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1.  Patient-Centered Access to Secure Systems Online (PCASSO): a secure approach to clinical data access via the World Wide Web. 
The Internet's World-Wide Web (WWW) provides an appealing medium for the communication of health related information due to its ease of use and growing popularity. But current technologies for communicating data between WWW clients and servers are systematically vulnerable to certain types of security threats. Prominent among these threats are "Trojan horse" programs running on client workstations, which perform some useful and known function for a user, while breaching security via background functions that are not apparent to the user. The Patient-Centered Access to Secure Systems Online (PCASSO) project of SAIC and UCSD is a research, development and evaluation project to exploit state-of-the-art security and WWW technology for health care. PCASSO is designed to provide secure access to clinical data for healthcare providers and their patients using the Internet. PCASSO will be evaluated for both safety and effectiveness, and may provide a model for secure communications via public data networks.
PMCID: PMC2233557  PMID: 9357644
2.  Protecting clinical data on Web client computers: the PCASSO approach. 
The ubiquity and ease of use of the Web have made it an increasingly popular medium for communication of health-related information. Web interfaces to commercially available clinical information systems are now available or under development by most major vendors. To the extent that such interfaces involve the use of unprotected operating systems, they are vulnerable to security limitations of Web client software environments. The Patient Centered Access to Secure Systems Online (PCASSO) project extends the protections for person-identifiable health data on Web client computers. PCASSO uses several approaches, including physical protection of authentication information, execution containment, graphical displays, and monitoring the client system for intrusions and co-existing programs that may compromise security.
PMCID: PMC2232202  PMID: 9929243
3.  A Study on User Authentication Methodology Using Numeric Password and Fingerprint Biometric Information 
BioMed Research International  2013;2013:427542.
The prevalence of computers and the development of the Internet made us able to easily access information. As people are concerned about user information security, the interest of the user authentication method is growing. The most common computer authentication method is the use of alphanumerical usernames and passwords. The password authentication systems currently used are easy, but only if you know the password, as the user authentication is vulnerable. User authentication using fingerprints, only the user with the information that is specific to the authentication security is strong. But there are disadvantage such as the user cannot change the authentication key. In this study, we proposed authentication methodology that combines numeric-based password and biometric-based fingerprint authentication system. Use the information in the user's fingerprint, authentication keys to obtain security. Also, using numeric-based password can to easily change the password; the authentication keys were designed to provide flexibility.
doi:10.1155/2013/427542
PMCID: PMC3787579  PMID: 24151601
4.  Giving Patients Access to Their Medical Records via the Internet 
Objective: The Patient-Centered Access to Secure Systems Online (pcasso) project is designed to apply state-of-the-art-security to the communication of clinical information over the Internet.
Design: The authors report the legal and regulatory issues associated with deploying the system, and results of its use by providers and patients. Human subject protection concerns raised by the Institutional Review Board focused on three areas—unauthorized access to information by persons other than the patient; the effect of startling or poorly understood information; and the effect of patient access to records on the record-keeping behavior of providers.
Measurements: Objective and subjective measures of security and usability were obtained.
Results: During its initial deployment phase, the project enrolled 216 physicians and 41 patients; of these, 68 physicians and 26 patients used the system one or more times. The system performed as designed, with no unauthorized information access or intrusions detected. Providers rated the usability of the system low because of the complexity of the secure login and other security features and restrictions limiting their access to those patients with whom they had a professional relationship. In contrast, patients rated the usability and functionality of the system favorably.
Conclusion: High-assurance systems that serve both patients and providers will need to address differing expectations regarding security and ease of use.
doi:10.1197/jamia.M1005
PMCID: PMC344575  PMID: 11861633
5.  E-SAP: Efficient-Strong Authentication Protocol for Healthcare Applications Using Wireless Medical Sensor Networks 
Sensors (Basel, Switzerland)  2012;12(2):1625-1647.
A wireless medical sensor network (WMSN) can sense humans’ physiological signs without sacrificing patient comfort and transmit patient vital signs to health professionals’ hand-held devices. The patient physiological data are highly sensitive and WMSNs are extremely vulnerable to many attacks. Therefore, it must be ensured that patients’ medical signs are not exposed to unauthorized users. Consequently, strong user authentication is the main concern for the success and large scale deployment of WMSNs. In this regard, this paper presents an efficient, strong authentication protocol, named E-SAP, for healthcare application using WMSNs. The proposed E-SAP includes: (1) a two-factor (i.e., password and smartcard) professional authentication; (2) mutual authentication between the professional and the medical sensor; (3) symmetric encryption/decryption for providing message confidentiality; (4) establishment of a secure session key at the end of authentication; and (5) professionals can change their password. Further, the proposed protocol requires three message exchanges between the professional, medical sensor node and gateway node, and achieves efficiency (i.e., low computation and communication cost). Through the formal analysis, security analysis and performance analysis, we demonstrate that E-SAP is more secure against many practical attacks, and allows a tradeoff between the security and the performance cost for healthcare application using WMSNs.
doi:10.3390/s120201625
PMCID: PMC3304131  PMID: 22438729
medical sensor network; secure healthcare; user authentication; mutual authentication; session key establishment; smart card
6.  Cryptanalysis and Security Improvements of ‘Two-Factor User Authentication in Wireless Sensor Networks’ 
Sensors (Basel, Switzerland)  2010;10(3):2450-2459.
User authentication in wireless sensor networks (WSN) is a critical security issue due to their unattended and hostile deployment in the field. Since sensor nodes are equipped with limited computing power, storage, and communication modules; authenticating remote users in such resource-constrained environments is a paramount security concern. Recently, M.L. Das proposed a two-factor user authentication scheme in WSNs and claimed that his scheme is secure against different kinds of attack. However, in this paper, we show that the M.L. Das-scheme has some critical security pitfalls and cannot be recommended for real applications. We point out that in his scheme: users cannot change/update their passwords, it does not provide mutual authentication between gateway node and sensor node, and is vulnerable to gateway node bypassing attack and privileged-insider attack. To overcome the inherent security weaknesses of the M.L. Das-scheme, we propose improvements and security patches that attempt to fix the susceptibilities of his scheme. The proposed security improvements can be incorporated in the M.L. Das-scheme for achieving a more secure and robust two-factor user authentication in WSNs.
doi:10.3390/s100302450
PMCID: PMC3264488  PMID: 22294935
authentication; wireless sensor network; security; smart card; cryptanalysis
7.  Detecting Inappropriate Access to Electronic Health Records Using Collaborative Filtering 
Machine learning  2013;95(1):87-101.
Many healthcare facilities enforce security on their electronic health records (EHRs) through a corrective mechanism: some staff nominally have almost unrestricted access to the records, but there is a strict ex post facto audit process for inappropriate accesses, i.e., accesses that violate the facility’s security and privacy policies. This process is inefficient, as each suspicious access has to be reviewed by a security expert, and is purely retrospective, as it occurs after damage may have been incurred. This motivates automated approaches based on machine learning using historical data. Previous attempts at such a system have successfully applied supervised learning models to this end, such as SVMs and logistic regression. While providing benefits over manual auditing, these approaches ignore the identity of the users and patients involved in a record access. Therefore, they cannot exploit the fact that a patient whose record was previously involved in a violation has an increased risk of being involved in a future violation. Motivated by this, in this paper, we propose a collaborative filtering inspired approach to predicting inappropriate accesses. Our solution integrates both explicit and latent features for staff and patients, the latter acting as a personalized “finger-print” based on historical access patterns. The proposed method, when applied to real EHR access data from two tertiary hospitals and a file-access dataset from Amazon, shows not only significantly improved performance compared to existing methods, but also provides insights as to what indicates an inappropriate access.
doi:10.1007/s10994-013-5376-1
PMCID: PMC3967851  PMID: 24683293
access violation; collaborative filtering; electronic health records; privacy breach detection
8.  Minutiae Matching with Privacy Protection Based on the Combination of Garbled Circuit and Homomorphic Encryption 
The Scientific World Journal  2014;2014:525387.
Biometrics plays an important role in authentication applications since they are strongly linked to holders. With an increasing growth of e-commerce and e-government, one can expect that biometric-based authentication systems are possibly deployed over the open networks in the near future. However, due to its openness, the Internet poses a great challenge to the security and privacy of biometric authentication. Biometric data cannot be revoked, so it is of paramount importance that biometric data should be handled in a secure way. In this paper we present a scheme achieving privacy-preserving fingerprint authentication between two parties, in which fingerprint minutiae matching algorithm is completed in the encrypted domain. To improve the efficiency, we exploit homomorphic encryption as well as garbled circuits to design the protocol. Our goal is to provide protection for the security of template in storage and data privacy of two parties in transaction. The experimental results show that the proposed authentication protocol runs efficiently. Therefore, the protocol can run over open networks and help to alleviate the concerns on security and privacy of biometric applications over the open networks.
doi:10.1155/2014/525387
PMCID: PMC3953427
9.  Audited credential delegation: a usable security solution for the virtual physiological human toolkit 
Interface Focus  2011;1(3):462-473.
We present applications of audited credential delegation (ACD), a usable security solution for authentication, authorization and auditing in distributed virtual physiological human (VPH) project environments that removes the use of digital certificates from end-users' experience. Current security solutions are based on public key infrastructure (PKI). While PKI offers strong security for VPH projects, it suffers from serious usability shortcomings in terms of end-user acquisition and management of credentials which deter scientists from exploiting distributed VPH environments. By contrast, ACD supports the use of local credentials. Currently, a local ACD username–password combination can be used to access grid-based resources while Shibboleth support is underway. Moreover, ACD provides seamless and secure access to shared patient data, tools and infrastructure, thus supporting the provision of personalized medicine for patients, scientists and clinicians participating in e-health projects from a local to the widest international scale.
doi:10.1098/rsfs.2010.0026
PMCID: PMC3262438  PMID: 22670214
grid security; e-health security; information assurance; security wrappers
10.  Sharing Data and Analytical Resources Securely in a Biomedical Research Grid Environment 
Objectives
To develop a security infrastructure to support controlled and secure access to data and analytical resources in a biomedical research Grid environment, while facilitating resource sharing among collaborators.
Design
A Grid security infrastructure, called Grid Authentication and Authorization with Reliably Distributed Services (GAARDS), is developed as a key architecture component of the NCI-funded cancer Biomedical Informatics Grid (caBIG™). The GAARDS is designed to support in a distributed environment 1) efficient provisioning and federation of user identities and credentials; 2) group-based access control support with which resource providers can enforce policies based on community accepted groups and local groups; and 3) management of a trust fabric so that policies can be enforced based on required levels of assurance.
Measurements
GAARDS is implemented as a suite of Grid services and administrative tools. It provides three core services: Dorian for management and federation of user identities, Grid Trust Service for maintaining and provisioning a federated trust fabric within the Grid environment, and Grid Grouper for enforcing authorization policies based on both local and Grid-level groups.
Results
The GAARDS infrastructure is available as a stand-alone system and as a component of the caGrid infrastructure. More information about GAARDS can be accessed at http://www.cagrid.org.
Conclusions
GAARDS provides a comprehensive system to address the security challenges associated with environments in which resources may be located at different sites, requests to access the resources may cross institutional boundaries, and user credentials are created, managed, revoked dynamically in a de-centralized manner.
doi:10.1197/jamia.M2662
PMCID: PMC2409996  PMID: 18308979
11.  WebCIS: large scale deployment of a Web-based clinical information system. 
WebCIS is a Web-based clinical information system. It sits atop the existing Columbia University clinical information system architecture, which includes a clinical repository, the Medical Entities Dictionary, an HL7 interface engine, and an Arden Syntax based clinical event monitor. WebCIS security features include authentication with secure tokens, authorization maintained in an LDAP server, SSL encryption, permanent audit logs, and application time outs. WebCIS is currently used by 810 physicians at the Columbia-Presbyterian center of New York Presbyterian Healthcare to review and enter data into the electronic medical record. Current deployment challenges include maintaining adequate database performance despite complex queries, replacing large numbers of computers that cannot run modern Web browsers, and training users that have never logged onto the Web. Although the raised expectations and higher goals have increased deployment costs, the end result is a far more functional, far more available system.
Images
PMCID: PMC2232714  PMID: 10566471
12.  Smart cards--the key to trustworthy health information systems. 
BMJ : British Medical Journal  1997;314(7080):573-577.
Some 20 years after they were first developed, "smart cards" are set to play a crucial part in healthcare systems. Last year about a billion were supplied, mainly for use in the financial sector, but their special features make them of particular strategic importance for the health sector, where they offer a ready made solution to some key problems of security and confidentiality. This article outlines what smart cards are and why they are so important in managing health information. I discuss some of the unique features of smart cards that are of special importance in the development of secure and trustworthy health information systems. Smart cards would enable individuals' identities to be authenticated and communications to be secured and would provide the mechanisms for implementing strong security, differential access to data, and definitive audit trails. Patient cards can also with complete security carry personal details, data on current health problems and medications, emergency care data, and pointers to where medical records for the patient can be found. Provider cards can in addition carry authorisations and information on computer set up.
PMCID: PMC2126025  PMID: 9055719
13.  Web Security for Access of Private Information via the Internet 
Authentication, authorization, accounting, and encryption are goals of security strategies for web information being accessed that is private. The definition of these terms is as follows:
• Authentication - validation that the individual (or system) is who they say they are
• Authorization - validation that the individual (or system) accessing information is authorized to do so
• Accounting - records are kept of what is accessed
• Encryption - use of a ‘scrambling’ algorithm such that the information can pass securely across the public Internet without being intelligible; information is specifically ‘unscrambled’ or deencrypted at the receiving end
Many tools can be used to meet these goals. The degree to which the goals are met is determined by how we use these tools. Methodologies similar to TSEC[1] and ITSEC[2] can be used to determine the appropriate level of protection for a particular web application. This poster describes a set of effective strategies for web application security and the level of protection each strategy provides.
PMCID: PMC2243435
14.  Security, privacy, and confidentiality issues on the Internet 
We introduce the issues around protecting information about patients and related data sent via the Internet. We begin by reviewing three concepts necessary to any discussion about data security in a healthcare environment: privacy, confidentiality, and consent. We are giving some advice on how to protect local data. Authentication and privacy of e-mail via encryption is offered by Pretty Good Privacy (PGP) and Secure Multipurpose Internet Mail Extensions (S/MIME). The de facto Internet standard for encrypting Web-based information interchanges is Secure Sockets Layer (SSL), more recently known as Transport Layer Security or TLS. There is a public key infrastructure process to `sign' a message whereby the private key of an individual can be used to `hash' the message. This can then be verified against the sender's public key. This ensures the data's authenticity and origin without conferring privacy, and is called a `digital signature'. The best protection against viruses is not opening e-mails from unknown sources or those containing unusual message headers.
doi:10.2196/jmir.4.2.e12
PMCID: PMC1761937  PMID: 12554559
Access to Information; Computer Security; Confidentiality; Data Collection; Information Services; Informed consent; Internet; Organizational Policy; Privacy
15.  RUASN: A Robust User Authentication Framework for Wireless Sensor Networks 
Sensors (Basel, Switzerland)  2011;11(5):5020-5046.
In recent years, wireless sensor networks (WSNs) have been considered as a potential solution for real-time monitoring applications and these WSNs have potential practical impact on next generation technology too. However, WSNs could become a threat if suitable security is not considered before the deployment and if there are any loopholes in their security, which might open the door for an attacker and hence, endanger the application. User authentication is one of the most important security services to protect WSN data access from unauthorized users; it should provide both mutual authentication and session key establishment services. This paper proposes a robust user authentication framework for wireless sensor networks, based on a two-factor (password and smart card) concept. This scheme facilitates many services to the users such as user anonymity, mutual authentication, secure session key establishment and it allows users to choose/update their password regularly, whenever needed. Furthermore, we have provided the formal verification using Rubin logic and compare RUASN with many existing schemes. As a result, we found that the proposed scheme possesses many advantages against popular attacks, and achieves better efficiency at low computation cost.
doi:10.3390/s110505020
PMCID: PMC3231354  PMID: 22163888
wireless sensor network security; user authentication; user anonymity; session key establishment; confidentiality
16.  Intelligent Sensors Security 
Sensors (Basel, Switzerland)  2010;10(1):822-859.
The paper is focused on the security issues of sensors provided with processors and software and used for high-risk applications. Common IT related threats may cause serious consequences for sensor system users. To improve their robustness, sensor systems should be developed in a restricted way that would provide them with assurance. One assurance creation methodology is Common Criteria (ISO/IEC 15408) used for IT products and systems. The paper begins with a primer on the Common Criteria, and then a general security model of the intelligent sensor as an IT product is discussed. The paper presents how the security problem of the intelligent sensor is defined and solved. The contribution of the paper is to provide Common Criteria (CC) related security design patterns and to improve the effectiveness of the sensor development process.
doi:10.3390/s100100822
PMCID: PMC3270872  PMID: 22315571
Common Criteria; IT security development; intelligent sensor; design pattern
17.  Evolution of a legacy system to a Web patient record server: leveraging investment while opening the system. 
A layered system is under development to enhance our legacy system as a backend in a WEB-enabled system. Each layer of the system has defined functionality, leverages the investment in the layer below, and follows the strategy of reducing support requirements for workstations. The mainframe system provides administrative integration of sub-systems, security, and the central data repository for most information. The second layer is a graphical user interface (GUI) to the system for Windows platforms. Support needs are limited by relying chiefly on X-terminals and application servers. The "Intranet" layer is a WEB Server building upon the second layer gateways to provide platform-independent access to selected information and images. The fourth layer, under evaluation, will extend access to the central data repository for Internet users of web browsers that support private-key/public-key encryption.
PMCID: PMC2232982  PMID: 8947740
18.  Security Analysis and Enhancements of an Effective Biometric-Based Remote User Authentication Scheme Using Smart Cards 
Recently, many biometrics-based user authentication schemes using smart cards have been proposed to improve the security weaknesses in user authentication system. In 2011, Das proposed an efficient biometric-based remote user authentication scheme using smart cards that can provide strong authentication and mutual authentication. In this paper, we analyze the security of Das's authentication scheme, and we have shown that Das's authentication scheme is still insecure against the various attacks. Also, we proposed the enhanced scheme to remove these security problems of Das's authentication scheme, even if the secret information stored in the smart card is revealed to an attacker. As a result of security analysis, we can see that the enhanced scheme is secure against the user impersonation attack, the server masquerading attack, the password guessing attack, and the insider attack and provides mutual authentication between the user and the server.
doi:10.1155/2012/519723
PMCID: PMC3415263  PMID: 22899887
19.  A method for interactive medical instruction utilizing the World Wide Web. 
We describe the implementation of interactive medical teaching programs in radiology and histology which utilize the Internet's World Wide Web (WWW). The WWW standard hypertext interface allows for simple navigation between related documents but does not provide a method for student tracking or question queries. Electronic forms, a recent feature of the WWW, provide the means to present question documents to remote clients and track student performance. A feature of our approach is dynamic creation of HTML documents based upon interaction with database applications. The approach allows multiple simultaneous, yet asynchronous interactions by geographically dispersed students upon the same instructional database and is scalable, providing the capability for multiple image/document servers. The security of the database is assured given that it is not accessible through the Internet.
PMCID: PMC2579144  PMID: 8563334
20.  Assuring the Privacy and Security of Transmitting Sensitive Electronic Health Information 
The interchange of electronic health records between healthcare providers and public health organizations has become an increasingly desirable tool in reducing healthcare costs, improving healthcare quality, and protecting population health. Assuring privacy and security in nationwide sharing of Electronic Health Records (EHR) in an environment such as GRID has become a top challenge and concern. The Centers for Disease Control and Prevention’s (CDC) and The Science Application International Corporation (SAIC) have jointly conducted a proof of concept study to find and build a common secure and reliable messaging platform (the SRM Platform) to handle this challenge. The SRM Platform is built on the open standards of OASIS, World Wide Web Consortium (W3C) web-services standards, and Web Services Interoperability (WS-I) specifications to provide the secure transport of sensitive EHR or electronic medical records (EMR). Transmitted data may be in any digital form including text, data, and binary files, such as images. This paper identifies the business use cases, architecture, test results, and new connectivity options for disparate health networks among PHIN, NHIN, Grid, and others.
PMCID: PMC2815468  PMID: 20351909
21.  Implementation of Medical Information Exchange System Based on EHR Standard 
Healthcare Informatics Research  2010;16(4):281-289.
Objectives
To develop effective ways of sharing patients' medical information, we developed a new medical information exchange system (MIES) based on a registry server, which enabled us to exchange different types of data generated by various systems.
Methods
To assure that patient's medical information can be effectively exchanged under different system environments, we adopted the standardized data transfer methods and terminologies suggested by the Center for Interoperable Electronic Healthcare Record (CIEHR) of Korea in order to guarantee interoperability. Regarding information security, MIES followed the security guidelines suggested by the CIEHR of Korea. This study aimed to develop essential security systems for the implementation of online services, such as encryption of communication, server security, database security, protection against hacking, contents, and network security.
Results
The registry server managed information exchange as well as the registration information of the clinical document architecture (CDA) documents, and the CDA Transfer Server was used to locate and transmit the proper CDA document from the relevant repository. The CDA viewer showed the CDA documents via connection with the information systems of related hospitals.
Conclusions
This research chooses transfer items and defines document standards that follow CDA standards, such that exchange of CDA documents between different systems became possible through ebXML. The proposed MIES was designed as an independent central registry server model in order to guarantee the essential security of patients' medical information.
doi:10.4258/hir.2010.16.4.281
PMCID: PMC3092130  PMID: 21818447
Electronic Health Record; VPN; Web Service Security Enhanced; Health Level 7 Standard; CDA R2
22.  Proposal for DICOM Multiframe Medical Image Integrity and Authenticity 
This paper presents a novel algorithm to successfully achieve viable integrity and authenticity addition and verification of n-frame DICOM medical images using cryptographic mechanisms. The aim of this work is the enhancement of DICOM security measures, especially for multiframe images. Current approaches have limitations that should be properly addressed for improved security. The algorithm proposed in this work uses data encryption to provide integrity and authenticity, along with digital signature. Relevant header data and digital signature are used as inputs to cipher the image. Therefore, one can only retrieve the original data if and only if the images and the inputs are correct. The encryption process itself is a cascading scheme, where a frame is ciphered with data related to the previous frames, generating also additional data on image integrity and authenticity. Decryption is similar to encryption, featuring also the standard security verification of the image. The implementation was done in JAVA, and a performance evaluation was carried out comparing the speed of the algorithm with other existing approaches. The evaluation showed a good performance of the algorithm, which is an encouraging result to use it in a real environment.
doi:10.1007/s10278-008-9103-6
PMCID: PMC3043673  PMID: 18266035
Security; image processing; integrity; authenticity; DICOM
23.  Internet as clinical information system: application development using the World Wide Web. 
Clinical computing application development at Columbia-Presbyterian Medical Center has been limited by the lack of a flexible programming environment that supports multiple client user platforms. The World Wide Web offers a potential solution, with its multifunction servers, multiplatform clients, and use of standard protocols for displaying information. The authors are now using the Web, coupled with their own local clinical data server and vocabulary server, to carry out rapid prototype development of clinical information systems. They have developed one such prototype system that can be run on most popular computing platforms from anywhere on the Internet. The Web paradigm allows easy integration of clinical information with other local and Internet-based information sources. The Web also simplifies many aspects of application design; for example, it includes facilities for the use of encryption to meet the authors' security and confidentiality requirements. The prototype currently runs on only the Web server in the Department of Medical Informatics at Columbia University, but it could be run on other Web servers that access the authors' clinical data and vocabulary servers. It could also be adapted to access clinical information from other systems with similar server capabilities. This approach may be adaptable for use in developing institution-independent standards for data and application sharing.
PMCID: PMC116267  PMID: 7496876
24.  Privacy and information security risks in a technology platform for home-based chronic disease rehabilitation and education 
Background
Privacy and information security are important for all healthcare services, including home-based services. We have designed and implemented a prototype technology platform for providing home-based healthcare services. It supports a personal electronic health diary and enables secure and reliable communication and interaction with peers and healthcare personnel. The platform runs on a small computer with a dedicated remote control. It is connected to the patient’s TV and to a broadband Internet. The platform has been tested with home-based rehabilitation and education programs for chronic obstructive pulmonary disease and diabetes. As part of our work, a risk assessment of privacy and security aspects has been performed, to reveal actual risks and to ensure adequate information security in this technical platform.
Methods
Risk assessment was performed in an iterative manner during the development process. Thus, security solutions have been incorporated into the design from an early stage instead of being included as an add-on to a nearly completed system. We have adapted existing risk management methods to our own environment, thus creating our own method. Our method conforms to ISO’s standard for information security risk management.
Results
A total of approximately 50 threats and possible unwanted incidents were identified and analysed. Among the threats to the four information security aspects: confidentiality, integrity, availability, and quality; confidentiality threats were identified as most serious, with one threat given an unacceptable level of High risk. This is because health-related personal information is regarded as sensitive. Availability threats were analysed as low risk, as the aim of the home programmes is to provide education and rehabilitation services; not for use in acute situations or for continuous health monitoring.
Conclusions
Most of the identified threats are applicable for healthcare services intended for patients or citizens in their own homes. Confidentiality risks in home are different from in a more controlled environment such as a hospital; and electronic equipment located in private homes and communicating via Internet, is more exposed to unauthorised access. By implementing the proposed measures, it has been possible to design a home-based service which ensures the necessary level of information security and privacy.
doi:10.1186/1472-6947-13-85
PMCID: PMC3751072  PMID: 23937965
Privacy; Confidentiality; Information security; Risk assessment; Pulmonary rehabilitation; Diabetes self-management education; Video conference; Tele-homecare
25.  Security Protection of DICOM Medical Images Using Dual-Layer Reversible Watermarking with Tamper Detection Capability 
Journal of Digital Imaging  2010;24(3):528-540.
Teleradiology applications and universal availability of patient records using web-based technology are rapidly gaining importance. Consequently, digital medical image security has become an important issue when images and their pertinent patient information are transmitted across public networks, such as the Internet. Health mandates such as the Health Insurance Portability and Accountability Act require healthcare providers to adhere to security measures in order to protect sensitive patient information. This paper presents a fully reversible, dual-layer watermarking scheme with tamper detection capability for medical images. The scheme utilizes concepts of public-key cryptography and reversible data-hiding technique. The scheme was tested using medical images in DICOM format. The results show that the scheme is able to ensure image authenticity and integrity, and to locate tampered regions in the images.
doi:10.1007/s10278-010-9295-4
PMCID: PMC3092037  PMID: 20414697
Digital watermark; security; image authentication; teleradiology; public-key cryptography

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