Towards A Well-Secured Electronic Health Record in the Health Cloud

Abstract

The major concerns for most cloud implementers particularly in the health care industry have remained data security and privacy. A prominent and major threat that constitutes a hurdle for practitioners within the health industry from exploiting and benefiting from the gains of cloud computing is the fear of theft of patients health data in the cloud. Investigations and surveys have revealed that most practitioners in the health care industry are concerned about the risk of health data mix-up amongst the various cloud providers, hacking to comprise the cloud platform and theft of vital patients' health data. An overview of the diverse issues relating to health data privacy and overall security in the cloud are presented in this technical report. Based on identifed secure access requirements, an encryption-based eHR security model for securing and enforcing authorised access to electronic health data (records), eHR is also presented. It highlights three core functionalities for managing issues relating to health data privacy and security of eHR in health care cloud.

Full text

Towards A Well-Secured Electronic Health
Record in the Health Cloud
Babafemi O. Odusote and Nicholas A. Ikhu-Omoregbe
Abstract—The major concerns for most cloud implementers particularly in the health care industry have remained data security
and privacy. A prominent and major threat that constitutes a hurdle for practitioners within the health industry from exploiting and
benefiting from the gains of cloud computing is the fear of theft of patients health data in the cloud. Investigations and surveys
have revealed that most practitioners in the health care industry are concerned about the risk of health data mix-up amongst the
various cloud providers, hacking to comprise the cloud platform and theft of vital patients’ health data. An overview of the
diverse issues relating to health data privacy and overall security in the cloud are presented in this technical report. Based on
identifed secure access requirements, an encryption-based eHR security model for securing and enforcing authorised access to
electronic health data (records), eHR is also presented. It highlights three core functionalities for managing issues relating to
health data privacy and security of eHR in health care cloud.
Index Terms—Cloud Computing, Data Privacy, Data Security, Electronic Health Records.
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1 INTRODUCTION
Loud computing has been defined by national insti-
tute of standards and technology (NIST) as a model
for enabling convenient, on-demand network access
to a shared pool of configurable computing resources
(software, hardware and services) that can be rapidly
provisioned and released with minimal management ef-
fort or service provider interaction [2]. It is an emerging
and fast growing computing paradigm that uses internet
technologies to enable and facilitate the provisioning of
service-oriented, adaptable and scalable IT-based capabili-
ties to external suscribers or clients [1], [3]. It has evolved
primarily three widely referenced and adopted service
models. [4], [5], [6], [7], [8].
1.1 Software-as-a-Service - SaaS (Application in the
cloud)
Several applications and computing resources required to
enable their execution can be provided to various
suscribers on-demand as a service. SaaS model engenders
the provision of computing capabilities resident in the
cloud to suscribers or clients. In this service model, the
management and control of the underlying cloud infra-
structure is completely out of bounds to the clients. The
provision of privacy protection and security for external
clients is also integral to the SaaS service model.
The total cost of ownership (TCO) of IT facilities such
as software, hardware, operations and maintenance is
greatly reduced. Several examples include business appli-
cations such as Customer Relationship Management
(CRM), On-line Payment Processing (OPP), Report Gen-
eration and Analysis (RGA), Order Management Systems
(OMS), Inventory Management Systems (IMS), communi-
cations and collaboration tools (such as e-mail and Web
conferencing), and a host of other computing capabilities.
1.2 Platform-as-a-Service - PaaS (Platform in the
cloud)
Computing platforms upon which several computing
applications can be developed and deployed can also be
provided to various suscribers on-demand as a service.
PaaS model is a deployment model that facilitates the
deployment of computing applications either acquired or
created and developed using programming languages
and tools supported by the cloud infrastructure. In this
model, the right of control and management of the de-
ployed applications and possibly the application hosting
environment configurations are granted to the client or
suscriber.
PaaS implements two levels of privacy protection and
security. They are application level and system level. The
former requires the client to succintly define and specify
the access control requirements and policies depending
on the application provided, while at the latter level, es-
sential security measures and mechanisms such as au-
thentication, authorization and end-to-end encryption can
be provided by the cloud host. The primary focus of the
PaaS provider is to offer an effective platform for the de-
ployment, management and control of the subscribers’
applications.
1.3 Infrastructure-as-a-Service - IaaS
(Infrastructure in the cloud)
With IaaS model, suscribers are provided with the fun-
damental computing capabilities – networks, storage,
processing, etc in which they are enabled to arbitrarily
deploy and run various classes of software applications
and systems including operating systems. In this model,
————————————————
 B.O. Odusote is with the Department of Computer and Information Sci-
ence, Covenant University, Ogun State, Nigeria.
 N.I.Omoregbe is with the Department of Computer and Information Sci-
ences, Covenant University, Ogun State, Nigeria.
C
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the clients’ right of control and management is strictly
limited to the deployed applications and operating sys-
tems.
They do not have control over the underlying cloud
infrastructure but the primarily responsibility for privacy
protection and security rests with the application devel-
oper. However, the sole focus of the infrastructure pro-
vider is to keep the infrastructure up and running in con-
sonance with the contract agreement while, the suscriber
is left with the responsibility of application deployment,
system management and control, monitoring, support,
backup and failover. This would require higly skilled
manpower within the clients’ organization.
Fig. 1: A Typical Cloud Architecture [6]
The cloud has witness the emergence of a number of
cloud computing platforms and technologies some of
which are highlighted in [7]: Amazon Elastic Compute
Cloud (Amazon EC2), Microsoft Azure, Google App En-
gine, Open Nebula, CloudSim, Sun Grid, Virtual Work-
space etc.
Since the advent of Information Technology (IT), or-
ganizations and corporations globally have experienced
enhancement and improvement in their various organiza-
tional processes and operations. The various health or-
ganizations are no exceptions [1]. Currently, the
healthcare industry is faced with growing regulatory
pressures coupled with high rising economic demands
that pose a dire and urgent need for a change and im-
provement in its Information Technology (IT) infrastruc-
ture [9], [11]. This is potentially driving the imminent
need for the adoption and acceptance of cloud compu-
ting, especially going by the various investments in the
health industry by the governments in Sub-Saharan Afri-
ca (SSA) towards achieving the United Nations Millenni-
um Development Goal (UN MDG) [10], [11]. It is a fast
evolving computing paradigm that has the promising
potential & inherent benefits to deliver this needed im-
provement [1].
Top on the priority list of the health care industry are:
improved quality of health care, increasing access, reduc-
ing cost, and ensuring health data privacy and security
[1]. However, a prominent and major threat that consti-
tutes a hurdle for practitioners within the health industry
from exploiting and benefiting from the gains of cloud
computing is the fear of theft of patients health data in the
cloud [1], [3]. Various investigations and surveys have
revealed that most health practitioners are concerned
about the risk of health data mix-up amongst the various
cloud providers, hacking to comprise the cloud platform
and theft of vital patients’ health data [3].
The resultant effects of these which could range from
time and cost of damage to lawsuit against the cloud pro-
vider or even the health organization would cause the
organizations a lot of public disrepute and embarassment
[3], [14].
This technical report, presents an overview of the di-
verse issues relating to health data privacy and overall
security in the cloud. Based on identified secure access
requirements, an integrated encryption-based security
model for securing and enforcing authorised access to
electronic health data (records), eHR is also presented. It
highlights three core functionalities for managing issues
relating to health data privacy and security of eHR in
health care clouds.
The rest of the paper is organized as follows. Section
2 presents an overview of the diverse issues relating to
health data privacy and overall security in the cloud. Sec-
tion 3 illustrates an integrated encryption-based security
model based on the identified secure access requirements
for both patient and healthcare professional in the context
of patient health care delivery. The presentation was
summarized and conclusions were made in Section 4.
2 RELATED WORKS
Cloud computing paradigm leverages on the offerings of
software-on-demand approach. It provides enterprises
and organizations with several benefits such as reduction
of IT-related operational costs. Health organizations no
longer need to invest heavily in building, owning or
maintaining applications for e-Health services such as
Health Records Management (HRM), Electronic Health
Records (eHR), Electronic Medical Records (eMR), etc, as
they can access these services through a network and
charged accordingly based on resource usage [13].
However, a clear undertanding of the various securi-
ty implications is an essential step to successfully leverage
health care on the cloud. Privacy and strict security en-
forcement are also crucial in attending to pertinent securi-
ty concerns that exists, with data movement from the in-
ternal computing center of the organization to that of an-
other organization.
Moreso, the quest for reduced IT-related operational
that the adoption of the cloud offers should not comprise
the responsibility for privacy and security. The organiza-
tion is primarily held responsible for the state of the or-
ganization services – handling issues such as availability,
performance, recovery and failover, monitoring and
management still lie within the confines and control of
the organization.
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The issues sorrounding cloud security and data pri-
vacy in the cloud are well known and are not brand new
in their entirety but are only casted in new computing
perspectives, owing to the fact that cloud computing is an
emerging paradigm from a combination of existing tech-
nologies such as service-oriented computing and
architectecture (SOC/SOA), utility computing, virtualiza-
tion, Web 2.0, etc. [15]. Consequently, cloud computing
represents a non-conventional, thought-stimulating para-
digm shift towards building a robust and wide-range
healthcare industry.
W.A. Jansen [3] presented a significant detailed over-
view and classification of the diverse relevant issues relat-
ing to health data privacy and overall security in the
cloud into several general categories. These categories
are: trust, data protection, identity management, availa-
bility, architecture, software isolation.
Furthermore, R. Zhang and L. Liu [8] opined that
risk management is in many ways usually involved in the
exercise of migrating into the cloud computing environ-
ment from a dedicated internal computing environment.
They suggested that, against the available safeguards and
envisaged benefits, the associated risks however must be
carefully balanced with the understanding that the organ-
ization will be primarily held responsible and accountable
for the security. If the associated costs and risks are out-
weighed by the accrued benefits, it will be efficient and
effective not to put too many controls [16]. One thing that
must be ensured particularly, with computing programs
and operations is right balance between the relative asso-
ciated risks and the strength of controls. [3], [17].
3 THE INTEGRATED ENCRYPTION-BASED SECURITY
MODEL
This security model is a component-based system of se-
curely coupled core components that cater for the privacy
and security requirements in the health cloud for patients
through the adoption of a cryptography technique - en-
cryption.
Considering the fact that within the healthcare organ-
izations, health patients could have attending doctors and
perhaps in some critical cases a number of other special-
ists or consultants from other health care delivery organi-
zations attending to them, assuming an ideal health cir-
cumstance where an assigned doctor has to deal with a
patient but the patient has some major health complica-
tions that resulted from acute disease like cancer such
that the doctor would need to seek expert opinions and
consultations from various practitioners who are special-
ists and consultants from the different health care deliv-
ery organizations particularly the patient’s personal phy-
sician who is fully conversant with the patient’s medical
history. These practitioners can then form a consultative
group for recommending the appropritate treatments for
this patient.
A well-trusted independent third party medical agent
can be norminated by the group to serve as the consulta-
tive group manager who would be responsible managing
and monitoring the activities of the group in accordance
with industry best practices. The manager will also dis-
solve the group after the completion of the patient’s diag-
nosis and prescriptive treatement process. There is also a
feedback means for the patient and the third party medi-
cal agent to liaise.
The group begins their consultation and diagnostic
treatment with each consultant granted an authorized
access to some of the patient’s electronic medical records
in the secured database of the patient’s health organiza-
tion in order to have a requisite knowledge of the medical
history of the patient.
After every consultation, the practitioners who par-
ticipated in the medical consultation would reach a medi-
cal conclusion regarding the next step treatment. The
group’s certified and endorsed outcomes such as diagno-
sis reports and treatment prescriptions recommended are
transmitted to the patient to include to his personal medi-
cal records database. This sceanrio is depicted in fig. 2
below.
Fig. 2: A Typical Scenario of eHR Patient’s Health Care Delivery
The consequence of the above described scenario raises
and brings to the fore a number of privacy and security
issues.
First, from the view point of the consultants and
practitioners, two crucial concerns are, how to obtain the
patient’s medical records without breaching the patient’s
privacy and how to validate that the electronic health
records from the various health organiztions where the
patient has receive treatments or even the patient’s per-
sonal health records are authentic. These two concerns are
captured as Aggregation & Integration and Secure Stor-
age & Acces Control Management of the patient’s elec-
tronic health records.
Second, from the viewpoint of the patient is the pa-
tient’s assurance and confidence in the trustworthiness of
the certifed and endorsed consultation outcomes from the
group of specialists. The patient would need to certify
that the medical report/certificate forwarded by the
group is authentic and genuine and has not been tam-
pered with. This is captured as Secured Transmission of
the medical report/certificate.
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A proposed integrated encryption-based security
model to cater for the implementation of the privacy and
security requirements for the patient’s health care deliv-
ery is highlighted as follows. This is depicted in the fig. 3
below.
Fig. 3: An Integrated Encryption-based Security Model
3.1 Secure eHR Aggregation and Integration
This first component componet of the security model
stems from the scenario described above as the first re-
quirement to meet which is to securely aggregate and
integrate the patient’s various eHRs independently man-
aged by different health care delivery organizations. The
requirement is address by the eHR aggregator and inte-
grator. It is designed to securely aggregate and integrate
the various eHRs into a newly aggregated eHR with a
signed security medical certificate attached. This is done
only after it has successfully verified and certified the
authenticity, confidentiality, integrity, non repudiation
and minimum authorised disclosure compliance of the
various eHRs from only the legitimate and trustworthy
health care deliver organizations. In this kind of ar-
rangement, a vital and critical concern that requires ade-
quate consideration is semantic interoperability – the
formats of storing the eHRs and the aggregated eHR must
facilitate interoperability between the eHR systems in
terms of effective data sharing and efficient combination
of eHRs from multiple databases into an aggregated eHR.
3.2 Secure eHR Storage and Management
This is component is designed as a storage for the
encypted integrated eHR and for enforcing authorised
access. These are taken care of by the secured storage
server which comprises of the encryption functionality
and the access control unit. The access control unit is de-
signed to prevent unauthorised access by enforcing stipu-
lated access control policies. Authorized practitioners can
only be permitted to access and obtain authorized parts of
the encrypted integrated patient’s eHR through authenti-
cation and authorization-based decryption mechanisms.
3.3 Secure eHR Usage and Transmission
This component is designed to provide the eHR users -
both the patient and the health care practitioner author-
ised access to information that can be verified. This is
captured by the certification/sigature and verification
functionalities. After every consultation, the practitioners
who participated in the medical consultation would reach
a medical conclusion regarding the next step treatment.
The group’s certified and endorsed outcomes such as di-
agnosis reports and treatment prescriptions recommend-
ed are transmitted to the patient with the practitioners’
digital signature. The patient can then verify the authen-
ticity, confidentiality and integrity of the certificate eHR
with his private key to include thereafter in his personal
medical records database. The digital certificate is includ-
ed for future reference in case of any disagreement in the
future. It can easily be used to obtain the identities of the
practitioners who participated in the consultative group
and signed the medical result.
4 CONCLUSION
Improved quality of health care, increasing access, reduc-
ing cost, and ensuring health data privacy and security
are issues top on the priority of the health care delivery
organizations within the healthcare industry. However,
the fear of theft of patients health data, hacking and data
mix-up amongst various providers in the cloud have con-
stituted major hurdles for practitioners within the health
industry from exploiting and benefiting from the gains of
cloud computing. In this technical report, an overview of
the diverse issues relating to health data privacy and
overall security in the cloud was presented. Based on
identified secure access requirements, an encryption-
driven eHR security model for securing and enforcing
authorised access to electronic health data (records), eHR
was also presented. It is strongly believed that the presen-
tation in this report can be used as a background for
cloud developers and particularly for health researchers
and practitioners in Sub-Saharan Africa (SSA) towards
achieving one of the United Nations Millennium Devel-
opment Goal (UN MDG).
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Babafemi O. Odusote is a Computer Science graduate of Covenant
University, Nigeria in 2007. He holds a M.Sc. in Computer Science in
2011 from the same institution. He is currently on his Ph.D Program
in the same Institution where he is a research fellow and lecturer in
the Department of Computer and Information Science. His research
interests include: Software Engineering, Mobile Computing, Grid
Computing, Cloud Computing, Service-Oriented Computing, e-
Learning, e-Commerce.
N. A. Ikhu-Omoregbe holds a B.Sc degree in Computer Science
from the University of Benin, Benin City, a M.Sc. degree in Computer
Science from the University of Lagos, and a PhD degree in Comput-
er Science from Covenant University, Ota, Nigeria. His research
interests include: Software Engineering, Mobile Computing, Multi-
media technologies, Mobile Healthcare and Telemedicine Systems,
and Soft Computing. He currently lectures in the Department of
Computer and Information Systems, Covenant University, Ota, and
has taught at Baden-Wurttemberg Cooperative State University,
Heidenheim as a visiting lecturer in the area of e-Health Systems.
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