The FDA's New Cybersecurity Guidance for Medical Devices Reminds Us That Safety & Security Go Hand in Hand

The new draft guidance on premarket submissions incorporates quality system regulations and doubles down on a life-cycle approach to product security.

Roman Kesler, VP of Research, Cybellum

May 26, 2022

5 Min Read
Medical device
Source: gajendra bhati via Alamy Stock Photo

It's hard to believe, but medical device manufacturers who are subject to Food and Drug Administration premarket approval — the FDA process of review to evaluate the safety and effectiveness of Class III medical devices — are still operating under the FDA's original medical device cybersecurity guidance from 2014 and a subsequent update in 2018. But that is about to change in a major way.

Instead of finalizing the 2018 premarket cybersecurity draft guidance, the FDA has decided to issue a new 2022 version to reflect the rapid evolution of cybersecurity, incorporating a new set of quality system regulations (QSRs) with significant changes to its 2018 predecessor.

New FDA Draft Guidance
The new draft guidance, titled "Cybersecurity in Medical Devices: Quality System Considerations and Content of Premarket Submissions," deals with myriad design, labeling, and documentation issues that will have to be addressed by medical device manufacturers before their new devices can gain FDA premarket approval.

The FDA's original guidance on cybersecurity was just nine pages while the 2022 version swells to 50 pages, reflecting advancements in the cybersecurity ecosystem and best practices. It appears that, when approving connected medical devices for market, the FDA will be taking a long look at how cybersecurity is implemented, especially regarding levels of risk to patient safety.

Updated Regulations: Why Now?
Requiring greater cybersecurity measures to protect medical devices and their operational and patient data is vital since the healthcare industry has become a massive target of cyberattacks. Data breaches hit an all-time high in 2021, exposing a record volume of protected health information. Besides pilfering data, a growing number of breaches attempt to disrupt the smooth operation of medical devices like computed tomography and magnetic resonance imaging machines, potentially causing incorrect diagnoses, unnecessary medical procedures, or direct harm to patients.

The American Hospital Association's senior adviser for cybersecurity and risk has stated that medical devices used in hospital rooms suffer from an average of 6.2 vulnerabilities. As devices become more complex and interconnected, opportunities for cyberattackers to exploit vulnerabilities are becoming greater, hence the need for updated regulations.

Incorporating Cybersecurity into Quality System Regulations to Boost Safety
With the new guidance, the FDA seeks to ensure that the next generation of medical devices will be far safer and secure throughout the entire device life cycle, from premarket and throughout the entire useful life, beginning from the earliest stages of design (shift-left) to post-production (shift-right).

With the proposed guidance, the FDA is doubling down on its efforts to incorporate cybersecurity into quality regulations to address the complexity of modern devices and today's evolving threat landscape.

From CBOM to SBOM: What's the Difference?
Surprisingly, one of the major changes that the new guidance brings is a leniency in the requirement for manufacturers to provide a complete software bill of materials (SBOM) instead of a more tedious cybersecurity bill of materials (CBOM), as was required in the 2018 draft. Medical device manufacturers were balking at the 2018 guidelines because of this stringency.

An SBOM is more in line with cybersecurity standards across most industries and aligns with the Biden administration's recently issued Executive Order 14028, "Improving the Nation's Cybersecurity." It contains all of the required software packages (commercial and open source) and their versions.

The much more complicated CBOM, according to the 2018 guidance, demands "a list of commercial, open source, and off-the-shelf software and hardware components to enable device users (including patients, care providers, and healthcare delivery organizations) to effectively manage their assets, understand the potential impact of identified vulnerabilities to the device — and the connected system — and to deploy countermeasures to maintain the device's essential performance."

A Secure Product Development Framework for Every Device
The latest guidance asks medical device manufacturers to consider using a secure product development framework (SPDF) to achieve the goals of the QSR: "An SPDF encompasses all aspects of a product's lifecycle, including development, release, support, and decommission."

Besides compliance with the draft guidance, the call for using an SPDF can add significant value to medical devices. As the draft guideline states: "Using SPDF processes during device design may prevent the need to re-engineer the device when connectivity-based features are added after marketing and distribution, or when vulnerabilities resulting in uncontrolled risks are discovered."

Is the New FDA Draft Guidance Binding?
Until July 7, the FDA is inviting medical device manufacturers and the public to comment on the new draft, which is expected to be finalized later this year when it will become the new FDA cybersecurity guidance for medical devices. While FDA guidance is nonbinding, the approved version will provide a road map for how medical device manufacturers should address cybersecurity in their products to ensure compliance and patient safety.

The FDA is not the only federal agency looking to strengthen cybersecurity regs. Legislation called the Protecting and Transforming Cyber Health Care (PATCH) Act was recently introduced in the US Congress. The act, the EO, and other proposed bills contain provisions that will strengthen the FDA's ability to require medical device manufacturers to meet certain cybersecurity objectives.

In order to future-proof for impending legislation, medical device manufacturers should start investigating solutions that can generate detailed SBOMs and continuously detect vulnerabilities and mitigate risks in order to stay compliant with the FDA's 2022 guidance and beyond.

About the Author(s)

Roman Kesler

VP of Research, Cybellum

Roman Kesler is VP of Research at Cybellum. Roman started at Cybellum as a security researcher and developer and progressed over five years to lead the research department. He was instrumental in the development of a product and device security platform, which automatically detects known and zero-day vulnerabilities in firmware with static and dynamic analysis.

Prior to Cybellum, Roman served for five years in a technology unit of the Israeli Defense Forces as a security developer. His research experience includes IDA Pro, IDA python, Ghidra, Python for Ghidra, Hex editors, radare2, WinDbg, GDB, and x64dbg.

He holds a B.Sc. in Applied Mathematics from Bar Ilan University and an MBA from Tel Aviv University.

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