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To find an attacker who has been inside a hospital network for months, correlate evidence from network devices, endpoints, identity systems, cloud services and critical applications—and retain enough protected log history to investigate activity retrospectively. Establish what normal activity looks like, prioritize clinical systems and connected medical devices, and regularly test whether monitoring detects persistence, lateral movement and command-and-control activity. Monitoring works only when alerts have named owners and a clear path to investigation and escalation.
What should healthcare security teams monitor?
No single sensor can show the full course of a long-running intrusion. Network records can reveal communication between systems; endpoint records can show activity on a host; identity records can expose unusual account use. Central correlation helps investigators connect those events and understand the scope of an incident.
| Evidence source | What it can help reveal | Coverage considerations |
|---|---|---|
| Network devices and intrusion detection systems (IDS) | Unexpected connections, unusual traffic patterns, and communication that may indicate lateral movement or command and control. | Maintain centrally managed IDS alerts and include relevant network boundaries and external connections. |
| Endpoints and hosts | Host-level activity that may indicate persistence, anomalous binaries or unexpected execution of remote monitoring and management (RMM) tools. | Network monitoring alone may not show what happened on a particular system. |
| Identity systems | Account and access activity that can help investigators connect a user or service identity to activity on systems. | Correlate identity records with network and host events rather than treating them as a separate alert stream. |
| Cloud services and critical applications | Activity in cloud-connected environments and applications that support important services or workflows. | Include cloud connections and application dependencies in diagrams and monitoring plans. |
| Connected medical devices and clinical support systems | Activity affecting devices or systems involved in patient care, including communications that could matter to clinical operations. | Inventory devices and map clinical dependencies before deciding how to monitor or segment them. |
This is a coverage model, not a claim that every device produces the same records or supports the same monitoring method. Account for vendor constraints, privacy obligations and clinical workflows when selecting telemetry and response actions.
How should a hospital build monitoring that can find a months-old intrusion?
1. Map the environment before tuning alerts
Keep an asset inventory and current network diagrams that show major networks, IP schemes, data flows, external connections, cloud connections, third-party or managed-service-provider access, and dependencies. Include connected medical devices and systems that support patient care. Without this context, analysts may struggle to distinguish expected communications from suspicious ones—or to understand which systems could be affected by a change.
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2. Collect and correlate records centrally
Gather relevant records from network devices, hosts, identity systems, cloud services and critical applications. Centralized log management and correlation make it easier to connect activity across systems and investigate an event’s scope. Secure logs against unauthorized alteration or loss, and back them up so they remain available for analysis.
CISA recommends maintaining and backing up logs for critical systems for a minimum of one year, if possible. This is guidance, not a universal legal retention requirement. Establish a retention period that accounts for applicable obligations, the organization’s risk and the practical ability to protect and search the data.
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3. Establish a baseline and tune for behavior
Build an understanding of normal network traffic and ordinary user and system behavior, then tune network and host-based monitoring to identify meaningful deviations. The aim is not to alert on every unusual event; it is to surface activity that merits investigation in the context of the hospital’s systems and workflows.
- Unexpected remote access or unusual communications between systems.
- Activity consistent with lateral movement from one host or network area to another.
- Host behavior that may indicate persistence, including anomalous binary execution.
- Communication patterns that may indicate command and control.
- Unexpected execution of remote monitoring and management tools.
4. Give every alert an owner and an escalation path
Assign named owners to monitoring queues and define how alerts are triaged, escalated and connected to incident response. Central monitoring is of limited use if an alert is not reviewed or investigators cannot determine who should act. Set expectations for coverage, including after-hours escalation, based on the organization’s staffing and risk.
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5. Test detections and improve them after exercises
Map relevant adversary behaviors to MITRE ATT&CK, use that vocabulary to identify which behaviors the monitoring program intends to detect, and exercise those detections. Review what generated an alert, what was missed and whether staff could investigate and escalate the signal. ATT&CK is a framework for describing behaviors; mapping a technique does not prove that a control detects it.
CISA’s red-team advisory describes lateral movement, persistence and command-and-control activity going undetected across multiple defensive and logging layers in a tested environment. That is a practical reason to validate the complete detection and response workflow—not just whether a product is installed.
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How do network segmentation and clinical safety fit together?
Segmentation restricts access between subnetworks, which can make lateral movement harder and help contain an affected area. It complements monitoring: detection helps identify suspicious activity, while segmentation can limit how far an intrusion reaches.
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Hospitals should map clinical and operational dependencies before changing network boundaries or access rules. A control that interrupts a device or service needed for patient care can create a different kind of risk. Inventory, data-flow diagrams and coordination with clinical, technical and vendor stakeholders help teams plan changes around those dependencies.
How can a hospital assess a monitoring service or approach?
When comparing an internal program, a managed monitoring service or technology options, assess the capabilities that determine whether an intrusion can be seen and acted on. These criteria do not establish that one vendor is best.
- Visibility: Does coverage include network, endpoint, identity, cloud, critical applications and clinical-device environments where appropriate?
- Logs: Can the organization securely retain and back up records, correlate them centrally and retrieve them for investigation?
- Detection: Is there a defined approach to detecting lateral movement, persistence and command-and-control behavior?
- Clinical fit: Can monitoring and response account for medical-device constraints and clinical workflows?
- Operations: Are alert ownership, after-hours escalation and incident-response integration explicit?
- Containment: Can the approach support segmentation and access restrictions without overlooking clinical dependencies?
- Validation: Is there repeatable evidence from exercises against relevant ATT&CK techniques, including review of missed signals?
For organizations exploring no-cost starting points, CISA’s logging resources list Logging Made Easy and Malcolm as tools to help collect and review key system logs. Check the current official documentation and assess fit for the hospital’s environment; their listing does not establish that either tool is suitable for every deployment.
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