Perspectives In Health Information
by Nikki Spence, MS; Niharika Bhardwaj, MBBS, MS; David P. Paul III, DDS, PhD; and Alberto Coustasse, DrPH, MD, MBA, MPH
Cybercriminals have begun to target the healthcare industry with ransomware, malware that encrypts an infected device and any attached devices or network drives. After encryption, cybercriminals demand a ransom before releasing the devices from encoding. Without adequate disaster recovery and backup plans, many businesses are forced to pay the ransom. We examined the extent of recent ransomware infections in healthcare settings, the risk liabilities and costs associated with such infections, and possible risk mitigation tactics. The methodology of this study was a literature review. The review was limited to sources published in English from 2005 to 2017. Of the 118 sources found, 74 were used in the results section. We also performed two semistructured interviews, one with an expert in health care law and the other with a chief information officer from a local teaching hospital who was an expert in healthcare information technology. Financial costs associated with business recovery after ransomware attacks on healthcare facilities are significant and are growing in both magnitude and scope. Other risks are a loss of future business and reputation damage. Research has suggested that the best plan of action is to have a proper business continuity and disaster plan with adequate data backups and to be vigilant in educating employees about the sources of ransomware to prevent potential attacks.
Keywords: cost; cyberattacks; hospitals; health information security; ransomware
The term ransomware refers to a type of malware used by attackers that first encrypts files and then attempts to extort money in return for the key to unlocking the data by demanding a ransom.1, 2 These ransoms are most often requested in the form of bitcoins, a type of cryptocurrency. When using bitcoins, transactions are irreversible and have a low fee of approximately USD 0.043 per operation, and the owner of a particular bitcoin account can remain anonymous.3 Because of the ability of bitcoin to make transactions accessible while protecting the anonymity of those involved, it has become the preferred currency for criminal activity, including that of ransomware hackers.4 According to a November 2015 report by the Cyber Threat Alliance, a single ransomware variant—Crypto Wall 3—was responsible for 406,887 attempted infections and $325 million in damages since it was discovered in January 2015.5, 6 In light of these financial estimates, researchers believe that new variants of this version of ransomware and other ransomware approaches are probably being developed and released.7 In fact, one assessment reports that new ransomware variants are developed at a rate of 100,000 a day.8
In the past, ransomware attacks were primarily used to target individuals; however, criminals can encrypt not only the files on an individual victim’s local computer but also the networked data to which that user had access. This makes organizations a more lucrative target for cybercriminals.9 In fact, according to the US Department of Health and Human Services Office for Civil Rights’ Breach Portal, which displays breaches of health data that affect 500 or more people, more than 325,000 healthcare data breaches have been reported until February of 2017.10
Ransomware is typically spread through fake emails that have been designed by the hacker to appear legitimate.11 These emails may contain a link to an infected website or include an attachment such as a Word document that contains macros. Once a link is clicked or a document is opened, the malware is downloaded and infects the machine quickly: estimates vary from seconds12, 13 to 20 minutes.14 During this time, the malware searches the hard drive, network files, external drives, and cloud drives for all data that can be encrypted. After encryption, an electronic “key” is required to unlock the files; this key is saved by the hacker and is not released until the victim pays a requested amount or ransom.15
Before 2016, healthcare organizations were not thought to be a primary target for ransomware.16 However, 14 hospitals had become the target of ransomware and a total of 173 hacking/information technology (IT) incident data breaches had been officially reported by October 16, 2016, 17, 18 Hospitals have become an easy target for hackers for two reasons: (1) the necessity of computer storage of information associated with patient care (e.g., electronic medical records) and (2) the security holes in IT systems.19 In fact, a report from Ponemon Institute in 2016 stated that 89 percent of healthcare organizations suffered at least one data breach involving the loss of patient data over a two-year period, and 45 percent had more than five such breaches.20, 21 Also, the frequency of successful hacking of patient medical files increased from 55 percent in 2015 to 64 percent in 2016.22 When hit with ransomware, some hospitals have been desperate to pay the ransom because of their need for the most up-to-date information, such as drug interactions, care directives, and medical history, in order to provide critical care to patients.23 Accordingly, the healthcare industry is now considered to be at a substantial risk of a ransomware attack,24 mainly because it trails other leading industries in securing vital data.25, 26
Hackers have found it easy to attack hospitals with ransomware because of hospitals’ rapid adoption of IT without a concomitant increase in the number and sophistication of IT support staff. This IT adoption occurred after the government allocated funds for the Meaningful Use program, which encouraged the use of electronic health records (EHRs). With the Meaningful Use incentives, EHR utilization increased from 9.4 percent in 2008 to 96.9 percent in 2014.27
With such a substantial increase in IT utilization in a short time frame, many healthcare facilities have been unable to adopt adequate network security and other information technology resources to combat potential attacks.28 Without sufficient funds, many hospitals do not have the staff to employ simple barriers to hackers, such as the quick installation of electronic patches. According to a 2016 report by Verizon, 85 percent of successful exploits take advantage of vulnerabilities such as old patches.29
The purpose of this study was to determine the extent of recent ransomware infections in the healthcare setting, the risk liabilities and costs associated with infections, and possible risk mitigation tactics.
The primary hypothesis of this research was that in the event of a ransomware attack, hospitals may suffer significant profit loss if they are not adequately prepared with adequate information technology resources and business continuity/disaster recovery policies.
The methodology of this study was an extensive and detailed literature review. The research design was an adaptation of the research framework used by Yao et al. (2010)30 and depicts the factors related to a ransomware attack and how they promote or discourage these attacks. The ransomware process starts with a cybercriminal targeting a hospital. When the hospital staff detects the ransomware, a decision must be made to pay the ransom if the staff had not previously planned for such an attack and were not able to use disaster recovery methods to restore data. If payment is made to the cybercriminal, it encourages hackers and other criminals to use ransomware attacks, whereas proper disaster recovery and risk mitigation discourage the ransomware process (shown in Figure 1). Because the emphasis of this review was on the use of new technology in healthcare settings, this research framework was suitable for the current study. The internal validity of this research framework, as well as the literature review framework, has been supported by its effective utilization in prior studies.31–34
The research study was conducted in three stages:
- Identifying literature and collecting data,
- Analyzing and evaluating the literature, and
- Categorizing the literature found.
Step 1: Literature Identification and Collection
The key terms “ransomware” or “cyber attack” and “healthcare” or “information security” or “disaster recovery” or “cost” were searched in scholarly electronic databases. Databases included PubMed, Academic Search Premier, ProQuest, and Google Scholar. The websites of the Federal Bureau of Investigations and the International Association of Privacy Professionals, along with certain reputable news websites, were also reviewed.
Step 2: Inclusion Criteria and Literature Analysis
The literature review generated 118 sources, of which 74 were used in the results section. Because ransomware has only recently become an issue in healthcare IT, searches were limited to articles published between 2005 and 2017 in the English language. Original articles, reviews, and research studies including primary and secondary data related to ransomware were included. Relevant articles were selected after the abstracts were reviewed to determine if they were related to the research criteria.
Step 3: Literature Categorization
The themes that emerged from the literature are presented in the results section and were categorized under the main categories of the research framework: detection of ransomware (details of previous ransomware events and cyberattacks on personal health information of healthcare facilities); risk mitigation and disaster recovery (risk mitigation and information security); and payment of ransom (risk liabilities and cost of a ransomware attack).
Additionally, two semistructured interviews were conducted, the first on August 26, 2016, with Paul English Smith, a lawyer who is an expert in healthcare legal concerns, and the second on August 31, 2016, with Dennis Lee, a chief information officer of a local teaching hospital (see Appendix A and Appendix B). These professionals are referred to as an “expert in healthcare law” and an “expert in healthcare information technology” throughout the review. These interviews were tape-recorded and transcribed. Appropriate answers were used in the study to support the findings from the literature and to provide more in-depth perspectives on the findings.
The rate of ransomware incidents has been growing, not just in the healthcare industry, but in all enterprise industries. The FBI estimated that by the end of 2016, monetary losses due to ransomware totaled more than $1 billion.35 The number of ransomware variants has also been increasing: according to a 2016 Symantec report, the number of ransomware variants increased 250 percent from 2013 to 2014.36More than 4 million ransomware variants were detected in the first quarter of 2015, including 1.2 million new ones, compared to fewer than 1.5 million total samples in the third quarter of 2013, when fewer than 400,000 were new.37 Interestingly, McAfee Labs (2016) predicted that ransomware attacks would peak in 2017 and decline thereafter, but others did not share in this optimism, believing instead that ransomware attacks will increase in both number and sophistication in 2018 and thereafter, at least until a solution to the problem is found and applied on a widespread basis.38–43 In an analysis of internet traffic in 2016 in the United States, Bitdefender, an internet security software firm, found that more than 61.8 percent of malicious internet files were found to contain some form of ransomware.44
Details of Previous Ransomware Events
The first documented case of hospital ransomware occurred at Surgeons of Lake County in 2012. A similar attack occurred two years later in 2014 at Clay County Hospital. In both events, the extent of the ransomware attack was not reported; a ransom was believed to be paid in both cases, but the amounts were never disclosed.45 However, it was not until the highly publicized ransomware attack at Hollywood Presbyterian Medical Center in February 2016 that hackers actively began to target healthcare facilities.46–48 In this attack, the staff was unable to access patient records, x-rays, and other equipment or to restore equipment from backup data and was forced to pay the ransom.49 Initial reports claimed that the criminal initially demanded a ransom of $3.6 million, but the ransom was negotiated down to approximately $17,000 or 40 bitcoins.50
Paying a ransom, however, does not ensure that cybercriminals will provide the encryption key for the locked files. In the case of Kansas Heart Hospital, the ransom was paid, but the key was not provided. Instead, the cybercriminals demanded a second, more substantial ransom, which was not paid.51
After the success of the ransomware attack on Hollywood Presbyterian Medical Center, the healthcare industry was targeted more frequently, with two hospitals attacked later that month and five hospitals targeted the next month. These affected hospitals did not pay the ransom but instead were able to restore information from their backups.52 Ransomware attacks on other hospitals and health systems quickly followed within a month.53–58 (See Table 1.)
Risk Liabilities and Cost of a Ransomware Attack
According to the legal expert whom we interviewed (see Appendix A), four risk categories are associated with ransomware attacks:
- medical malpractice,
- data privacy,
- property and reputation, and
- cost and expense issues.
Although medical malpractice has been a regular concern for hospitals, there could be an additional risk of medical malpractice during a ransomware attack if patient care is affected or if a patient is harmed as a result of ransomware, for example, if a medication error affected a patient when the computerized prescription order entry (CPOE) system was down.59 In a 2013 study of the effects of CPOE on medication errors, data were pooled from the 2006 American Society of Health-System Pharmacists Annual Survey, the 2007 American Hospital Association Annual Survey, and the 2008 Electronic Health Record Adoption Database to estimate the reduction in medication errors that occurs when CPOE is used. This study found that CPOE reduced the rate of errors by 48 percent.60 Multiple other studies have provided evidence that CPOE minimizes medication errors.61–63 If a hospital relying on a CPOE system were to lose that system for any reason, the number of prescription errors associated with returning to a manual prescription system would increase substantially, perhaps doubling, especially during a forced transition when individuals who were familiar with the CPOE system would have to be retrained or trained to use the manual method.64
The second threat has been the risk of patient data privacy loss, which could lead to a HIPAA violation. During the first response to a breach, it is vital for staff to identify, if possible, the type of malware that has infected their network. After the malware has been detected, professionals should assess the risks of that particular malware and whether a solution to decrypt the files can be found.65, 66 Unfortunately, decryption without the necessary key is extremely unlikely, and no free tools are currently available to decrypt files.67, 68
The risk of reputation loss and loss of future business were calculated in an annual study that included interviews with 400 individuals and examined the costs related to these factors in 49 companies in the United States.69 This study found that, in 2011, the organizations examined averaged more than $3 million in losses related to reputation loss, abnormal turnover of customers, increased customer acquisition activities, and diminished goodwill. In a follow-up study, 24 percent of companies surveyed expressed concern that their reputation would be diminished if they were to suffer a ransomware attack.70
The final risk is losses due to costs and expenses. In 2016, the average total cost of a data breach was $3.62 million.71 The average cost per record in the healthcare industry in 2014 was $355, which would be a substantial amount for a large or small hospital to pay per record.72 This total may or may not include additional costs associated with a data breach, which could vary depending on the size of the organization and number of patients affected. Such variable costs include credit monitoring provided to patients, which may cost anywhere from $8 to $30 per patient, depending on the level of oversight needed.73
If the institution chooses to pay the ransom, the amount must be considered. The average ransom demanded has been approximately $10,000 for enterprises and $710 for individuals. In a report published by cyberdata and security vendor Imperva, attackers have often tailored the ransom to the country in which the affected institution is located. For example, the average ransom demand in the United States has been $710. However, in countries such as Israel, Russia, and Mexico, the average demand has been $500. For this reason, companies in more developed nations such as the United States are more favorite targets, as they are thought to be able to afford to pay a greater ransom.74
Cyberattacks on Personal Health Information in Healthcare Facilities
When ransomware accesses patient data, cyberattacks on healthcare facilities become a much more significant problem.75 If a server or computer is not encrypted at rest and information is encrypted only during incoming and outgoing transactions, a ransomware virus could exploit this vulnerability and copy the information on the server.76 If this were to happen, the provider would be open to all the previously mentioned costs in addition to the cost associated with HIPAA data breach violations.77 In recent years, the number of cyberattacks on personal health information stored on the computer systems of healthcare facilities has been increasing rapidly; see Table 2 for an exhaustive review of recent ransomware attacks involving the unauthorized theft of patient health information.78–84
Although the extent of illegally obtained patient health information collected varies by institution and by attacker, most facilities noted the loss of patient names, addresses, telephone numbers, email addresses, dates of birth, IP addresses, marital status, race, provider information, patient Social Security numbers, health insurance numbers, and mental or health condition or treatment information. In 2016, 34.5 percent of all identity thefts occurred as a result of breaches through the healthcare sector, second only to the business sector, which accounted for 45.2 percent of identified violations. However, the number of identity theft breaches associated with the healthcare sector has grown more quickly than in any other industry for every year between 2010 and 2016.85 A study from Johns Hopkins University in 2017 found that between October 21, 2009, and December 31, 2016, there were 1,798 data breaches. Among them were 257 breaches reported by 216 hospitals.86 Clearly, cybercriminals have discovered the high vulnerability of healthcare facilities to cyberattack and the low risk involved. The stolen personal health information sold in 2014 for $10 per piece, about 10 or 20 times the value of a US credit card number, as it could be used to create fake IDs to buy medical equipment or drugs that can be resold, or combined with a false provider number to file made-up claims with insurers.87
Risk Mitigation and Information Security
One study analyzed the different types of ransomware (CryptoWall 3.0, CryptoLocker, CTB-Locker, TeslaCrypt, NK_, VO_, Locky) along with potential ransomware prevention methods (PC update, PC and server data backup, web page file and site safety checks, shared folder management, system security settings, read-only folder settings). It was noted that only PC updates and read-only folder settings worked effectively for all types of ransomware.88
The IBM Security Services Cyber Security Intelligence Index, an annual report compiling the results of forensic investigations into the security incidents of the year, reported specific events affecting more than 1,000 IBM Security Services clients in more than 133 countries in 2014. The findings of the report showed that in 2014, more than 95 percent of all investigated security incidents were attributed to “human error,” with the most common reason being a user’s click of a malicious attachment or unsafe web link.89
At the 2016 Cryptography and Information Security Conference, a cybersecurity event, 200 information security professionals who attended were interviewed. The results of the interview showed that 58 percent of those questioned reported that their company had seen an increase in spear phishing in the last year.90Spear phishing—sending an email that appears to originate from a high-ranking member of the organization91—has a much higher chance (71 percent) of being successful than just sending an email with an attachment that the receiver can click to open (1 to 3 percent).92 Of those interviewed, 52 percent did not feel confident that their executives could successfully identify a phishing scam.93
Employees are often the “entry point” for ransomware.94 Based on a survey of 618 individuals in small to medium-sized organizations who have responsibility for containing ransomware infections in their company, 58 percent reported that negligent employees put their organization at risk of a ransomware attack, while only 29 percent were very confident (9 percent) or confident (20 percent) that their employees would be able to detect risky links or sites that could result in a ransomware attack.95 In an empirical study conducted by PhishMe, 8 million simulated phishing emails were sent to 3.5 million enterprise employees. In this study, 87 percent of employees who opened the malicious attachment did so within the day. Of the users who clicked the malicious files in the initial email, 68 percent exposed a malicious file again when they received a second simulated phishing email.96 This risk could obviously be mitigated by better employee education. One company, KnowBe4, was able to decrease the number of employees who clicked on a potential phishing scam from 15.9 percent to 1.2 percent.97
Data backup has proven to be a critical step in any prevention plan: without a way to restore the encrypted files, businesses may have no choice but to pay the ransom to continue doing business.98 However, when it comes to ransomware attacks, merely backing up data is not enough. Data must also be backed up in such a manner that the backup process itself is not connected to computers or networks, lest the backup also become encrypted and held for ransom. One example of this would be to physically store the information offline or in a cloud storage solution not attached to the network. Some instances of ransomware have even been known to seek out and destroy network backups, making the offsite physical storage of backup data even more critical to prevent the backups from contamination.99 For years, many studies have suggested a 3-2-1 approach to backing up: have at least three copies of the data, utilize two different media formats, and have one of the copies be off-site.100–102 The software company Veeam suggested adding a level of security (3-2-1-1) by storing one of the media offline, creating an offline or semi-offline copy of the data.103 However, backups suffer from several inherent problems. Although backups provide a viable option to restore data that are not frequently accessed, they are always a “snapshot in time” and will always be behind current data; that is, some of the most current data will nearly always be lost.104 Also, the use of paper forms may be necessary if a digital backup is not quickly available, but at least some, if not many, staff could be unfamiliar with these forms, potentially further impeding patient treatment.105 Finally, because cybercriminals recognize that many organizations are moving their backups to the cloud, eventually a way may be found to attack these backups also.106, 107
Recognizing this vulnerability, Lee et al. proposed a cloud-based system for preventing ransomware and reported that this system could perform real-time network, file, and server monitoring and data backups—thus improving detection and reducing the damage resulting from ransomware.108 However, further research is needed before such systems are operationalized.
The results of this study showed that if a ransomware attack is successful, healthcare providers can face substantial financial and even clinical consequences. Proper risk mitigation and disaster recovery are crucial to reduce costs and the likelihood of data loss. During a ransomware attack, information systems are shut down, and staff members’ work is hindered by the denial of access to crucial information systems that they rely on for decision making.
Some potential costs that may be incurred by an organization during and after an attack are the cost of an initial response team, the loss of potential business while the response team restores backup data and installs new equipment, and the cost associated with a call center if one must be temporarily set up to answer patient questions about the attack. Hospitals could also suffer actual damage to hospital property. Property damage from ransomware may involve any software, hardware, or EHR records that are lost or damaged during the attack. Equipment such as servers could be so extensively damaged by malware that there is no way to recover them, which would then result in further costs to the hospital (expert in healthcare information technology interview; see Appendix B). Fortunately, to date, no patient deaths have been attributed to a ransomware attack on a hospital, although concerns about the possibility of such an occurrence abound.109–111 However, the consequences of any patient death due to a ransomware attack are sufficiently severe that the Food and Drug Administration has begun to coordinate with other federal agencies regarding how best to respond should one occur.112
If only for business continuity reasons, it is crucial for healthcare facilities large and small to have a disaster recovery plan with steps in place to recover from any malware attack. In addition to establishing such a policy, businesses must also have adequate storage of data apart from networked backups. Companies must further make sure to test their backups regularly to ensure that the information is being saved correctly and can be restored. Without appropriate backups, businesses’ options during a ransomware incident are limited to either paying the ransom or completely losing all data (expert in healthcare information technology interview; see Appendix B).
Although data backup and recovery plans are essential, efforts should be made to prevent an attack before it starts. Users have been identified as the weakest link for hackers, and user education, as well as adequate detection of policy violations, has the potential to make a significant difference in deterring risky end-user behavior that makes a network vulnerable to attack. One specific suggestion regarding how to prevent users from inadvertently exposing hospitals to a ransomware attack is to prohibit individuals from opening personal emails on the facility’s computers, because “an organization’s internal e-mail client is likely to have more sophisticated spam filters than web-based providers such as Gmail and Hotmail.”113Unfortunately, convincing busy physicians and healthcare staff to avoid this practice would be difficult, at best.
If ransomware only encrypts files and does not steal information, the attack may not be considered a HIPAA breach. However, if the ransomware also takes patient data before encoding it, many factors have to be considered to determine whether the attack constitutes a HIPAA violation. One factor in deciding if a HIPAA breach occurred is what data media and equipment were infected and whether those devices had been encrypted at rest. This means that if a server with patient information encrypts only the information being transmitted and not the information on the server, this information could be subject to theft, which would constitute a HIPAA violation. If the server were encrypted at all times, even at rest, it would not be considered a breach if criminals copied the information since they would not be able to access the files (expert in healthcare law interview; see Appendix A).
Notwithstanding financial losses, one of the most significant concerns for hospitals should be reputation loss. Much of the cost associated with an attack can be recovered by cybersecurity insurance. The hospital’s reputation, however, and the damage of public trust in the facility can result in irreparable harm and profit loss if patients decide to go to another hospital. With the loss of business, smaller hospitals may not be able to afford to stay in business long after an attack (expert in healthcare law interview; see Appendix A).
The literature review was limited by the search strategy. Publication bias, along with the restricted number of databases utilized, may have constrained the contents of the study. Researcher bias may have also have been present and could have limited the review. Another limitation of this study was the lack of current research on ransomware in healthcare settings. Presently, little in-depth analysis has been conducted to determine the average cost per attack. Without this information, this study relied on data from other business fields and expert interview information, which may or may not apply to the average healthcare facility during and after a ransomware attack.
Because ransomware is a relatively new concern in healthcare, information on the long-term consequences, effects, and damages that a healthcare facility may face after a ransomware attack was also limited. Also, no information was available on the different effects on a business if a ransom is paid versus if the company is able to complete a full data recovery from backups. This information would have been useful to illustrate the benefits and challenges associated with each of these outcomes. It seems reasonable that the leadership of many healthcare facilities could be hesitant to admit publicly not only that their computer systems are vulnerable to a ransomware attack but that such an attack (or attacks) had been successful. To the extent that healthcare systems failed to publicly acknowledge attempted or successful ransomware attacks, the scope of the problem would be understated.
Future research should examine the effects attributable to ransomware in healthcare. A systematic review and or a meta-analysis should be performed to gain a more precise measurement of the effects (i.e., costs and consequences) of cyberattacks and ransomware in healthcare facilities.
Because of the payment of ransoms in 2016 by Hollywood Presbyterian Medical Center and Kansas Heart Hospital, it is possible that in the future, the healthcare industry not only will be a significant target for additional ransomware attacks but also will become a target for other cybercriminal attacks, such as different types of malware or denial-of-service attacks, or that cybercriminals could target individual medical devices such as pacemakers,114 especially those that are connected to internal networks.115 If the majority of healthcare facilities refuse to pay the ransom, this trend may decrease over time, but this outcome seems unlikely because the risk to cybercriminals appears slight, given that no convictions have been reported, and the chance of gain for cybercriminals appears to be substantial.
Also, if ransomware can take advantage of patient data, the anticipated trend in cyberattacks on healthcare facilities could potentially become a more significant issue. Although ransomware does not currently appear to have been explicitly developed to view patient information and therefore an attack would not be a HIPAA concern, this may not continue to be the case in the future. If a server or computer is not encrypted at rest and is encrypted only during incoming and outgoing transactions, a ransomware virus could exploit this vulnerability and copy the information on the server. If this were to happen, the provider would be open to all the previously mentioned costs in addition to the costs associated with HIPAA data breach violations. Hackers would also be able to leverage the threat of public release of patient information to obtain a higher ransom from facilities. In this case, institutions might be even more willing to pay the ransom. If successful, such tactics would undoubtedly lead to an increase in ransomware attacks on healthcare facilities.
As stated by Chinthapalli (2017),116 hospitals should have clear digital hygiene, with policies in place to remind employees that not all emails should be opened. Additionally, backups should be made daily (or up to every hour) using tape drives, which cannot be hacked digitally. Furthermore, hospitals should establish a ransomware policy detailing step by step the actions to be taken in the event of this crisis. Hospitals should be ready to deal with ransomware because many hospitals will unquestionably be affected by it in the near future.117, 118
The number of ransomware attacks and variants has increased substantially in recent years. Healthcare facilities have become a significant target for these attacks, and in response to this increase, it is crucial that they develop a proper disaster recovery plan and adequately educate their users on information security. With proper planning in place, a healthcare facility is not only more likely to survive an attack but also more likely to decrease costs associated with an attack and to mitigate the risk to its reputation.
Nikki Spence, MS, is an alumni of the health informatics program at Marshall University in Huntington, WV.
Niharika Bhardwaj, MBBS, MS, is an alumni of the health informatics program at Marshall University in Huntington, WV.
David P. Paul III, DDS, PhD, is a professor emeritus of marketing and healthcare management at Monmouth University in West Long Branch, NJ.
Alberto Coustasse, DrPH, MD, MBA, MPH, is a professor of healthcare administration at the Lewis College of Business, Marshall University in South Charleston, WV.
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