Special Topic: Downtime is a clinical event

Show Notes

When ransomware locked hospitals' computers, more of the Medicare patients already in their beds died. As care depends on more software, AI included, keeping that software safe must come before speed or savings.

Read the special topic and its sources: https://physicianintheloop.org/specials/breach-is-a-clinical-event/

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Downtime is a clinical event

When ransomware locked hospitals' computers, more of the Medicare patients already in their beds died. As care depends on more software, AI included, keeping that software safe must come before speed or savings.

Ransomware attacks on hospitals endanger the patients already inside them. Ransomware locks staff out of their computer systems and demands a ransom to restore access. Researchers who linked a database of hospital ransomware attacks to Medicare claims have now measured what follows: in a study published in February, they found that among patients already admitted when an attack began, the in-hospital death rate rose by more than a third.

The study is observational. Compared with matched hospitals in the same states that were not hit, the death rate, which averaged under 4 percent, rose by about 1.3 percentage points. A comparison with hospitals attacked later gave a similar result. The study covers only patients in traditional Medicare, and the deaths in question are deaths in the hospital. Such attacks are common: the American Hospital Association says the FBI reported 460 ransomware attacks on health care in 2025, more than on any other sector of critical infrastructure. When a hospital's systems go down, by attack or by failure, the result is a patient-safety event, and as care comes to depend on more software, artificial intelligence included, keeping that software safe and running must come before speed or savings. That calls for firm security minimums for hospitals and the companies that hold their records, public money for the hospitals that cannot afford them, and medical staffs ready to work without the screens.

The harm spreads beyond the hospital under attack. When ransomware struck a neighboring health system's hospitals for a month in 2021, academic emergency departments in San Diego County took in more ambulances and more patients, including more than twice as many with confirmed strokes; more than twice as many people left without being seen, and waits grew longer. The study compared the weeks before and during the attack in one community, and its authors suggest that such attacks should be treated as disasters, with coordinated planning and response.

Other outages show the same disruption, though not always the same toll. A retrospective analysis of the WannaCry attack of 2017 found that infected hospitals in the National Health Service admitted about 6% fewer patients a day; it found no difference in deaths in emergency departments, which its authors called a crude measure of harm. A failure can do similar damage without any attacker. In July 2024 a faulty software update from the security firm CrowdStrike took down network services at about a third of the hospitals whose systems researchers could scan, and more than a fifth of the services that went down supported direct patient care. The authors note that generalizable data on what such outages do to patients are lacking.

In London the harm has been counted. After a ransomware attack in June 2024 on Synnovis, which provides blood testing and other pathology services to the National Health Service, the health service's managers confirmed 170 incidents in which patients came to harm, one of them severe, the Health Service Journal reported. King's College Hospital later said that a long wait for a blood test result caused by the attack had contributed to a patient's death. In Vermont in 2020, an attack left the University of Vermont Medical Center able to give chemotherapy to fewer than half the patients a day it normally could, its president said.

Not every death blamed on an outage was caused by one. In 2020 a woman turned away from Düsseldorf's University Hospital, which hackers had crippled, died after being diverted to another hospital; a chief public prosecutor in Cologne investigated and concluded: "The delay was of no relevance to the final outcome." In Alabama, a mother sued the hospital where her daughter was born during a 2019 ransomware attack, alleging that a doctor could not properly monitor the delivery; the baby suffered severe brain injuries and died the next year, and the hospital denied wrongdoing but later settled the suit.

Artificial intelligence raises the stakes on both sides. The hospital association told the Senate that governments and criminal hackers are beginning to use it to find software flaws quickly, and Anthropic reported last year that an attacker had used its coding tool in a data-theft and extortion campaign against at least 17 organizations, including in health care. Defenders use it too: testing with an Anthropic model turned up flaws in Epic's software that could allow undetected access to patient records, The New York Times reported. The evidence on downtime comes from record systems and networks rather than from AI, but its logic carries over to any tool that care depends on. ECRI, an independent patient-safety nonprofit, ranks misuse of AI chatbots first and unpreparedness for a sudden loss of electronic systems second among this year's health technology hazards. Guidance from the Joint Commission and the Coalition for Health AI tells health care organizations to treat AI-related safety events "like patient safety events."

Some of the defenses are basic, and a bill in Congress would require them. The Health Care Cybersecurity and Resiliency Act, which passed the Senate by unanimous consent on Sept. 30, would direct the health department to require multifactor authentication, a second check beyond a password, and encryption of patient information, among other minimums. The rules would cover health care providers and health plans, the vendors that handle patient records for them and other private organizations in the health sector, and would take effect three years after enactment. Vendors matter because one can fail many hospitals at once: the attack on Change Healthcare, which the hospital association says touches one in three patient records, disrupted patient care for months. The House received the bill on Oct. 5 and has yet to take it up.

Providers have resisted security mandates before. Late last year a group of health care organizations urged the health department to withdraw the security rules it had proposed in January 2025, saying they would place "substantial new financial burdens on health care providers." Every dollar a small hospital spends on security, the argument runs, is a dollar it cannot spend on care, and the deaths rest on a single observational study. The cost is real, and one study is not the last word. But every study cited here found disruption, to care or to the technology behind it. The American study that counted deaths found more of them, and in London the harm was confirmed case by case. The minimums also match how two recent vendor breaches began. Change Healthcare's attackers got in with someone else's login through a portal that did not have multifactor authentication, its parent's chief executive told senators. Oracle has told customers that the intruder in its health-records breach used stolen customer credentials. That breach may have exposed the records of nearly 20 million people, a reported count Oracle has not confirmed. Where a small hospital cannot afford the minimums, the public should pay, which is what the bill's grants are for.

The House should pass the bill with its coverage of vendors intact. Its grants, which name no sum, need money behind them: the hospital association says nearly half of rural hospitals lost money in 2023. States need not wait, since the $50 billion Rural Health Transformation Program already lets them pay for software, hardware and technical help that enhances cybersecurity.

Hospitals can act sooner still, writing multifactor authentication, encryption and regular testing into vendor contracts as they renew them, AI vendors included. For physicians the test is simpler: no clinical tool, AI or otherwise, should go live until the medical staff knows how care continues when it fails. The Joint Commission already advises hospitals to be ready to run with life- and safety-critical technology offline for four weeks or longer, with a downtime committee that includes the medical staff, regular drills and, afterward, root cause analyses of the consequences for patient care. Medical staffs should hold their hospitals to that plan as they would to a plan for mass casualties, and review every delayed result and diverted patient as a patient-safety event, so that the harm is counted rather than guessed at.

The patients in the Medicare study were already in their beds when the screens went dark, and more of them died in the hospital than would otherwise have been expected. As more of their care runs through software, AI included, keeping that software safe and running is part of treating them, and it comes before speed or savings.

This special topic was read by an AI voice. Its sources are linked at physicianintheloop.org.