Athens Orthopedic Clinic incident response leaves patients in the dark and out of pocket for protection

On June 26, after learning that databases with patients’ protected health information had been put up for sale on the dark web, began investigating and trying to alert the victim entities so that they could take immediate steps to try to mitigate harm to patients.

By that evening, I had sent an email to Athens Orthopedic Clinic (AOC) in Georgia, to say that it appeared that they had been hacked. I followed up the next day via e-mail and a phone call to make sure they received my notification. On June 29, they issued a statement confirming that they were investigating a potential breach that they had first been made aware of in the previous 48 hours.

But their incident response after that point raises questions about any risk assessment and plan for breach response that they may have had in place, and how decisions they made may have negatively impacted the very patients to whom they were and are responsible.

Did AOC’s Response to Ransom Demands Lead to Retribution by Hackers?

Dealing with a ransom demand, as was the case here, is never an easy situation or decision. Paying a ransom does not guarantee that the extorters will not come back at a later time and demand more money. Nor does it guarantee that the criminals will not take the ransom and then sell the patient data on the dark web anyway. There is really no clear guidance for healthcare entities as to how to respond to this type of situation, as HHS’s recent guidance on how to respond to a ransomware demand doesn’t really apply when you know that the attacker actually has all of your patients’ information and is threatening to misuse it, leak it, or sell it.

But ticking off the criminals by telling them that you’ll pay and then not paying, or stringing them along – even if it is at someone’s suggestion – may have backfired for AOC’s patients. Had AOC simply refused to pay the ransom from the outset or had they paid it, TheDarkOverlord (TDO) hackers likely would not have as responded as punitively as they did. According to emails has read, at various points, AOC indicated that it was willing to pay some ransom but needed to work out a payment system. Later, they indicated they were willing to do a wire transfer. At other points, they didn’t respond by deadlines TDO had given them, infuriating the hackers.  Read in sequence, the emails might appear to be stringing TDO along, stalling them, or jerking them around. And according to statements made to by TDO in encrypted chats, some of the public leaks of AOC’s patient information were in direct response to AOC failing to follow through on what it had told the hackers it would do.

The TL;DR version is that TDO informed this site that they were determined to make an example of AOC to show the world that you don’t screw around with TDO. And they even warned AOC. As just one example, a snippet from one of their emails to AOC:

If you continue to play these fucking games with us, a sort of hostage kill off is going to occur and leave thousands of patients records publicly listed and abused with your name signed to all of it as the source.

So would patient data have been publicly leaked or would as much data have been leaked if AOC had made a decision, informed the attackers of that decision, and stuck to it?  AOC’s ever-changing responses and missed deadlines appears to have resulted in more patients  having their details leaked on Pastebin.

Are Patients’ Data Still At Risk?

Although AOC may have become a victim due to a vendor’s failure to secure their credentials, and while AOC trauma surgeon Chip Ogburn wrote a passionate and obviously heartfelt letter to patients assuring them that AOC is  committed to rectifying the data breach, there are also other questions raised by AOC’s incident response.

That AOC didn’t know that they had been hacked and only learned of the hack weeks later when they were alerted to it by this site is not surprising to anyone familiar with breaches. But it still begs the question as to what software or technical safeguards AOC had in place to detect intrusions and the exfiltration of hundreds of thousands of patients’ records that included image files. Both HHS and the FTC may have questions about that.

See also: Quest Records LLC Breach linked to TheDarkOverlord hacks; more entities investigate if they’ve been hacked  

And once AOC confirmed that there had been an intrusion and patient data had been acquired, why didn’t they immediately change all passwords – even after the hackers contacted them and lectured them on their failure to change passwords?  AOC’s statement on their web site says, in part (emphasis added by me):

If you were a patient of any Athens Orthopedic Clinic location or the patient of a doctor or provider who worked with any of our locations on or before June 14, 2016, we regret to tell you that that our electronic medical records system has been compromised and that your personal information is vulnerable.

but has seen correspondence indicating that information of patients seen after June 14 was still accessible to the hackers. These emails indicate that TDO informed AOC in mid-July that they still had access to AOC’s internal network. They even mentioned specific systems that were still vulnerable. Here are some snippets from TDO emails to AOC during June and July:

…. We are still in your system right now in fact. You have done little to mitigate against an advanced attacker. Pulling the internet plug won’t help when you have embedded devices that run over a cellular network.

…. Now up to this point, you should have already changed all the passwords and usernames for all your systems, but they were not changed for all your systems. They should have been amended immediately from the time we sent the first email. We understand it may take a day or two…. However, within a few hours of the second email they should have definitely been changed seeing as how we specifically listed some systems by name. For record, they were not changed even at this time.

It is now over two weeks later, and the passwords are still not changed. Let’s just use the PACS imaging system as an example here. We just logged in a few minutes ago. Even after telling you directly which systems were compromised, nothing has been done to correct the issue.

So why didn’t AOC change all the passwords promptly? Did the FBI or someone advise them not to change the passwords for some reason? Why could the hackers presumably still access the network and patient data weeks after AOC knew they had been hacked?

On July 26, one month after AOC learned they had been hacked, TDO claimed in an encrypted chat with that they still had access to AOC through a backdoor they had installed. does not know if AOC’s consultants have found a backdoor where TDO claimed to have installed one on their network. This site doesn’t even know if they even looked for one where TDO claimed to have installed one. Despite alerting them that there is a claimed backdoor and requesting an opportunity to talk to the security team directly, there has been no direct communication.  Although has no evidence to suggest that TDO continued to acquire more patients’ information after June 14, this site also has no statement from TDO that they didn’t acquire more information. AOC’s patients, some of whom are reportedly already angry and think AOC hasn’t done enough, may understandably wonder whether AOC’s network might still be at risk.

Was More Disclosure in Order?

Patients may also want to ask AOC why it did not disclose  that their data was, and remains, up for sale on the dark web and why they were not informed that some of their personal information had also been publicly posted on Pastebin. The letter sent to patients, which may be some patients’ only source of information, doesn’t disclose either of those facts – or the fact that TDO claimed that they have already sold some patients’ information.

Wouldn’t you want to know if your identity information and other information was up for sale to criminals?  Wouldn’t you want to know if your information might have already been sold? Should AOC have told its patients these things?

AOC’s Inadequate Mitigation of Harm

Under the circumstances, it was somewhat shocking to read that AOC has not offered its patients credit monitoring services. Even though I have been critical of how much such services actually help, it’s almost de rigueur in this day and age to offer such services when identity information has been acquired by criminals.

Does AOC have an insurance policy that covers the costs of a breach? In an email from AOC’s attorney to the hackers on July 2, the attorney claimed that AOC doesn’t have insurance to cover cyber-related losses:

Your  financial demand is significant given that AOC’s current insurance provider does not cover cyber related losses.

Of course, the attorney could have been lying to TDO to try to get them to reduce the ransom demand or to just stall them, but the attorney’s email appears consistent with a recent public statement by CEO Kayo Elliott, quoted by Jim Thompson of OnlineAthens, suggesting that they may not have insurance (or sufficient insurance) for data breaches:

“And of course, they wish we could pay for extended credit monitoring. So do we. We truly regret that we are unable to do so, as we are not able spend the many millions of dollars it would cost us to pay for credit monitoring for nearly 200,000 patients and keep Athens Orthopedic as a viable business. I recognize and am truly sorry for the position this puts our patients in.”

Note that although Elliott refers to “extended credit monitoring,” it is not clear to this site that AOC has offered any credit monitoring services at their expense.

Is AOC running an operation with 17 locations  without any cyber-insurance to cover breach costs? In light of the attorney’s statement and the CEO’s statement, and as much as I hold the hackers responsible for their own conduct, I found myself in agreement with the hackers’ response to the attorney’s email of July 2:

If you have not already, you should advise your client that the year is sixteen past two-thousand and that they should have already had the necessary insurance policies to cover such incidents as this one.

Insurance is part of the cost of doing business, and AOC’s incident response has failed its patients, leaving them with a heavy burden of worrying for years to come whether their identity information is circulating underground and being misused for fraudulent purposes. And of course, any medical/protected health information is forever.

So although feels significant sympathy for AOC and any healthcare entity that gets hacked and has to deal with the breach remediation and response, right now I feel more sympathy for AOC’s patients, who I believe deserve both greater disclosure of the risks they now face and more support than they appear to have gotten so far.

If You Were Affected by This Breach

Because I think AOC did not give its patients enough information and advice to help them protect themselves, here’s my personal advice to AOC patients :

First: If you are an AOC patient who was notified of the breach, your best protection may be to put a  freeze on your credit report – not a fraud alert. If you need to allow merchants or financial institutions to check your credit, you can lift (“thaw”) the freeze, but a freeze will generally give you better protection against misuse of your information than a fraud alert or fee-based credit monitoring service. You can read this article on the pro’s and con’s of fraud alerts vs. credit freezes.  And you can see this information from Georgia on the procedure and the fees for credit freezes if you decide to pursue that route. 

Second: if AOC had or has your current health insurance account information in their files, check your explanation of benefits statements from your health insurer when you receive them each month to see if you recognize all the providers and services. If you don’t recognize a provider, contact your insurer and tell them that you are concerned that there might be fraudsters using your insurance information and ask them to investigate or verify the claim. While it may not be likely that your records will be corrupted by fraudulent use of your health insurance  in ways that could affect your future medical care, it can happen, so don’t take any chances with that. In some cases, you may be able to get a new insurance account number issued, but if you’re a Medicare patient, well, you’re probably out of luck on that. 

Third: run a Google search on your name (as it would appear in AOC’s records) regularly to see if your personal information is showing up in any places it shouldn’t be – such as Pastebin or other sites where hackers leak data. Google doesn’t index all sites, and you may not find yourself even if your data are listed in a dark web marketplace, but you may find something that can clue you that you need to take more steps to protect yourself.  And if you gave AOC your email address, also run a check for that email address on haveIbeenpwnd. If that email address has shown up in any data leaks they have compiled, they will show you where your email address was leaked, and you can sign up for (free) future notifications if that email address shows up in other data leaks. As of today’s date, they do not appear to have indexed the pastes on Pastebin that had more than 1,500 AOC patients’ information. 

Fourth: You have the right to request/demand that AOC delete all information they hold about you. Or at least that’s what they claim in their privacy policy. If you no longer trust them to protect your information or to respond appropriately to any breach, you may wish to avail yourself of this right. Just be sure to get a copy of all your records first, of course. 

Finally, if you have been affected by this breach, you can use the Comments section below this post to let us know, although there’s not much I can really do for you other than to let you vent and connect with others in the same situation. Do not put your name and phone number in any comment or invite attorneys to contact you – I delete personal information to protect my site visitors’ privacy. And I do not allow attorneys to use my Comments sections to advertise for or recruit potential plaintiffs. If they try it, their comment goes straight to trash. Note that all comments are moderated, so any comment you submit may not show up right away.

Update 1: As of last night, the AOC and other databases were still listed for sale on TheRealDeal market (see my previous posts about the ad listing). As of now, they are all gone. Interesting….

Update 2 (Aug. 16): The site received the following comment via e-mail that I am posting with the submitter’s permission:

Data Breach notification letters that ask patients to to procure their own credit monitoring services or to simply put a flag on their account is usually a red flag that there are other things the Covered Entity that allowed a breach to happen are also doing incorrectly. I expect affected patients to form a class action lawsuit, as GA is currently not a state that has a Private Right of Action law. The moral of this story: hire qualified, healthcare specific IT, either internal employee(s) or an outsourced company and pay for security. It can be done, even in small practices. Had this clinic had basic IT security in place, perhaps they could have logged and even blocked access to the hackers.

Amy Wood
President / HIPAA Privacy Officer
Certified Healthcare IT Security Administrator
Certified HIPAA Security Professional
Continuing Education Registered Provider (CA)

ACS Technologies, LLC notes that at this point, we do not have any forensics report or any report that would evaluate the state of AOC’s infosecurity program prior to the breach, although they have stated that they had already hired experts to help them improve their security before the breach.

Update 3 (8-17): Today I found more than 860 AOC patients’ data still exposed online, including their contact details, Social Security numbers, date of birth, and in some cases, insurance info.

About the author: Dissent