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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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Items 301–400 of 674
Privacy Preserving Architecture for Healthcare Information Systems
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“The importance of these technical issues has been well supported by other systematic reviews [6,16,59,60].”
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Abomhara, M., & Lazrag, M. B. (2016) · IEEE International Conference on e-Health Networking, Applications and Services (Healthcom) · doi:10.1109/healthcom.2016.7749461 · Cited by 9
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Shatnawi, A. S., Munson, E. V., & Thao, C. (2017) · ACM Symposium on Document Engineering (DocEng) · doi:10.1145/3103010.3121038 · Cited by 9
“Considerable research has been published on providing secure access control and updates in a distributed, cooperative environment for online tree-structured documents such as XML [3, 4].”
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Chavda, V. P., Patel, K., Patel, S. H., & Apostolopoulos, V. (2023) · Wiley eBooks · doi:10.1002/9781119865728.ch13 · Cited by 11
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B-SSMD: A Fine-Grained Secure Sharing Scheme of Medical Data Based on Blockchain
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Lebredo, H., Fernández-Álvarez, D., & Gayo, J. E. L. (2023) · International Journal on Semantic Web and Information Systems · doi:10.4018/ijswis.333633 · Cited by 8
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Ruotsalainen, P. S., Blobel, B. G. M. E., & Pohjolainen, S. A. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12050657 · Cited by 9
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BackgroundA decade of security research in ubiquitous computing: results of a systematic literature review
Kušen, E., & Strembeck, M. (2016) · International Journal of Pervasive Computing and Communications · doi:10.1108/ijpcc-03-2016-0018 · Cited by 8
“Alemn et al. (2013) give an overview of security and privacy for electronic health records.”
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Drevin, L., Kruger, H., Bell, A.-M., & Steyn, T. (2017) · IFIP advances in information and communication technology · doi:10.1007/978-3-319-58553-6_8 · Cited by 8
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The promise of natural language processing in healthcare
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“1,27,28 As long as NLP can improve healthcare quality and access, measures should be taken to implement NLP safely and ethically.”
BackgroundThe Feasibility and Significance of Employing Blockchain-Based Identity Solutions in Health Care
Zhang, P., & Kuo, T.-T. (2021) · Smart innovation, systems and technologies · doi:10.1007/978-981-33-6470-7_11 · Cited by 9
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Evaluation of Anonymization Tools for Health Data
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“Consequently, it is fundamental to curb medical cyber piracy and secure the network infrastructure that supports them (Fernández-Alemán et al. 2013).”
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Ibrahim, A. (2016) · UKnowledge (University of Kentucky) · doi:10.13023/etd.2016.307 · Cited by 7
“Existing methods of authorization in electronic health information systems can be divided into cryptographic and non-cryptographic approaches [62] [157].”
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Pandit, N. K., Das, S., & Panda, C. K. (2024) · IEEE International Conference on Information Technology, Electronics and Intelligent Communication Systems (ICITEICS) · doi:10.1109/iciteics61368.2024.10625459 · Cited by 7
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Mimo, E. D. M., & McDaniel, T. L. (2021) · IEEE International Smart Cities Conference (ISC2) · doi:10.1109/isc253183.2021.9562841 · Cited by 6
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BackgroundAccess Control of EHR Records in a Heterogeneous Cloud Infrastructure
Szabó, Z., & Bilicki, V. (2021) · Acta Cybernetica · doi:10.14232/actacyb.290283 · Cited by 6
Tajdari, S., Irajpour, A., Shahriari, M., & Saghaei, M. (2022) · Journal of Medical Ethics and History of Medicine · doi:10.18502/jmehm.v15i6.11048 · Cited by 8
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On the Use of XML in Medical Imaging Web-Based Applications
Mata, C., Oliver, A., Lalande, A., Walker, P. M., & Martı́, J. (2016) · IRBM · doi:10.1016/j.irbm.2016.10.001 · Cited by 6
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“However, the transition from paper-based health records to Electronic Health Records (EHR) lurks new challenges related to the secure transmission and privacy-handling of data, since health information is considered to be one of the most confidential types of personal information [14].”
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Jahan, S., Chowdhury, M., Islam, R., & Gao, J. (2018) · Communications in computer and information science · doi:10.1007/978-3-319-94421-0_16 · Cited by 6
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Raja, K., & Hanifa, S. M. (2017) · IOP Conference Series Materials Science and Engineering · doi:10.1088/1757-899x/225/1/012184 · Cited by 5
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Dimitriadis, I., Mavroudopoulos, I., Kyrama, S., Toliopoulos, T., Gounaris, A., Vakali, A. I., Billis, A. S., & Bamidis, P. D. (2022) · Social Network Analysis and Mining · doi:10.1007/s13278-022-00891-y · Cited by 5
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Rodrigues, B., Amorim, I., Silva, I., & Mendes, A. S. (2024) · Lecture notes in computer science · doi:10.1007/978-3-031-54204-6_11 · Cited by 5
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Zapata, B. C., Niñirola, A. H., Fernández‐Alemán, J. L., & Toval, A. (2014) · RISTI - Revista Ibérica de Sistemas e Tecnologias de Informação · doi:10.4304/risti.13.35-50 · Cited by 5
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Adelmeyer, M., Meier, P., & Teuteberg, F. (2019) · Journal of the Association for Information Systems · Cited by 5
Fernández‐Alemán, J. L., García, A. B. S., Garcı́a-Mateos, G., & Toval, A. (2015) · Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) · doi:10.1109/embc.2015.7318628 · Cited by 5
“Authentication solutions based on smartcards combining a token and a PIN are sometimes employed in EHRs [8, 9].”
Self-citationQuality evidence, quality decisions: Ways to improve security and privacy of EHR systems
Osop, H., & Sahama, T. R. (2016) · IEEE International Conference on e-Health Networking, Applications and Services (Healthcom) · doi:10.1109/healthcom.2016.7749424 · Cited by 5
“It is a model that is used to denote security and privacy attributes [22] and is the fundamental goals for security [23].”
MethodAnonymity-preserving Reputation Management System for health sector
Jabeen, F., Hamid, Z., Abdul, W., Ghouzali, S., Khan, A., Malik, S. U. R., Khan, M. S., & Nawaz, S. (2018) · PLoS ONE · doi:10.1371/journal.pone.0195021 · Cited by 7
Medhekar, A., & Nguyen, J. (2020) · Advances in medical technologies and clinical practice book series · doi:10.4018/978-1-7998-3274-4.ch008 · Cited by 5
Khan, A. W., Yaseen, G., Khan, M. I., & Khan, F. N. (2022) · doi:10.1002/9781119821779.ch7 · Cited by 5
Future of Healthcare: Biomedical Big Data Analysis and IoMT
Tamiziniyan, G., & Keerthana, A., V (2022) · doi:10.1002/9781119769200.ch13 · Cited by 5
Năstasă, I., Artamonov, A.-R., Busnatu, Ș., Mincă, D. G., & Andronic, O. (2025) · Informatics · doi:10.3390/informatics12030066 · Cited by 4
Esmaeilzadeh, P., & Maddah, M. (2026) · Health Systems · doi:10.1080/20476965.2026.2637433 · Cited by 5
Kariotis, T. C., Prictor, M., Gray, K. M., & Chang, S. (2025) · JMIR Medical Informatics · doi:10.2196/64162 · Cited by 4
“While existing literature has focused on the availability of privacy functions in EHRs [58,72], participants in this study highlighted the importance of having skills and capabilities to manage these functions, as well as support pathways outside the IECR to address privacy issues.”
Reid, S., Naidu, C. S., Kantor, G., & Seebregts, C. J. (2020) · South African Medical Journal · doi:10.7196/samj.2020.v110i3.14111 · Cited by 4
“[2] Security and privacy of electronic health records are also a concern.[3] In the USA, the switch to electronic-based record-keeping has received significant support from policymakers espousing a national, interoperable health information system as a priority.”
BackgroundAdenuga, O. A., Kekwaletswe, R. M., & Adenuga, O. T. (2020) · International Journal for Digital Society · doi:10.20533/ijds.2040.2570.2020.0205 · Cited by 4
Blockchain in Smart Healthcare Systems
Mahajan, S. (2021) · Advances in healthcare information systems and administration book series · doi:10.4018/978-1-7998-9606-7.ch001 · Cited by 4
Balde, L., Zhang, J., Elkhalil, A., & Khudayberdiev, O. (2021) · International Conference on Intelligent Systems and Knowledge Engineering (ISKE) · doi:10.1109/iske54062.2021.9755341 · Cited by 4
E-Healthcare Using Block Chain Technology and Cryptographic Techniques: A Review
Haq, H. B. U., Abbas, A., Khan, R. A., Akhtar, A. N., Akram, W., Nawaz, S., Mayo, F. I., & Bhatti, A. I. (2022) · Pakistan Journal of Engineering and Technology · doi:10.51846/vol5iss4pp21-28 · Cited by 4
Ethics in Public Health Informatics
Gashu, K. D., & Guadie, H. A. (2024) · Sustainable development goals series · doi:10.1007/978-3-031-71118-3_7 · Cited by 4
Estudio sobre la importancia y la seguridad de uso de las contraseñas en el ámbito laboral sanitario
Fernández‐Alemán, J. L., Sánchez-Henarejos, A., García-Amicis, V. M., Toval, A., García, A. B. S., & Hernández-Hernández, I. (2014) · Gaceta Sanitaria · doi:10.1016/j.gaceta.2014.07.003 · Cited by 4
Self-citationPerlich, A., Sapegin, A., & Meinel, C. (2015) · International Conference on Health Informatics · doi:10.5220/0005204503520359 · Cited by 4
“Even though the sharing of medical data between stakeholders is an integral part of the concept of EHR, some 25% of the selected articles had no indication on data encryption (Fernández-Alemán et al., 2013).”
BackgroundAn Empirical Research on InfoSec Risk Management in IoT-based eHealth
Aman, W., & Snekkenes, E. A. (2013) · doi:10.13140/rg.2.1.4635.8245 · Cited by 4
Security framework for portable NFC mobile based health record system
Sethia, D., Gupta, D. S., & Saran, H. (2016) · IEEE International Conference on Wireless and Mobile Computing, Networking and Communications (WiMob) · doi:10.1109/wimob.2016.7763175 · Cited by 4
“to maintain privacy and security of the healthcard [2] as also stated in the regulations of Health Insurance Portability and Accountability Act (HIPAA) and the European Data Protection Directive 95/46/EC.”
BackgroundMethodHu, S., Zhou, L., Dong, N., Zhou, Y., Gao, Z., Xu, J., & Liang, Z. (2016) · IEEE International Conference on Bioinformatics and Biomedicine (BIBM) · doi:10.1109/bibm.2016.7822654 · Cited by 4
Kamarudin, N. H., Yussoff, Y. M., & Hashim, H. (2016) · Indian Journal of Science and Technology · doi:10.17485/ijst/2016/v9is1/106842 · Cited by 4
Seiedfarajollah, S., Safdari, R., Ghazisaeedi, M., & Keikha, L. (2019) · Eastern Mediterranean Health Journal · doi:10.26719/emhj.19.006 · Cited by 4
Dieng, Y., Diop, I., Faye, Y., & Malack, C. A. N. (2019) · International Conference on Information Systems and Technologies (ICIST) · doi:10.1145/3361570.3361576 · Cited by 4
A Health Monitoring Framework based on Edge of Things for Smart Healthcare System
Chaudhary, R. R. K., Chatterjee, K., & Singh, A. P. (2021) · International Conference on Computing, Communication and Automation · doi:10.1109/iccca52192.2021.9666367 · Cited by 4
“The author of this paper discusses privacy-preserving strategies for processing and storing sensitive medical data in the context of the Edge of Things paradigm [20].”
MethodRafid, F. A., Benissan, E., Murr, L., Ermakov, I., Oikonomou, K., & Zhang, P. (2022) · IEEE International Conference on Blockchain, Smart Healthcare and Emerging Technologies (SmartBlock4Health) · doi:10.1109/smartblock4health56071.2022.10034646 · Cited by 4
“One study estimated that 195,000 deaths occur yearly due to medical errors, with 10 of 17 being identity, or “wrong patient”, errors [7].”
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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