To find an attacker who has remained inside a hospital network for months, correlate network, endpoint, identity, cloud, and critical-application records in a central monitoring workflow. Build a current map of clinical systems and connected medical devices, baseline expected activity, investigate alerts for persistence and lateral movement, and regularly test whether your controls actually detect those behaviors.
Start with a map of what must be protected
Monitoring is only as useful as the organization’s understanding of what is connected and how it communicates. Keep an asset inventory and network diagrams current, including major networks and IP schemes, data flows, external connections, cloud services, third-party and managed-service-provider access, and dependencies between systems.
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Include network-connected medical devices and the systems that support patient care. A device may depend on a server, vendor connection, or clinical application that is not obvious from a network diagram alone. Map those relationships before deciding where to collect data or change access controls; an intervention that interrupts a clinical dependency can affect care.
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A long-running intrusion can leave different clues in different places. Network-only monitoring may miss activity on a compromised host, while endpoint-only monitoring may not reveal communication patterns across the wider environment. CISA recommends centralized log management that correlates network and host security records, along with centrally managed intrusion-detection-system (IDS) alerts.
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| Evidence source | What it can help reveal |
|---|---|
| Network devices and IDS | Communication between systems, unusual connections, and traffic that may indicate lateral movement or command-and-control activity. |
| Endpoints and hosts | Unexpected binaries, suspicious processes, persistence mechanisms, and activity that network records alone may not explain. |
| Identity systems | Unusual account or access activity that can help investigators understand how an intruder is moving between systems. |
| Cloud services and critical applications | Activity in services or business systems that may not be visible in on-premises network records. |
| Medical-device and clinical-system environments | Activity involving connected devices and the systems or services they depend on; coverage should be designed around the clinical environment and its dependencies. |
Centralize and protect records so investigators can correlate events and determine their scope. 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; organizations should also account for applicable obligations and their incident-response needs.
Baseline normal activity, then tune detections
Establish what ordinary network traffic and user and system behavior look like in each part of the environment. A useful baseline helps analysts distinguish an unusual event from routine clinical operations, scheduled maintenance, or approved vendor access. Review and tune network appliances and host-based security products against that expected activity rather than assuming default alerts will fit a hospital’s workflows.
Prioritize investigation of anomalies that may indicate an intruder is establishing persistence or expanding access, including:
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- Unexpected binaries or unusual activity on a host.
- Unusual remote access or connections between systems that do not normally communicate.
- Activity consistent with lateral movement or persistence.
- Communication patterns that may indicate command and control (C2).
- Unexpected execution of remote monitoring and management (RMM) tools.
These behaviors are investigation leads, not proof of compromise. Their meaning depends on the asset, its normal use, and the surrounding evidence.
Make alerts actionable
Assign each alert category a named owner and define how it is triaged, escalated, and connected to incident response. Central collection without clear ownership can leave important warnings unattended. The workflow should make it possible to correlate an alert with related host, identity, application, or cloud activity and determine who can investigate it.
For any monitoring approach or managed service, assess whether it provides coverage across the environments that matter, secure log retention and correlation, detection of persistence and lateral movement, compatibility with clinical devices and workflows, clear alert ownership, and escalation that fits the organization’s response plan. Tool categories such as IDS, SIEM, EDR, and managed monitoring describe capabilities; they do not by themselves establish that a particular product or provider is suitable.
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Test whether the monitoring catches real behaviors
Do not treat the presence of a security tool or an ATT&CK mapping as evidence that a detection works. MITRE ATT&CK provides a common vocabulary for describing adversary behaviors; it is not a product or a validation result. Map relevant behaviors to the technologies and procedures intended to detect them, exercise those detections, review what was missed, and tune both tools and analyst workflows.
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 reason to validate the whole detection process, not just whether logs are being generated: check whether signals are collected, correlated, raised as alerts, and acted on.
Use segmentation to limit an intrusion’s reach
Monitoring helps reveal suspicious activity; segmentation can reduce the paths an intruder can use between parts of the network and limit the impact of a compromised area. Restrict access between subnetworks according to operational needs, and map clinical safety and system dependencies before changing connectivity. Segmentation complements detection rather than replacing it: an attacker may still be present within an allowed zone or use an authorized path.
A practical monitoring cycle
- Map: Update the asset inventory, network diagrams, data flows, external and third-party connections, and clinical dependencies.
- Collect: Bring network, host, identity, cloud, and critical-application records into a centrally managed, protected logging process.
- Baseline: Document expected traffic and activity, including legitimate clinical workflows and vendor access.
- Detect and route: Tune alerts for suspicious binaries, remote access, lateral movement, persistence, C2, and unexpected RMM execution; assign owners and escalation paths.
- Validate: Exercise relevant adversary behaviors, examine missed signals, and adjust detections and response procedures.
- Constrain: Apply segmentation and access restrictions with clinical dependencies and safety in view.
CISA’s logging guidance also lists no-cost tools, including Logging Made Easy and Malcolm, for collecting and reviewing key system logs. Their inclusion does not establish that either is suitable for a particular hospital deployment; check the tools’ current official documentation and assess them against the environment’s requirements.
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