Start by removing password entry wherever a safer authentication path exists, then enforce multifactor authentication on every remote and privileged access route. Pair that with appliance hardening so management planes do not expose unnecessary services. The goal is to make stolen credentials less useful and reduce the number of places attackers can turn phishing into access.
Why This Matters for Security Teams
Ransomware crews often do not need to “break in” when identity flows already hand them usable access. In healthcare, that usually means remote support accounts, VPN paths, service credentials, API keys, and admin consoles that were built for uptime first and attack resistance second. The fastest win for defenders is to make those paths harder to abuse by removing passwords where a stronger method exists, then limiting how much privilege any one identity can carry. NIST’s guidance on identity and access management in the NIST Cybersecurity Framework 2.0 fits this problem well because it treats access as an ongoing control, not a one-time login event.
Identity-centric ransomware also maps directly to patterns seen in NHI incidents. NHIMG research shows that 80% of identity breaches involved compromised non-human identities such as service accounts and API keys in the Ultimate Guide to NHIs, and 91.6% of secrets remain valid five days after notification, which makes slow cleanup a real exposure window. In practice, many security teams encounter credential abuse only after encryption starts, rather than through intentional monitoring of identity paths.
How It Works in Practice
The practical goal is to reduce the number of identities that can be phished, replayed, or reused after theft. Start with the highest-risk pathways: remote access, privileged admin access, EHR support tools, backup consoles, and management planes for appliances. Replace password prompts with phishing-resistant options where possible, then require multifactor authentication on every route that can reach clinical systems or infrastructure.
A workable pattern is to combine three controls:
- Credential minimisation: remove static passwords and long-lived secrets from the workflow where a stronger path exists.
- Privilege reduction: use PAM and RBAC to separate routine access from elevated actions, then enforce JIT elevation only when needed.
- Surface hardening: lock down appliance management interfaces, disable unused services, and isolate admin networks from user traffic.
That matters because identity sprawl is common. NHIMG’s Top 10 NHI Issues notes that 97% of NHIs carry excessive privileges, while the Ultimate Guide to NHIs also reports that only 20% of organisations have formal processes for offboarding and revoking API keys. That is why identity review, rotation, and revocation must be part of ransomware readiness, not just IAM hygiene.
Healthcare teams should align this work with NIST Cybersecurity Framework 2.0 and apply zero trust principles to every management path, including vendor access and support tunnels. These controls tend to break down when legacy clinical devices require shared accounts because those systems often cannot support modern authentication or per-user attribution.
Common Variations and Edge Cases
Tighter identity control often increases operational friction, requiring organisations to balance clinical uptime against stronger authentication. That tradeoff is especially visible in emergency departments, imaging systems, and third-party maintenance windows, where teams may be tempted to keep shared passwords or broad admin access “just in case.”
Current guidance suggests that exceptions should be temporary, documented, and monitored, not treated as permanent architecture. Where passwordless access is not yet possible, use compensating controls such as short-lived credentials, jump hosts, device posture checks, and session recording. For vendor support, segment access so a supplier can reach only the exact system needed, only during the approved window, and only with JIT approval. The Cisco Active Directory credentials breach and Codefinger AWS S3 ransomware attack both underline a simple lesson: once credentials are exposed, attackers move quickly to the most powerful reachable system.
There is no universal standard for this yet across all medical devices, but the direction is clear in NIST Cybersecurity Framework 2.0 and zero trust guidance. The safest approach is to assume identity paths will be targeted first and to design every exception so it can expire, be audited, and be removed without manual heroics.
Standards & Framework Alignment
This section maps relevant standards and security frameworks to the operational risks and controls described in this guidance.
OWASP Non-Human Identity Top 10 address the attack and risk surface, while NIST CSF 2.0 and NIST Zero Trust (SP 800-207) set the governance and control requirements practitioners need to meet.
| Framework | Control / Reference | Relevance |
|---|---|---|
| NIST CSF 2.0 | PR.AC-4 | Identity and access control are central to reducing ransomware entry paths. |
| NIST Zero Trust (SP 800-207) | Zero trust supports segmenting admin access and verifying every session. | |
| OWASP Non-Human Identity Top 10 | NHI-03 | Covers secret rotation and revocation, which limits credential reuse after theft. |
Apply least privilege and MFA to every remote and privileged healthcare access path.
