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Security and privacy in electronic health records: a systematic literature review.
Open accessAbstract
Objective To report the results of a systematic literature review concerning the security and privacy of electronic health record (EHR) systems.Data sources Original articles written in English found in MEDLINE, ACM Digital Library, Wiley InterScience, IEEE Digital Library, Science@Direct, MetaPress, ERIC, CINAHL and Trip Database.Study selection Only those articles dealing with the security and privacy of EHR systems.Data extraction The extraction of 775 articles using a predefined search string, the outcome of which was reviewed by three authors and checked by a fourth.Results A total of 49 articles were selected, of which 26 used standards or regulations related to the privacy and security of EHR data. The most widely used regulations are the Health Insurance Portability and Accountability Act (HIPAA) and the European Data Protection Directive 95/46/EC. We found 23 articles that used symmetric key and/or asymmetric key schemes and 13 articles that employed the pseudo anonymity technique in EHR systems. A total of 11 articles propose the use of a digital signature scheme based on PKI (Public Key Infrastructure) and 13 articles propose a login/password (seven of them combined with a digital certificate or PIN) for authentication. The preferred access control model appears to be Role-Based Access Control (RBAC), since it is used in 27 studies. Ten of these studies discuss who should define the EHR systems' roles. Eleven studies discuss who should provide access to EHR data: patients or health entities. Sixteen of the articles reviewed indicate that it is necessary to override defined access policies in the case of an emergency. In 25 articles an audit-log of the system is produced. Only four studies mention that system users and/or health staff should be trained in security and privacy.Conclusions Recent years have witnessed the design of standards and the promulgation of directives concerning security and privacy in EHR systems. However, more work should be done to adopt these regulations and to deploy secure EHR systems.
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“More sophisticated methods such as biometric factors specific to the user involve high deployment costs and additional hardware costs [80].”
MethodSelf-citationDesigning cloud-based electronic health record system with attribute-based encryption
Xhafa, F., Li, J., Zhao, G., Li, J., Chen, X., & Wong, D. S. (2015) · Multimedia Tools and Applications · doi:10.1007/s11042-013-1829-6 · Cited by 76
Balancing confidentiality and care coordination: challenges in patient privacy
Ibrahim, A. M., Abdel‐Aziz, H. R., Mohamed, H. A. H., Zaghamir, D. E. F., Wahba, N. M. I., Hassan, G. A., Shaban, M., El-Nablaway, M., Aldughmi, O. N., & Aboelola, T. H. (2024) · BMC Nursing · doi:10.1186/s12912-024-02231-1 · Cited by 81
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“These days, data analysts in most healthcare organizations are more interested in collecting and studying new types and sources of underleveraged data, such as mobile health, sensor networks, emails and social media, in addition to the electronic health record (EHR) data.”
BackgroundAl-Zubaidie, M., Zhang, Z., & Zhang, J. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16091490 · Cited by 60
“Therefore, EHR systems require mechanisms to ensure the privacy of patients’ data while protecting authorisation policies and healthcare provider requests [15].”
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“Second, the health care industry is still unreceptive to allowing patient data to move across the blockchain network [12].”
BackgroundMethodFree Blood Donation Mobile Applications
Ouhbi, S., Fernández‐Alemán, J. L., Toval, A., Idri, A., & Pozo, J. R. (2015) · Journal of Medical Systems · doi:10.1007/s10916-015-0228-0 · Cited by 59
Self-citationAnalysis of health professional security behaviors in a real clinical setting: An empirical study
Fernández‐Alemán, J. L., Sánchez-Henarejos, A., Toval, A., García, A. B. S., Hernández-Hernández, I., & Fernández-Luque, L. (2015) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2015.01.010 · Cited by 58
Self-citationDigital health eco-systems: An epochal review of practice-oriented research
Stephanie, F. L., & Sharma, R. (2019) · International Journal of Information Management · doi:10.1016/j.ijinfomgt.2019.10.017 · Cited by 64
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Health Information System Role-Based Access Control Current Security Trends and Challenges
de Carvalho, M. A., & Bandiera‐Paiva, P. (2018) · Journal of Healthcare Engineering · doi:10.1155/2018/6510249 · Cited by 56
“In the following year, their next publication accounted for 27 articles out of 49 while searching for security and privacy in EHR when reporting the use of RBAC as authorization method [13].”
BackgroundElectronic Health Record Monitoring System and Data Security Using Blockchain Technology
Hasib, K. T. A. M., Chowdhury, I., Sakib, S., Khan, M. M., Alsufyani, N., Alsufyani, A., & Bourouis, S. (2022) · Security and Communication Networks · doi:10.1155/2022/2366632 · Cited by 58
“In [13], the authors showed that the International Data Encryption Standard Algorithm (IDEA) with salt will be used to protect patient-sensitive data during transmission.”
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Yigzaw, K. Y., Olabarriaga, S. D., Michalas, A., Marco-Ruiz, L., Hillen, C., Verginadis, Y., de Oliveira, M. T., Krefting, D., Penzel, T., Bowden, J., et al. (2022) · Elsevier eBooks · doi:10.1016/b978-0-12-823413-6.00014-8 · Cited by 62
Securing Electronic Health Record System in Cloud Environment Using Blockchain Technology
Murala, D. K., Panda, S. K., & Sahoo, S. K. (2023) · Intelligent systems reference library · doi:10.1007/978-3-031-22835-3_4 · Cited by 51
Shrivastava, U., Song, J., Han, B. T., & Dietzman, D. (2021) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2021.104401 · Cited by 51
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Smart City and Smart-Health Framework, Challenges and Opportunities
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“In addition, various attempts are contributed towards the privacy protection in heath, Trust- worthy Health and Wellness (THaW) is one of the representative projects in this context [7][13].”
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“This includes Confidentiality (access protection), Integrity (maintenance of data accuracy), Availability (data accessible upon demand), Accountability (responsibility on data content) and Disaster Recovery [24,25].”
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“Another major concern regarding personal electronic data is data security [22].”
BackgroundSecure Healthcare Record Sharing Mechanism with Blockchain
Butt, G. Q., Syed, T. A., Riaz, R., Rizvi, S. S., & Paul, A. (2022) · Applied Sciences · doi:10.3390/app12052307 · Cited by 49
An Infrastructure Framework for Remote Patient Monitoring Interventions and Research
Claggett, J. L., Petter, S., Joshi, A. M., Ponzio, T. A., & Kirkendall, E. S. (2024) · Journal of Medical Internet Research · doi:10.2196/51234 · Cited by 68
“Additionally, the implementation of access control mechanisms can help ensure that only authorized users can access and share patient data, further safeguarding privacy [56].”
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RSA based encryption approach for preserving confidentiality of big data
Sharma, K., Agrawal, A., Pandey, D., Khan, R. A., & Dinkar, S. K. (2019) · Journal of King Saud University - Computer and Information Sciences · doi:10.1016/j.jksuci.2019.10.006 · Cited by 48
Synergy of AI and Blockchain to Secure Electronic Healthcare Records
Rathore, N., Kumari, A., Patel, M., Chudasama, A. S., Bhalani, D., Tanwar, S., & Alabdulatif, A. (2024) · Security and Privacy · doi:10.1002/spy2.463 · Cited by 49
Trust and Reputation Management in Healthcare Systems: Taxonomy, Requirements and Open Issues
Jabeen, F., Hamid, Z., Akhunzada, A., Abdul, W., & Ghouzali, S. (2018) · IEEE Access · doi:10.1109/access.2018.2810337 · Cited by 51
“, Hard Trust) [21], [31], [43], [44] and that emphasize the benefits of trust, which can be established using non-cryptographic techniques [36], [44], [45].”
BackgroundInfluentialA study of cyber attacks: In the healthcare sector
Bhosale, K. S., Nenova, M., & Iliev, G. (2021) · Junior Conference on Lighting (Lighting) · doi:10.1109/lighting49406.2021.9598947 · Cited by 45
The ethical challenges of personalized digital health
Maeckelberghe, E. L. M., Zdunek, K., Marceglia, S. R. F., Farsides, B., & Rigby, M. (2023) · Frontiers in Medicine · doi:10.3389/fmed.2023.1123863 · Cited by 46
Lee, S., Kim, J., Kwon, Y., Kim, T., & Cho, S. (2022) · Journal of Medical Internet Research · doi:10.2196/29108 · Cited by 47
“Moreover, as the EMR-sharing process is performed by a third-party data center or cloud service provider, personal information of the patient can be exposed [24-26].”
BackgroundA Survey of Big Data Issues in Electronic Health Record Analysis
Cyganek, B., Graña, M., Krawczyk, B., Kasprzak, A., Porwik, P., Walkowiak, K. M., & Woźniak, M. (2016) · Applied Artificial Intelligence · doi:10.1080/08839514.2016.1193714 · Cited by 44
“An important aspect of the health record system is to ensure the confidentiality of the patient personal data (Fernandez-Aleman et al. 2013).”
BackgroundTrust assessment of security for e-health systems
Bahtıyar, Ş., & Çağlayan, M. U. (2013) · Electronic Commerce Research and Applications · doi:10.1016/j.elerap.2013.10.003 · Cited by 42
“…or seek medical care for certain sensitive conditions if they cannot trust that their personal health information will be managed with high level of confidentiality (Avancha et al. 2012, Martí et al. 2013, Appari and Johnson 2010, Haas et al. 2011, Trcek and Brodnik 2013, Alemán et al. 2013).”
Background
Metadata
- Authors
- Fernández-Alemán, J. L., Señor, I. C., Lozoya, P. Á. O., & Toval, A.
- Affiliations
- Universidad de Murcia (ES)
- Corresponding author
- Señor, Inmaculada Carrión
- ORCID
- Toval, Ambrosio
- Venue
- Journal of Biomedical Informatics
- Publisher
- Elsevier BV
- Published
- 2013-06
- Volume
- 46
- Issue
- 3
- Pages
- 541-562
- ISSN
- 1532-0464 (ISSN-L)
- OpenAlex
- W2128232860
- Cited by
- 675
- References
- 127
- Citations by year
- 2026: 23 · 2025: 39 · 2024: 72 · 2023: 59 · 2022: 46 · 2021: 59 · 2020: 57 · 2019: 82 · 2018: 57 · 2017: 48 · 2016: 56 · 2015: 38 · 2014: 29 · 2013: 10
- FWCI
- 7.79
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Biomedical Informatics (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Spanish Ministry of Science and Technology (TIN2009-13718-C02-01, TIN2009-13718-C02-02)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Physical Sciences › Computer Science › Computer Networks and Communications › Access Control and Trust
- Health Sciences › Health Professions › Health Information Management › Thoreau and American Literature
- Keywords
- electronic health records, health information security, privacy, HIPAA, Data Protection Directive 95/46/EC, public key infrastructure, digital signatures, pseudo-anonymity, role-based access control, access control, audit logging, user authentication
- MeSH terms
- Europe, United States, Computer Security, Privacy, Health Insurance Portability and Accountability Act, Electronic Health Records
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