Cybersecurity is more than just a buzzword – it’s an essential component of your healthcare organization’s protection plan and one of the only things standing between your patients and the bad actors ready to misuse their personal and financial information. The threat is real – cyberattacks and data breaches are on the rise in the healthcare industry. According to a report from the Intelligence and National Security Alliance (INSA) (Office of the Director of National Intelligence, 2024), it was discovered that the number of ransomware attacks on hospitals doubled from 2022 to 2023.
This constant threat means that risk management needs to be a priority for those in executive positions in the healthcare industry. Regularly assessing certain healthcare cybersecurity metrics is a primary component of performance monitoring.
More specifically, cybersecurity Key Performance Indicators (KPIs) in healthcare are an essential part of assessing how effective the program is and how it can be improved. In a prior post, Why Healthcare Leaders Need to Make Cybersecurity a Priority Today, we discussed why this monitoring is so crucial; now, learn more about which healthcare cybersecurity KPIs you should be tracking.
KPI #1: Risk Scorecard Ratings
Cybersecurity risk scorecards in healthcare are important tools for a healthcare business, as they provide an assessment of the current status of its cybersecurity system. To carry out this assessment, certain cybersecurity elements are assigned scores regarding an organization’s security practices and vulnerabilities. Using a risk scorecard enables organizations to identify potential security risks and gain valuable insights into action steps to improve security.
NIST CFS Scorecards
The National Institute of Standards and Technology (NIST) operates under the US Department of Commerce and provides guidelines for organizations and businesses to optimize their cybersecurity practices. The NIST Cybersecurity Framework scorecard compares security systems to the eponymous gold-standard framework. This can provide crucial information to help determine where an organization’s cybersecurity system currently stands and where it needs to improve.
The NIST CFS scorecard categorizes the system’s posture into five functions that make up the core of the framework.
They are:
- Identify – This aspect of the framework involves understanding an organization’s operations, policies, technology, controls, risks, and people. After assessing these essential pieces of the organization, leaders can identify risks and apply mitigating controls.
- Protect – Organizations must establish safeguards to block cyber threats. These proactive measures are intended to prevent cyber hackers from breaching an IT system. Safeguards must meet or exceed Payment Card Industry Data Security Standard (PCI DSS) and HIPAA compliance metrics to protect sensitive data.
- Detect – This refers to identifying any threats or risks to security. As cyber hackers have breached even the most robust security systems, it is essential for organizations to monitor for any irregularities.
- Respond – Unfortunately, even with preventative measures, cybersecurity breaches can still occur. This is why having a plan of action to respond to these breaches is so important.
- Recover – After a breach has occurred, an organization must implement a plan to recover, both from small incidents and major disasters. Establishing a recovery plan means an organization is prepared in the event of an emergency, including backing up data and noting the standards for infrastructure configuration.
CIS Benchmarks
The Center for Internet Security offers a regulated approach, providing cybersecurity benchmarks for healthcare facilities and other organizations.
These benchmarks are categorized into three levels based on the complexity of an organization’s IT system:
Level 1
Level one covers the basics, such as establishing password rules and building the strength of the cybersecurity system. It is typically used for smaller companies and organizations that utilize basic IT equipment and services.
Level 2
This level offers a larger plan that is better suited for mid-sized or big companies with complex IT systems. Along with this plan is a guide to assist users in making wise decisions related to security policies.
Level 3
Level three provides the most advanced plan with the most significant number of recommendations for updating and improving the security system. It also involves a Security Technical Implementation Guide (STIG) that outlines a wide variety of topics, such as encryption and plans for disaster recovery.
Internal Versus External Audits
Audits are typically done to ensure compliance with regulations. An internal audit can be performed by a single security officer or several security team members. A report is made from this audit, showing how effective the organization’s security strategy is and how it can be improved upon.
External audits are usually performed by an outside source, such as an independent auditor or security team. These audits are often completed to inform the organization’s partners, business associates, and their stakeholders. External audits typically generate a report describing the current status of the organization’s security posture.
Organizations should consider performing an audit in the following situations:
- After strategy changes
- Alongside major structural shifts
- After a change in leadership roles, such as executives or security officers
- When a merger takes place, or when the organization is under new ownership
- Alongside a change in the guidelines for information security
- During the implementation of new IT infrastructures
- With a recurring need to address HIPAA or HITECH compliance regulations
KPI #2: Incident Response Time
Cybersecurity threats pose a risk to patient safety, care, and private data, all of which can negatively affect patient experience and damage an organization’s reputation. In an industry where patient privacy is of paramount importance, data breaches can be devastating for healthcare facilities. A speedy incident response time in healthcare is an essential consideration after a cyber attack. A quick response means the damage may be controlled, minimizing the extent of the breach.
Because of the serious financial consequences, sensitive data, and patients at risk, it is important to meet industry benchmarks for response times. Cyber attacks can occur quickly before an organization is aware of the breach, so the widely accepted industry benchmark incident response time is under one hour. If possible, the response time should be as close to instantaneous as possible.
Another aspect of preparing for cyber threats is creating an incident playbook. In this context, a “playbook” refers to a set of guidelines and rules that go into effect in the event that a cyber attack takes place. A playbook enables efficient responses to an emergency and ensures that emergency responses are consistent throughout the organization.
Additionally, automated incident responses help increase the speed at which an incident is identified and addressed. They also allow for consistent procedures and smaller IT workloads, enabling the IT staff to focus on other pressing matters.
KPI #3: System Uptime
System uptime in healthcare is essential for keeping patients safe, maintaining smooth and efficient operations, and stabilizing finances. Minimizing downtime decreases the risk of serious errors occurring.
Patient Safety
During downtime, disruptions to critical diagnostic tools, such as lab results or imaging, can occur. This can mean delays in patient treatment or even incorrect diagnoses.
Efficient Operations
Downtime in the system also causes slower workflows, creating inefficiency in operations. It can also cause an increase in staff workloads due to the need to perform tasks manually. Reductions in productivity can result.
Financial Stability
Financial issues can also compound during downtime. Cancellation of appointments or procedures, postponed billing, or fines due to compliance violations can worsen an already tricky financial situation. Hiring the IT staff necessary to rectify the situation can lead to additional costs.
Maintaining the availability of an Electronic Health Records system is essential for increasing efficiency in operations, smoother workflows, and better healthcare. An EHR can be a crucial way to mitigate downtime.
Meeting Compliance Regulations
According to the HIPAA Security Rule (American Medical Association, 2025), healthcare organizations must protect private electronic records by utilizing the proper administrative, physical, and technical safeguards to ensure that they are kept secure.
Service Level Agreements (SLA) can help healthcare facilities to build the foundation for risk management, outline healthcare IT performance metrics, and ensure that compliance requirements are met. SLA monitoring, therefore, plays a significant role in creating a strong cybersecurity posture.
Additionally, it’s essential to outline backup strategies and protocols for recovering from a system failure or a cyber attack. A backup strategy can help an organization safeguard personal data while also keeping the IT system operational. Automated data backups can be placed in several locations, stored on the premises of the healthcare facility, offsite, or on the cloud.
Disaster recovery plans are crucial for healthcare organizations to address any disruptions to their security system.
A strong disaster recovery plan involves:
- Assessing IT risk management for healthcare
- Implementing a data backup plan that complies with HIPAA
- Detailing procedures for recovering
- Creating a plan for communication
- Using resilient systems
- Establishing strong security safeguards
KPI #4: Breach Detection and Reporting Time
As noted in the HIPAA Journal (HIPAA Journal, 2025), a recent data analysis found that healthcare organizations take an average of 3.7 months to report a ransomware attack. This is the quickest of all industries analyzed in the study. Healthcare data breach metrics are crucial for this speedy assessment of the risks involved, after which the clock begins ticking for the organization to notify affected individuals.
A healthcare organization must alert all individuals impacted by the data breach by mail or email. To ensure everyone is notified, the organization must post a breach notification on its website homepage for at least 90 days or inform a major media source. In this notice, the organization must include a contact number for individuals to ask questions regarding the breached data.
These notifications must be sent to individuals by no later than 60 days after the breach was identified (US Department of Health and Human Services, 2013). If possible, notifying patients earlier is even better.
Notifications must include:
- A short description of what happened
- An outline of the kind of information involved
- How individuals who were impacted should proceed to prevent further harm
- Details on how the organization is responding to the breach with an investigation, doing everything possible to mitigate negative consequences, and preventing future breaches.
If a healthcare facility delays reporting the data breach, serious consequences can result. First, data that is lost or unable to be accessed by healthcare staff may lead to delayed treatment or medication administration. More errors can be made if important medical files are corrupted. Emergency care may also be disrupted.
Additionally, patients may feel a lack of trust in the healthcare facility and become hesitant to return. They may also experience identity theft or fraud. The healthcare organization may face large fines, be forced to pay settlements, and lose revenue due to losing its patients’ trust.
Start Tracking the Right Metrics for Healthcare Cybersecurity Success
Establishing a cybersecurity dashboard for healthcare is helpful for assessing the security posture of your healthcare facility. Taking proactive measures can protect your organization from potential threats. Healthcare IT Service Management (ITSM) offers cybersecurity support to meet the needs of healthcare providers. Our expertise can help protect both healthcare facilities and their patients from cyberattacks.
Contact us to schedule your risk assessment and begin addressing your most crucial cybersecurity KPIs today.
Sources:
- Office of the Director of National Intelligence. (2024). Ransomware attacks surge in 2023. National Counterintelligence and Security Center. https://www.dni.gov/files/CTIIC/documents/products/Ransomware_Attacks_Surge_in_2023.pdf
- American Medical Association. (n.d.). HIPAA security rule: Risk analysis. https://www.ama-assn.org/practice-management/hipaa/hipaa-security-rule-risk-analysis
- HIPAA Journal. (2024). Ransomware and data breach reporting times worsening. https://www.hipaajournal.com/ransomware-data-breach-reporting-times
- U.S. Department of Health and Human Services. (n.d.). Breach notification rule. https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html
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