| Recurring |
one_organization, multiple_organization |
(a) The software failure incident related to vulnerabilities in the VistA electronic medical records system has happened again within the same organization, the U.S. Department of Veterans Affairs. The article mentions that the VA has had a slow but high-stakes drama playing out for years regarding the replacement of VistA with a commercial product [131215]. Security researchers have found real security issues in VistA that could affect patient care, and attempts to disclose these vulnerabilities to the VA have been unsuccessful as VistA is on the verge of being phased out with a new medical records system designed by Cerner Corporation [131215].
(b) The software failure incident related to vulnerabilities in VistA is not limited to the VA but also extends to other hospitals that are running VistA that are not VA-related. The article highlights that VistA is not only deployed across the VA health care system but is also used elsewhere, indicating that similar incidents may have occurred at other organizations utilizing VistA [131215]. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident related to the design phase is evident in the case of the VA's electronic medical records system, VistA. The platform, developed in the late 1970s, has faced decades of underinvestment, leading to erosion of the system. Security researchers identified significant security issues in VistA, such as weak encryption of internal credentials, which could potentially allow attackers to impersonate healthcare providers and manipulate patient records [131215].
(b) The software failure incident related to the operation phase is highlighted by the challenges faced during the rollout of a new medical records system designed by Cerner Corporation to replace VistA. The VA announced a delay in the general rollout of the new system until 2023 due to outages and potential patient harm experienced during pilot deployments. This operational failure indicates issues with the implementation and operation of the new system [131215]. |
| Boundary (Internal/External) |
within_system |
(a) The software failure incident related to the security issues in the VistA electronic medical records system at the U.S. Department of Veterans Affairs is primarily within the system. The vulnerability in how VistA encrypts internal credentials, discovered by security researcher Zachary Minneker, is a result of the home-brewed encryption developed for VistA in the 1990s, which can be easily defeated without an additional layer of network encryption like TLS [131215]. The failure to address these security issues within the system has led to concerns about potential unauthorized access and manipulation of patient records [131215]. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident in this case is primarily due to non-human actions, specifically related to the security weakness in how VistA encrypts internal credentials. Security researcher Zachary Minneker discovered a vulnerability in the encryption mechanism of VistA that could allow an attacker to impersonate a health care provider within the system and potentially modify patient records or prescribe medications [131215].
(b) On the other hand, human actions also play a role in this software failure incident. The delay in rolling out the new $10 billion Cerner system by the VA until 2023 due to pilot deployment issues and outages led to potential harm to patients. Additionally, the lack of a clear vulnerability disclosure program for VistA and the decision to phase out VistA using a new system designed by Cerner Corporation also involve human actions [131215]. |
| Dimension (Hardware/Software) |
software |
(a) The software failure incident related to hardware: The article discusses a security weakness in the VistA electronic medical records system used by the U.S. Department of Veterans Affairs. Specifically, the article mentions a vulnerability in how VistA encrypts internal credentials, which could allow an attacker on a hospital's network to impersonate a health care provider within VistA and potentially modify patient records or prescribe medications [131215].
(b) The software failure incident related to software: The article highlights that the security weakness in VistA was due to the home-brewed encryption developed for VistA in the 1990s, which was found to be easily defeated. This indicates a software-related issue within the VistA system that could lead to unauthorized access and manipulation of patient records [131215]. |
| Objective (Malicious/Non-malicious) |
malicious, non-malicious |
(a) The software failure incident discussed in the article is related to a malicious objective. Security researcher Zachary Minneker identified a worrying weakness in how VistA encrypts internal credentials, which could potentially allow an attacker to impersonate a health care provider within VistA and manipulate patient records, submit diagnoses, or even prescribe medications. Minneker's findings were presented at the DefCon security conference, and he has been trying to disclose these vulnerabilities to the VA through their vulnerability disclosure program and Bugcrowd, but VistA is out of scope for both programs. The incident highlights a serious security flaw in the system that could be exploited by malicious actors [131215].
(b) The software failure incident can also be considered non-malicious in the sense that it was not intentionally introduced to harm the system. The underlying issue with VistA's encryption mechanism was a result of underinvestment and outdated security practices over the years. The system, developed in the 1990s, lacked modern encryption standards like TLS, making it vulnerable to attacks. Additionally, the delay in rolling out a new medical records system by the VA, designed by Cerner Corporation, due to outages and potential patient harm cases, further emphasizes the non-malicious nature of the failure, stemming from technical and operational challenges rather than intentional harm [131215]. |
| Intent (Poor/Accidental Decisions) |
poor_decisions |
(a) The intent of the software failure incident in this case seems to be more related to poor decisions. The failure is attributed to decades of underinvestment in the VistA platform by the U.S. Department of Veterans Affairs, leading to erosion of the platform's security and functionality [131215]. Additionally, the decision to delay the rollout of the new Cerner system due to outages and potential patient harm cases also reflects poor decision-making in the management of the electronic medical records system [131215]. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident related to development incompetence is evident in the case of the VistA electronic medical records system used by the U.S. Department of Veterans Affairs. The article highlights that security researchers identified a significant weakness in how VistA encrypts internal credentials, which could potentially allow attackers to impersonate healthcare providers and manipulate patient records [131215]. Despite attempts by a security researcher to disclose these findings to the VA through vulnerability disclosure programs, VistA was considered out of scope for such initiatives, indicating a lack of responsiveness or understanding of the severity of the issue within the organization.
(b) The software failure incident related to accidental factors is demonstrated by the delays and outages experienced during the pilot deployments of the new medical records system designed by Cerner Corporation, which the VA is attempting to phase in to replace VistA. These issues led to almost 150 cases where patients could potentially have been harmed, highlighting unintended consequences of the system implementation [131215]. |
| Duration |
permanent |
(a) The software failure incident described in the article is more of a permanent nature. The article discusses how the VistA platform used by the U.S. Department of Veterans Affairs has been facing security issues due to outdated encryption methods, which could potentially allow attackers to impersonate healthcare providers and manipulate patient records [131215]. Additionally, the article mentions that the VA is in the process of phasing out VistA and transitioning to a new medical records system designed by Cerner Corporation due to ongoing issues and outages with the current system [131215]. These factors indicate a long-standing and persistent software failure issue rather than a temporary one. |
| Behaviour |
value |
(a) crash: The software failure incident described in the article does not involve a crash where the system loses state and does not perform any of its intended functions. Instead, the focus is on security vulnerabilities in the VistA electronic medical records system used by the U.S. Department of Veterans Affairs [131215].
(b) omission: The incident does not involve the system omitting to perform its intended functions at an instance(s). Rather, it highlights security weaknesses in how VistA encrypts internal credentials, potentially allowing attackers to impersonate healthcare providers and manipulate patient records [131215].
(c) timing: The failure is not related to the system performing its intended functions correctly but too late or too early. The main issue discussed is the security vulnerability in VistA's encryption mechanism, which poses a risk to patient data and care [131215].
(d) value: The software failure incident is primarily about the system performing its intended functions incorrectly due to security vulnerabilities in VistA's encryption method. This could lead to unauthorized access, data manipulation, and potential harm to patients [131215].
(e) byzantine: The incident does not involve the system behaving erroneously with inconsistent responses and interactions. Instead, it focuses on a specific security weakness in VistA's encryption that could be exploited by attackers to gain unauthorized access and manipulate patient records [131215].
(f) other: The behavior of the software failure incident can be categorized as a security vulnerability that exposes the system to potential unauthorized access and data manipulation. The incident highlights the importance of addressing security flaws in critical systems like electronic medical records to protect patient information and care [131215]. |