To consumers, the Internet of Things might bring to mind a smart fridge that lets you know when to buy more eggs, or the ability to control your home's lighting and temperature remotely through your phone.

But for cybersecurity professionals, internet-connected medical devices are more likely to be top-of-mind.

Not only is the Internet of Medical Things, or IoMT, surging - with the global market projected to reach$160 billion by 2027, according to Emergen Research - the stakes can be quite high, and sometimes even matters of life or death.

The risk to the individual patients is very small, experts caution, noting bad actors are far more likely to disrupt hospital operations, use unsecure devices to access other parts of the network or hold machines and data hostage for ransom.

"When people ask me, 'Should I be worried?' I tell them no, and here's why," said Matthew Clapham, a veteran product cybersecurity specialist. "In the medical space, every single time I've probed areas that could potentially compromise patient safety, I've always been impressed with what I've found."

That doesn't mean the risk is zero, noted Christos Sarris, a longtime information security analyst. He shared an anecdote in Cisco Secure's recent e-book, "Building Security Resilience," about finding malware on an intensive care unit device that compromised a pump used to deliver precise doses of medicine.

Luckily, the threat, which was included in a vendor-provided patch, was caught during testing.

"The self-validation was fine," Sarris said in a follow-up interview. "The vendor's technicians signed off on it. So we only found this usual behavior because we tested the system for several days before returning it to use."

But because such testing protocols take valuable equipment out of service and soak up the attention of often-stretched IT teams, they're not the norm everywhere, he added.

Sarris and Clapham were among several security experts we spoke to for a deeper dive into the challenges of IoT medical device security and top-line strategies for protecting patients and hospitals.

Every device is different

Connected medical devices are becoming so integral to modern health care that a single hospital room might have 20 of them, Penn Medicine's Dan Costantino noted in Healthcare IT News.

Sarris, who is currently an information security manager at Sainsbury's, outlined some of the challenges this reality presents for hospital IT teams.

Health care IT teams are responsible for devices made by a multiplicity of vendors - including large, well-known brands, cheaper off-brand vendors, and small manufacturers of highly speciality instruments, he said. That's a lot to keep up with, and teams don't always have direct access to operating systems, patching and security testing, and instead are reliant on vendors to provide necessary updates and maintenance.

"Even today, you will rarely see proper security testing on these devices," he said. "The biggest challenge is the environment. It's not tens, it's hundreds of devices. And each device is designed for a specific purpose. It has its own operating system, its own operational needs and so forth. So it's very, very difficult - the IT teams can't know everything."

Cisco Advisory CISO Wolfgang Goerlich noted that one unique challenge for securing medical devices is that they often can't be patched or replaced. Capital outlays are high and devices might be kept in service for a decade or more.

"So we effectively have a small window of time - which can be measured in hours or years, depending on how fortunate we are - where a device is not vulnerable to any known attacks," he said. "And then, when they do become vulnerable, we have a long-tailed window of vulnerability."

Or, as Clapham summed it up, "The bits are going to break down much faster than the iron."

The Food and Drug Administration is taking the issue seriously, however, and actively working to improve how security risks are addressed throughout a device's life cycle, as well as to mandate better disclosure of vulnerabilities when they are discovered.

"FDA seeks to require that devices have the capability to be updated and patched in a timely manner; that premarket submissions to FDA include evidence demonstrating the capability from a design and architecture perspective for device updating and patching... and that device firms publicly disclose when they learn of a cybersecurity vulnerability so users know when a device they use may be vulnerable and to provide direction to customers to reduce their risk," Kevin Fu, acting director of medical device security at the FDA's Center for Devices and Radiological Health explained to explained to MedTech Dive last year.

The network side

For hospitals and other health care providers, improving the security posture of connected devices boils down to a few key, and somewhat obvious, things: attention to network security, attention to other fundamentals like a zero-trust security framework more broadly, and investing in the necessary staffing and time do to the work right, Goerlich said.

"If everything is properly segmented, the risk of any of these devices being vulnerable and exploited goes way, way down," he said. "But getting to that point is a journey."

Sarris agrees, noting many hospitals have flat networks - that is, they reduce the cost and effort needed to administer them by keeping everything connected in a single domain or subdomain. Isolating these critical and potentially vulnerable devices from the rest of the network improves security, but increases the complexity and costs of oversight, including for things like providing remote access to vendors so they can provide support.

"It's important to connect these devices into a network that's specifically designed around the challenges they present," Sarris said. "You may not have security control on the devices themselves, but you can have security controls around them. You can use micro segmentation, you can use network monitoring, et cetera. Some of these systems, they're handling a lot of sensitive information and they don't even support the encryption of data in transit - it can really be all over the place."

The device side

The COVID-19 pandemic put a lot of financial pressure on health systems, Goerlich noted. During the virus' peaks, many non-emergency procedures were delayed or canceled, hitting hospitals' bottom lines pretty hard over several years. This put even greater pressure on already strained cybersecurity budgets at a time of increasing needs.

"Again, devices havetimeas a security property," Goerlich said, "which means we've got two years of vulnerabilities that may not have been addressed. And which also probably means we're going to try to push the lifecycle of that equipment out and try to maintain it for two more years."

Clapham, who previously served as director of cybersecurity for software and the cloud at GE Healthcare, said device manufacturers are working hard to ensure new devices are as secure as they can be when they're first rolled out and when new features are added through software updates.

"When you're adding new functionality that might need to talk to a central service somewhere, either locally or in the cloud, that could have implications for security - so that's where we go in and do our due diligence," he said.

The revolution that needs to happen is one of mindset, Clapham said. Companies are waking up to the new reality of not just making a well-functioning device that has to last for over a decade, but of making a software suite to support the device that will need to be updated and have new features added over that long lifespan.

This should include adding additional headroom and flexibility in the hardware, he said. While it adds to costs on the front end, it will add longevity as software is updated over time. (Imagine the computer you bought in 2007 trying to run the operating system you have now.)

"Ultimately, customers should expect a secure device, but they should also expect to pay for the additional overhead it will take to make sure that device stays secure over time," he said. "And manufacturers need to plan for upgradability and the ability to swap out components with minimal downtime."

Additional Resources

• Cisco Secure Portfolio Explorer: Health Care, Medical Device & IoT Security
• Five Ways to Improve Your Security Posture in Health Care, Cisco Secure blog post
• Why Health Care Provider CIOs Need to Prioritize Medical Device Security, Cisco Secure blog post
• A Conversation with Wolfgang Goerlich: Security Doesn't Have To Be the Department of No, In Scope podcast
• A Conversation with Matthew Clapham: Making Medical Products More Secure, In Scope podcast

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