How legacy devices create backdoors into healthcare systems

Legacy devices create systematic backdoors through four primary vulnerabilities namely unpatched software, network exposure, default configurations, and interoperability gaps. The consequences cascade through healthcare ecosystems. 

An article published in the International Journal of Scientific & Technology Research Volume 9 echoes the central issues with legacy systems, noting, “Many legacy systems are crucial for organizations and difficult to fully move over new systems like railway ticket reservation system for a transport system, flights, buses, billing system in a mall, etc. There are many challenges occur during the maintenance of legacy systems: Data Loss, Security Vulnerabilities, Cost Affects, Usability, Unknown Dependencies, Performance Effect, Integration Issues.”

Until manufacturers and providers align on standardized update frameworks, as proposed in the PATCH Act, these backdoors will persist, forcing hospitals to choose between patient safety and network integrity.

What are legacy devices? 

Legacy devices in healthcare are outdated medical technologies, systems, or devices that are no longer supported, updated, or adequately protected against modern cybersecurity threats.  An AMIA conference paper, Legacy systems: managing evolution through integration in a distributed and object-oriented computing environment, states, “Legacy systems are crucial for organizations since they support key functionalities. But they become obsolete with aging and the apparition of new techniques. Managing their evolution is a key issue in software engineering.”

These include older versions of electronic health record (EHR) systems, imaging equipment, and laboratory information systems (LIS). Legacy devices often persist in healthcare environments due to their critical role in clinical workflows, high replacement costs, and the long operational lifespan of hardware compared to the shorter lifecycle of software updates.

Why are legacy devices still commonly used in healthcare 

Legacy devices persist in healthcare due to complex economic, operational, and systemic constraints that create a technological inertia paradox. While 73% of healthcare organizations still rely on outdated systems like Windows 7 or proprietary platforms, this stems from four interrelated factors. 

Capital expenditure burden

High-cost medical hardware (e.g., MRI machines, ventilators) often have lifespans of over 10 years, but manufacturers typically design software support cycles to be shorter. Replacing a $2M MRI system solely for OS updates is financially untenable for most hospitals, especially when hardware remains clinically functional. This creates an incentive to prioritize asset depreciation schedules over cybersecurity.

Clinical workflow entanglement

Legacy devices frequently integrate with hospital networks through deprecated protocols like HL7 v2 or DICOM standards. Migrating to modern systems risks disrupting critical care pathways. A 2024 BMC Geriatrics study found that 28% of EHR transition errors were caused by data entry failures. Organizations face an innovation trap. Adopting new software could introduce patient safety risks, while maintaining legacy systems elevates cyberattack surfaces.

Skills gap and institutional knowledge

Many legacy systems depend on retiring staff who understand COBOL-based platforms or proprietary interfaces. As noted by Legacy Data Access CEO Tony Jaros, "Newer IT teams fear breaking undocumented legacy dependencies during migration." This knowledge asymmetry forces hospitals into vendor lock-in, where manufacturers charge premium fees for legacy system maintenance, a practice generating $337M annually in U.S. federal healthcare costs alone.

Regulatory-clinical tension

While HIPAA requires "reasonable" security measures, the FDA’s 510(k) clearance process allows legacy medical devices to remain operational if hardware meets original safety benchmarks. This creates regulatory blind spots where a ventilator’s mechanical components pass inspections.

Hardware versus software lifecycle 

Medical devices operate under a fundamental asymmetry. Hardware designed for 10-30 years of service coexists with software update cycles averaging 3-7 years. This mismatch stems from divergent innovation timelines, hardware development follows biological and mechanical R&D cadences (5-15 years), while software adheres to Moore’s Law (18-24 months). 

An FBI Cyber Division notification states, “Medical device hardware often remains active for 10-30 years, however, underlying software life cycles are specified by the manufacturer, ranging from a couple months to maximum life expectancy per device allowing cyber threat actors time to discover and exploit vulnerabilities.”  

Economic drivers exacerbate this gap. Bringing a novel therapeutic device to market costs $522 million on average, incentivizing manufacturers to prioritize new product lines over legacy system updates. 

How legacy devices become backdoors

Unpatched software

According to the study To Patch or Not to Patch: Motivations, Challenges, and Implications for Cybersecurity, “There have been, and continue to be, various examples of attackers using publicized but unpatched vulnerabilities to launch their attacks; even the scanning for these vulnerabilities by attackers continues for periods after patches have been released [11]. This problem has been exacerbated by the advent of generative artificial intelligence (GenAI) systems and Large language models (LLMs) (e.g., ChatGPT, Claude, CoPilot, Gemini, etc.) as they are able to analyze systems for vulnerabilities and even exploit zero-days” The FBI documented in the above mentioned notification a 47% rise in medical device exploits from 2021-2024, often leveraging deprecated protocols like HL7 v2.

Hard-coded backdoors

The 2025 Contec CMS8000 incident revealed an embedded NFS backdoor routing patient data to unauthorized IP addresses. Such design flaws, whether intentional or accidental, persist in telehealth devices due to rushed FDA clearances prioritizing functionality over security audits.

Default configurations

A conference titled ‘System performance optimization via design and configuration space exploration’ notes, “Engineers in practice often just accept the default settings, leading such systems to significantly underperform relative to their potential. This problem, in turn, has impacts on cost, revenue, customer satisfaction, business reputation, and mission effectiveness.” Legacy devices can retain factory credentials, enabling brute-force attacks on networked ventilators and dialysis machines. 

Should healthcare organizations be concerned about built in backdoors

According to the study Vulnerability to Cyberattacks and Sociotechnical Solutions for Health Care Systems: Systematic Review, “Studies conducted through the simulation of medical devices have similarly revealed that pacemakers and pulse oximeters can be hacked and compromised without a physician’s knowledge.”

Healthcare organizations should therefore be concerned about built-in legacy software backdoors, as these threaten patient safety and data integrity. The study also shows the prevalence of vulnerabilities in medical devices, often stemming from outdated systems like Windows XP, which lack modern security updates and are frequently exploited by cybercriminals. 

Another study analyzing vulnerabilities from 2001 to 2022 identified critical issues such as poor credential management and hard-coded credentials in devices like EHR systems, infusion pumps, and radiology information systems. These vulnerabilities compromise patient data and create entry points for further attacks.

The way forward

A viable way forward involves implementing sociotechnical solutions that combine technical fixes with organizational changes. This includes adopting zero-trust architectures, where legacy devices are isolated from core networks to limit attack vectors. Additionally, regulatory reforms are crucial; proposals like the FDA's Cybersecurity Modernization Act aim to mandate longer software support lifecycles for medical devices, aligning them with hardware longevity.

Related: HIPAA Compliant Email: The Definitive Guide (2025 Update)

FAQs

What is a backdoor in cybersecurity?

A backdoor is an unauthorized access point into a system or network that bypasses normal security controls. It can be a hidden vulnerability intentionally or unintentionally built into software or hardware. 

How can a backdoor in a legacy device compromise an entire healthcare network?

When a legacy device with a backdoor is connected to a healthcare network, attackers can use it as an entry point. Once inside, they may move laterally through the network, gaining access to sensitive patient data, disrupting clinical operations, or even controlling other interconnected devices. 

Are there any regulatory guidelines to ensure cybersecurity in legacy devices?

Yes, regulatory bodies such as the FDA and CISA have issued guidelines and alerts focusing on cybersecurity risks in legacy devices.