolic function significantly improves the feature selection process and ultimately enhances ransomware early detection performance.

When all computers shut down: the clinical impact of a major cyber-attack on a general hospital.

Importance: Healthcare organizations operate in a data-rich environment and depend on digital computerized systems; thus, they may be exposed to cyber threats. Indeed, one of the most vulnerable sectors to hacks and malware is healthcare. However, the impact of cyberattacks on healthcare organizations remains under-investigated. Objective: This study aims to describe a major attack on an entire medical center that resulted in a complete shutdown of all computer systems and to identify the critical actions required to resume regular operations. Setting: This study was conducted on a public, general, and acute care referral university teaching hospital. Methods: We report the different recovery measures on various hospital clinical activities and their impact on clinical work. Results: The system malfunction of hospital computers did not reduce the number of heart catheterizations, births, or outpatient clinic visits. However, a sharp drop in surgical activities, emergency room visits, and total hospital occupancy was observed immediately and during the first postattack week. A gradual increase in all clinical activities was detected starting in the second week after the attack, with a significant increase of 30% associated with the restoration of the electronic medical records (EMR) and laboratory module and a 50% increase associated with the return of the imaging module archiving. One limitation of the present study is that, due to its retrospective design, there were no data regarding the number of elective internal care hospitalizations that were considered crucial. Conclusions and relevance: The risk of ransomware cyberattacks is growing. Healthcare systems at all levels of the hospital should be aware of this threat and implement protocols should this catastrophic event occur. Careful evaluation of steady computer system recovery weekly enables vital hospital function, even under a major cyberattack. The restoration of EMR, laboratory systems, and imaging archiving modules was found to be the most significant factor that allowed the return to normal clinical hospital work.

Entropy Sharing in Ransomware: Bypassing Entropy-Based Detection of Cryptographic Operations.

This study presents a groundbreaking approach to the ever-evolving challenge of ransomware detection. A lot of detection methods predominantly rely on pinpointing high-entropy blocks, which is a hallmark of the encryption techniques commonly employed in ransomware. These blocks, typically difficult to recover, serve as key indicators of malicious activity. So far, many neutralization techniques have been introduced so that ransomware utilizing standard encryption can effectively bypass these entropy-based detection systems. However, these have limited capabilities or require relatively high computational costs. To address these problems, we introduce a new concept entropy sharing. This method can be seamlessly integrated with every type of cryptographic algorithm and is also composed of lightweight operations, masking the high-entropy blocks undetectable. In addition, the proposed method cannot be easily nullified, contrary to simple encoding methods, without knowing the order of shares. Our findings demonstrate that entropy sharing can effectively bypass entropy-based detection systems. Ransomware utilizing such attack methods can cause significant damage, as they are difficult to detect through conventional detection methods.

[Cybersecurity and use of ICT in the health sector]. / Ciberseguridad y uso de las TIC en el Sector Salud.

Cybercrime in the health sector is a growing threat in the digital age. With computerization of medical records and telemedicine on the rise, cyberattacks can have devastating consequences. Leaking sensitive data or hijacking systems can compromise patient's privacy and jeopardize healthcare. To counter this threat, robust cybersecurity measures are required as a protective measure. This article aims to expose the main dangers and threats faced by ICT, as well as present cybersecurity with its bioethical implications and, finally, the ideal scheme for it in the health sector in order to create a safer and more efficient environment. This article aims to address these issues and provide a comprehensive view of how cybersecurity and ICT can coexist safely and effectively in the healthcare field.

Investigating the role of Cybersecurity's perceived threats in the adoption of health information systems.

Information technology is one of the most rapidly growing technologies globally. Over the last decade, its usage in healthcare has been remarkable. Over the last decade, its usage in healthcare has been remarkable. The study examines the impact of various factors as barriers to adopting the information system in healthcare. These factors are categorized into three major types: external attacks, which include phishing attacks and ransomware; employee factors, including lack of skills and the issue of information misuse; and technological factors, including complexity and vulnerability. The findings show that external attacks and technological factors are the main barriers to adopting information systems, while employee factors have no significant impact on the adoption of information systems in the healthcare industry of Pakistan. The study provides implications for healthcare policy makers, professionals and organziations regarding the successful adoption of health information system.

Enhancing Cyber-Resilience for Small and Medium-Sized Organizations with Prescriptive Malware Analysis, Detection and Response.

In this study, the methodology of cyber-resilience in small and medium-sized organizations (SMEs) is investigated, and a comprehensive solution utilizing prescriptive malware analysis, detection and response using open-source solutions is proposed for detecting new emerging threats. By leveraging open-source solutions and software, a system specifically designed for SMEs with up to 250 employees is developed, focusing on the detection of new threats. Through extensive testing and validation, as well as efficient algorithms and techniques for anomaly detection, safety, and security, the effectiveness of the approach in enhancing SMEs' cyber-defense capabilities and bolstering their overall cyber-resilience is demonstrated. The findings highlight the practicality and scalability of utilizing open-source resources to address the unique cybersecurity challenges faced by SMEs. The proposed system combines advanced malware analysis techniques with real-time threat intelligence feeds to identify and analyze malicious activities within SME networks. By employing machine-learning algorithms and behavior-based analysis, the system can effectively detect and classify sophisticated malware strains, including those previously unseen. To evaluate the system's effectiveness, extensive testing and validation were conducted using real-world datasets and scenarios. The results demonstrate significant improvements in malware detection rates, with the system successfully identifying emerging threats that traditional security measures often miss. The proposed system represents a practical and scalable solution using containerized applications that can be readily deployed by SMEs seeking to enhance their cyber-defense capabilities.

Plant and Salamander Inspired Network Attack Detection and Data Recovery Model.

The number of users of the Internet has been continuously rising, with an estimated 5.1 billion users in 2023, which comprises around 64.7% of the total world population. This indicates the rise of more connected devices to the network. On average, 30,000 websites are hacked daily, and nearly 64% of companies worldwide experience at least one type of cyberattack. As per IDC's 2022 Ransomware study, two-thirds of global organizations were hit by a ransomware attack that year. This creates the desire for a more robust and evolutionary attack detection and recovery model. One aspect of the study is the bio-inspiration models. This is because of the natural ability of living organisms to withstand various odd circumstances and overcome them with an optimization strategy. In contrast to the limitations of machine learning models with the need for quality datasets and computational availability, bio-inspired models can perform in low computational environments, and their performances are designed to evolve naturally with time. This study concentrates on exploring the evolutionary defence mechanism in plants and understanding how plants react to any known external attacks and how the response mechanism changes to unknown attacks. This study also explores how regenerative models, such as salamander limb regeneration, could build a network recovery system where services could be automatically activated after a network attack, and data could be recovered automatically by the network after a ransomware-like attack. The performance of the proposed model is compared to open-source IDS Snort and data recovery systems such as Burp and Casandra.

Neutralization Method of Ransomware Detection Technology Using Format Preserving Encryption.

Ransomware is one type of malware that involves restricting access to files by encrypting files stored on the victim's system and demanding money in return for file recovery. Although various ransomware detection technologies have been introduced, existing ransomware detection technologies have certain limitations and problems that affect their detection ability. Therefore, there is a need for new detection technologies that can overcome the problems of existing detection methods and minimize the damage from ransomware. A technology that can be used to detect files infected by ransomware and by measuring the entropy of files has been proposed. However, from an attacker's point of view, neutralization technology can bypass detection through neutralization using entropy. A representative neutralization method is one that involves decreasing the entropy of encrypted files by using an encoding technology such as base64. This technology also makes it possible to detect files that are infected by ransomware by measuring entropy after decoding the encoded files, which, in turn, means the failure of the ransomware detection-neutralization technology. Therefore, this paper derives three requirements for a more sophisticated ransomware detection-neutralization method from the perspective of an attacker for it to have novelty. These requirements are (1) it must not be decoded; (2) it must support encryption using secret information; and (3) the entropy of the generated ciphertext must be similar to that of plaintext. The proposed neutralization method satisfies these requirements, supports encryption without decoding, and applies format-preserving encryption that can adjust the input and output lengths. To overcome the limitations of neutralization technology using the encoding algorithm, we utilized format-preserving encryption, which could allow the attacker to manipulate the entropy of the ciphertext as desired by changing the expression range of numbers and controlling the input and output lengths in a very free manner. To apply format-preserving encryption, Byte Split, BinaryToASCII, and Radix Conversion methods were evaluated, and an optimal neutralization method was derived based on the experimental results of these three methods. As a result of the comparative analysis of the neutralization performance with existing studies, when the entropy threshold value was 0.5 in the Radix Conversion method, which was the optimal neutralization method derived from the proposed study, the neutralization accuracy was improved by 96% based on the PPTX file format. The results of this study provide clues for future studies to derive a plan to counter the technology that can neutralize ransomware detection technology.

RBEF: Ransomware Efficient Public Blockchain Framework for Digital Healthcare Application.

These days, the use of digital healthcare has been growing in practice. Getting remote healthcare services without going to the hospital for essential checkups and reports is easy. It is a cost-saving and time-saving process. However, digital healthcare systems are suffering from security and cyberattacks in practice. Blockchain technology is a promising technology that can process valid and secure remote healthcare data among different clinics. However, ransomware attacks are still complex holes in blockchain technology and prevent many healthcare data transactions during the process on the network. The study presents the new ransomware blockchain efficient framework (RBEF) for digital networks, which can identify transaction ransomware attacks. The objective is to minimize transaction delays and processing costs during ransomware attack detection and processing. The RBEF is designed based on Kotlin, Android, Java, and socket programming on the remote process call. RBEF integrated the cuckoo sandbox static and dynamic analysis application programming interface (API) to handle compile-time and runtime ransomware attacks in digital healthcare networks. Therefore, code-, data-, and service-level ransomware attacks are to be detected in blockchain technology (RBEF). The simulation results show that the RBEF minimizes transaction delays between 4 and 10 min and processing costs by 10% for healthcare data compared to existing public and ransomware efficient blockchain technologies healthcare systems.

Temporal Data Correlation Providing Enhanced Dynamic Crypto-Ransomware Pre-Encryption Boundary Delineation.

Ransomware is a type of malware that employs encryption to target user files, rendering them inaccessible without a decryption key. To combat ransomware, researchers have developed early detection models that seek to identify threats before encryption takes place, often by monitoring the initial calls to cryptographic APIs. However, because encryption is a standard computational activity involved in processes, such as packing, unpacking, and polymorphism, the presence of cryptographic APIs does not necessarily indicate an imminent ransomware attack. Hence, relying solely on cryptographic APIs is insufficient for accurately determining a ransomware pre-encryption boundary. To this end, this paper is devoted to addressing this issue by proposing a Temporal Data Correlation method that associates cryptographic APIs with the I/O Request Packets (IRPs) based on the timestamp for pre-encryption boundary delineation. The process extracts the various features from the pre-encryption dataset for use in early detection model training. Several machine and deep learning classifiers are used to evaluate the accuracy of the proposed solution. Preliminary results show that this newly proposed approach can achieve higher detection accuracy compared to those reported elsewhere.

E2E-RDS: Efficient End-to-End Ransomware Detection System Based on Static-Based ML and Vision-Based DL Approaches.

Nowadays, ransomware is considered one of the most critical cyber-malware categories. In recent years various malware detection and classification approaches have been proposed to analyze and explore malicious software precisely. Malware originators implement innovative techniques to bypass existing security solutions. This paper introduces an efficient End-to-End Ransomware Detection System (E2E-RDS) that comprehensively utilizes existing Ransomware Detection (RD) approaches. E2E-RDS considers reverse engineering the ransomware code to parse its features and extract the important ones for prediction purposes, as in the case of static-based RD. Moreover, E2E-RDS can keep the ransomware in its executable format, convert it to an image, and then analyze it, as in the case of vision-based RD. In the static-based RD approach, the extracted features are forwarded to eight various ML models to test their detection efficiency. In the vision-based RD approach, the binary executable files of the benign and ransomware apps are converted into a 2D visual (color and gray) images. Then, these images are forwarded to 19 different Convolutional Neural Network (CNN) models while exploiting the substantial advantages of Fine-Tuning (FT) and Transfer Learning (TL) processes to differentiate ransomware apps from benign apps. The main benefit of the vision-based approach is that it can efficiently detect and identify ransomware with high accuracy without using data augmentation or complicated feature extraction processes. Extensive simulations and performance analyses using various evaluation metrics for the proposed E2E-RDS were investigated using a newly collected balanced dataset that composes 500 benign and 500 ransomware apps. The obtained outcomes demonstrate that the static-based RD approach using the AB (Ada Boost) model achieved high classification accuracy compared to other examined ML models, which reached 97%. While the vision-based RD approach achieved high classification accuracy, reaching 99.5% for the FT ResNet50 CNN model. It is declared that the vision-based RD approach is more cost-effective, powerful, and efficient in detecting ransomware than the static-based RD approach by avoiding feature engineering processes. Overall, E2E-RDS is a versatile solution for end-to-end ransomware detection that has proven its high efficiency from computational and accuracy perspectives, making it a promising solution for real-time ransomware detection in various systems.

A National Survey of Hospital Cyber Attack Emergency Operation Preparedness.

OBJECTIVE: Cyberattacks on healthcare systems are increasing in frequency and severity. Hospitals need to integrate cybersecurity preparedness into their emergency operations planning and response to mitigate adverse outcomes during increasingly likely cyber events. No data currently exist regarding the level of preparedness of United States hospital systems for cybersecurity attacks. We surveyed hospital emergency managers to assess cybersecurity preparedness for these events. METHODS: Fifty-seven emergency managers representing hospitals across the United States participated in an online Qualtrics survey regarding current preparedness and response procedures for cybersecurity hazards. RESULTS: Survey responses between April 2019 and May 2021 demonstrated that a majority of hospital systems surveyed included cybersecurity disasters in their HVA (82.4%; 47/57), and most ranked it as 1 of their top 5 priorities (57.4%; 27/47). However, over half denied specifically mentioning cybersecurity in their Emergency Operations Plans (EOPs; 52.6%; 30/57). Fourteen of the 57 hospital systems (24.5%) endorsed previously activating an emergency response for a cybersecurity incident unrelated to information technology (IT) failure. CONCLUSIONS: The survey results suggest that American hospitals are currently underprepared for cybersecurity disasters. We emphasize the importance of prioritizing cybersecurity in Hazard Vulnerability Analyses (HVAs) and implementing specific EOP annexes for cybersecurity emergencies.

Under pressure: Effect of a ransomware and a screen failure on trust and driving performance in an automated car simulation.

One major challenge for automated cars is to not only be safe, but also secure. Indeed, connected vehicles are vulnerable to cyberattacks, which may jeopardize individuals' trust in these vehicles and their safety. In a driving simulator experiment, 38 participants were exposed to two screen failures: silent (i.e., no turn signals on the in-vehicle screen and instrument cluster) and explicit (i.e., ransomware attack), both while performing a non-driving related task (NDRT) in a conditionally automated vehicle. Results showed that objective trust decreased after experiencing the failures. Drivers took over control of the vehicle and stopped their NDRT more often after the explicit failure than after the silent failure. Lateral control of the vehicle was compromised when taking over control after both failures compared to automated driving performance. However, longitudinal control proved to be smoother in terms of speed homogeneity compared to automated driving performance. These findings suggest that connectivity failures negatively affect trust in automation and manual driving performance after taking over control. This research posits the question of the importance of connectivity in the realm of trust in automation. Finally, we argue that engagement in a NDRT while riding in automated mode is an indicator of trust in the system and could be used as a surrogate measure for trust.

Effective Ransomware Detection Using Entropy Estimation of Files for Cloud Services.

A variety of data-based services such as cloud services and big data-based services have emerged in recent times. These services store data and derive the value of the data. The reliability and integrity of the data must be ensured. Unfortunately, attackers have taken valuable data as hostage for money in attacks called ransomware. It is difficult to recover original data from files in systems infected by ransomware because they are encrypted and cannot be accessed without keys. There are cloud services to backup data; however, encrypted files are synchronized with the cloud service. Therefore, the original file cannot be restored even from the cloud when the victim systems are infected. Therefore, in this paper, we propose a method to effectively detect ransomware for cloud services. The proposed method detects infected files by estimating the entropy to synchronize files based on uniformity, one of the characteristics of encrypted files. For the experiment, files containing sensitive user information and system files for system operation were selected. In this study, we detected 100% of the infected files in all file formats, with no false positives or false negatives. We demonstrate that our proposed ransomware detection method was very effective compared to other existing methods. Based on the results of this paper, we expect that this detection method will not synchronize with a cloud server by detecting infected files even if the victim systems are infected with ransomware. In addition, we expect to restore the original files by backing up the files stored on the cloud server.

The crippling effects of a cyberattack at an academic level 1 trauma center: An orthopedic perspective.

INTRODUCTION: Malicious cyberattacks are increasing in frequency and severity with healthcare institutions spending an average of over 10 million dollars to resolve the consequences of healthcare data breaches. This cost does not include the effect of a downtime event should a healthcare system electronic medical record (EMR) lose functionality. An Academic Level 1 trauma center suffered a cyberattack resulting in a total EMR downtime of 25 days. Orthopedic operative time was used as a surrogate for OR functionality during the event and a framework with specific examples is presented to promote rapid adaptation during downtime events. METHODS: Operative time losses were identified by calculating a running average of weekday total in room operative time during a total downtime event secondary to a cyberattack. This data was compared to week-of-the-year matched data from the year prior and the year after the attack. A framework for creating adaptations to a total downtime event was created by repeatedly interviewing different provider groups and identifying how they adjusted care to the challenges faced. RESULTS: Total weekday in room operative time during the attack decreased by 53.4% ± 12.2% and 53.2% ± 14.9% when comparing the matched period one year prior and one year after, respectively. Immediate challenges to patient care were identified by small groups of highly motivated individuals, with self-assigned agile teams formed. These teams sequenced system processes, identified failure points, and created real-time solutions. A frequently updated EMR backup mirror and hospital disaster insurance were crucial for mitigating the impact of the cyberattack. CONCLUSIONS: Cyberattacks are expensive and their downstream effects, including downtime events, can be crippling. Agile team formation, process sequencing, and understanding EMR backup times are tactics used to combat the challenges of a prolonged total downtime event. LEVEL OF EVIDENCE: Level III retrospective cohort.