Cited by 160Thoreau and American LiteratureElectronic Health Records SystemsPrivacy-Preserving Technologies in Data

The DOI matches its Crossref record; 178 of the 180 references it cites were found in a registry or an index; none of the 112 sources its claims cite is checked for support yet.

Secondary Use of Electronic Health Record: Opportunities and Challenges

Open access

Shah, Shahid Munir, Khan, Rizwan Ahmed·2020·IEEE Access

DOI 10.1109/access.2020.3011099

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Abstract

In the present technological era, healthcare providers generate huge amounts of clinical data on a daily basis. Generated clinical data is stored digitally in the form of Electronic Health Record (EHR) as a central data repository of hospitals. Data contained in EHR is not only used for the patients' primary care but also for various secondary purposes such as clinical research, automated disease surveillance and clinical audits for quality enhancement. Using EHR data for secondary purposes without consent or in some cases even with consent creates privacy issues. Secondly, EHR data is also made accessible to various stakeholders including different government agencies at various geographical sites through wired or wireless networks. Sharing of EHR across multiple agencies makes it vulnerable to cyber attacks and also makes it difficult to implement strict privacy laws as in some cases data is shared with organization that is governed by specific regional law. Privacy of individuals could be severely affected when their sensitive private information contained in EHR is leaked or exposed to the public. Data leaks can cause financial losses or an individual may encounter social boycott if his / her medical condition is exposed in public. To protect patients personal data from such threats, there exists different privacy regulations such as General Data Protection Regulation (GDPR), Health Insurance Portability and Accountability Act (HIPAA) and My Health Record (MHR). However, continually evolving state-of-the-art techniques in Machine Learning (ML), Data Analytics (DA) and hacking are making it even more difficult to completely protect an individual's/patient's privacy. In this article, we have systematically examined various secondary uses of EHR with the aim to highlight how these secondary uses affect patients' privacy. Secondly, we have critically analyzed GDPR & HIPAA regulations and highlighted their possible areas of improvement, considering escalating use of technology and different secondary uses of EHR.

AI snapshot

Written from the paper’s full text.

TL;DR

This review examines secondary uses of electronic health record (EHR) data—such as clinical research, public health surveillance, and clinical audit—and argues that these uses create privacy and security risks that current regulations only partly address. It critically analyzes GDPR and HIPAA, highlighting gaps around consent, data minimization, re-identification, cloud storage, and non-covered entities.

Key findings

EHR secondary uses include clinical research, public health surveillance, and clinical audit/quality assurance; these can expose sensitive data and create privacy, financial, and social harms.
EHR data quality is problematic for secondary use: reported accuracy ranges from 44% to 100%; in one study, 31% of 1.1 million adult patients visited two or more hospitals and 1% visited five or more; in another, only 48% of 3,068 pancreatic cancer patients had complete pathology records.
Security incidents cited include theft of 20,000 records from Catawba Valley Medical Center, 4.5 million patients affected by a hospital-group hack, and 80 million people affected by a health-insurance data loss; US EHR data is described as growing 48% annually.
GDPR principles such as purpose limitation, data minimization, storage limitation, and the right to be forgotten conflict with EHR archiving and secondary analysis; pseudonymisation can be defeated by re-identification. HIPAA is described as outdated, limited to covered entities, and unable to protect data in non-covered platforms such as social media or fitness trackers.

Methods

Design: narrative/systematic-style review that “systematically examined” secondary uses of EHR and “critically analyzed” GDPR and HIPAA.
Data/sample: no empirical sample; the paper reviews literature, EHR standards (HL7, FHIR), secondary-use domains, security/privacy challenges, and two regulations (GDPR and HIPAA).
Analysis: thematic synthesis of secondary uses, data-quality challenges, security/privacy risks, and regulatory gaps; no formal search protocol, inclusion criteria, or quantitative meta-analysis is reported.

Limitations

Stated: the research domain is interdisciplinary and “hard to find literature,” requiring more collaborative efforts from medicine, computing, and law.
Evident: the review does not report a systematic search strategy, database list, or inclusion/exclusion criteria, so its coverage and selection of sources cannot be assessed.
Evident: it critically analyzes GDPR and HIPAA but mentions My Health Record (MHR) only in passing, and it offers no empirical validation of the proposed regulatory improvements.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1109/access.2020.3011099

Cites

178 of 178 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 112 cited sources checked · 0 supported · 0 flagged

A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“As shown in Figure 4 depicts that the major portion of EHR data consisted of unstructured elements.”
- Also stated in: § VIII. CONCLUSION · plain
  “Figure4depicts that the major portion of EHR data consisted of unstructured elements.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > III. ELECTRONIC HEALTH RECORD INFORMATION SOURCES
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In the paper
“EHR are capable of storing structured, coded and electronic patient data all together to form a complete history of patient's health [6].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [6] source
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In the paper
“Electronic data saved as EHR makes a Decision Support System (DSS) for monitoring health outputs to improve health care quality [7]”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [7] source
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, EHR data has not been utilized to its full potential for secondary uses and one of the reasons for under utilization of EHR data is non uniformity in its data components.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > III. ELECTRONIC HEALTH RECORD INFORMATION SOURCES
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- Rests on an assumption: EHR data has not been utilized to its full potential for secondary uses.
In the paper
“It improves overall healthcare quality, omits paperwork, reduces medical errors and increases work efficiency as well as reduces overall healthcare cost [34].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > III. ELECTRONIC HEALTH RECORD INFORMATION SOURCES
What the sources say
- Not checked yetcites [34] source
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In the paper
“It was the main reason behind the slow adoption of the EHR system in healthcare organizations even if their adoption was highly beneficial for them [25].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > A. EHR STANDARDS
What the sources say
- Not checked yetcites [25] source
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In the paper
“It improves overall healthcare quality, omits paperwork, reduces medical errors and increases work efficiency as well as reduces overall healthcare cost [34].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > III. ELECTRONIC HEALTH RECORD INFORMATION SOURCES
What the sources say
- Not checked yetcites [34] source
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
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In the paper
“It improves overall healthcare quality, omits paperwork, reduces medical errors and increases work efficiency as well as reduces overall healthcare cost [34].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > III. ELECTRONIC HEALTH RECORD INFORMATION SOURCES
What the sources say
- Not checked yetcites [34] source
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Show all 66 claims

Probably not a substantial claim. 49
It may state two separate claims as one. 58

A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Using EHR data for secondary purposes without consent or in some cases even with consent creates privacy issues.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > Abstract
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Probably not a substantial claim. The paper may give no reason why it holds.
- Rests on an assumption: Patients are often unwilling to share their private health data for secondary uses, sharing it only for personal care.
In the paper
“In case, if EHR data is leaked/theft or stolen from the database it can be misused (by altering dosage of drugs or treatment procedure etc.) and may cause severe complications or even lead to the patient's death [11].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [11]
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In the paper
“EHR system acts as a central database of information for patient documentation and billing, maintaining quality, and supporting patient related sensitive decisions [9].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [9] source
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“EHR reduces the probability of errors related to medical data analysis as it stores complete medical records and thus lowers overall healthcare cost [10].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [10]
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In the paper
“Information contained in EHR is also used for different secondary purposes (other than patient personal care) such as clinical research, health promotions, clinical audit and clinical governance, national screening and preventive campaigns, audits against national standards, national statistics, planning future services, and resource allocations etc., [12]”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [12]
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In the paper
“EHR are the patients' computerized health records that contain patients' complete information along with their medical history in a format (refer Figure 1) that can be easily shared among different health care providers or can be accessed by them through different linked locations when required [5].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [5]
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In the paper
“However, different limitations were exposed in this version such as a difficult implementation process, having a number of optional segments and above all lack of proper representation that is capable enough to identify techniques for exchanging messages and interfaces [30].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) FAST HEALTHCARE INTEROPERABILITY RESOURCES (FHIR)
What the sources say
- Not checked yetcites [30]
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In the paper
“The HL7 standard allows different healthcare organizations to share and exchange patient information via encoded data exchange.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) HEALTH LEVEL SEVEN (HL7) STANDARD
What the sources say
- Not checked yetcites [9] source
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In the paper
“These standards have potential capabilities of supporting work flows in small devices like mobile phones [33].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) FAST HEALTHCARE INTEROPERABILITY RESOURCES (FHIR)
What the sources say
- Not checked yetcites [33]
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Using patient sensitive information for different secondary purposes without their consent can seriously affect their privacy.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
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Probably not a substantial claim.
- Rests on an assumption: Patients are often unwilling to share their private health data for secondary uses, sharing it only for personal care.
In the paper
“Afterwards this organization defined HL7-Clinical Document Architecture (HL7 CDA) as EHR messaging standard for easy integration, interchange, sharing and retrieval of information across different clinical information systems.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) HEALTH LEVEL SEVEN (HL7) STANDARD
What the sources say
- Not checked yetcites [26]
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In the paper
“Although HL7 version 3 resolved much of the problems of previous versions, it could not resolve the incompatibility issue raised because of a variety of sub versions [31].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) FAST HEALTHCARE INTEROPERABILITY RESOURCES (FHIR)
What the sources say
- Not checked yetcites [31]
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None of the sources cited for this claim have been checked yet.
In the paper
“These standards provide legislation to protect personal data but with fast paced advancement in Data Analytics (DA) and Artificial Intelligence (AI) [18], [19] poses new challenges for such standards.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > I. INTRODUCTION
What the sources say
- Not checked yetcites [18]
- Not checked yetcites [19]
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Data contained in EHR (in the form of clinical notes) is often noisy, incomplete and inconsistent as well as it contains grammatical errors, misspelled words etc.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > IV. DEEP LEARNING FOR EHR DATA ANALYSIS
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Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes? Based: unclear
It may state two separate claims as one.
- Rests on an assumption: Data contained in EHR in the form of clinical notes is often noisy, incomplete and inconsistent as well as contains grammatical errors and misspelled words.
In the paper
“However, these methods are time consuming and not reliable to capture all the structured information.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > III. ELECTRONIC HEALTH RECORD INFORMATION SOURCES
What the sources say
- Not checked yetcites [35]
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In the paper
“3) their robustness against high complex functions, and 4) their performance gets better on large datasets and it further improves as data grows in size [47].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > IV. DEEP LEARNING FOR EHR DATA ANALYSIS
What the sources say
- Not checked yetcites [47] source
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“Such data elements are not represented in any standard coding scheme such as ICD codes, therefore, their retrieval, reporting and aggregation is not easy like structured data using commonly available database tools [34].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > III. ELECTRONIC HEALTH RECORD INFORMATION SOURCES
What the sources say
- Not checked yetcites [34]
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In the paper
“PHS is a process of collecting, analyzing and interpreting data related to a specific disease for administering and assessing public health on the whole [64].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > B. PUBLIC HEALTH SURVEILLANCE
What the sources say
- Not checked yetcites [64] source
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In the paper
“During the ongoing COVID-19 outbreak, the importance of digital data recording systems (like EHR) has been clearly revealed and demonstrated to the whole world [79].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > B. PUBLIC HEALTH SURVEILLANCE
What the sources say
- Not checked yetcites [79]
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is because patients do not always trust a single healthcare organization and may visit several such organizations to get a sense of satisfaction.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > B. INCOMPLETENESS
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- Rests on an assumption: Patients do not always trust a single healthcare organization.
In the paper
“Study conducted in [88] showed that out of 1.1 million adult patients, 31% visited two or more hospitals, whereas, one percent patients visited five or more hospitals for acute care during a five year period of their study.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > B. INCOMPLETENESS
What the sources say
- Not checked yetcites [88]
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In the paper
“Since, the data in EHR contains more detailed information than the other sources, therefore, in case of cyber attacks (Ransomware, Distributed Denial of Service (DDoS) etc.), a big population can be affected at once that can lead much beyond the financial losses [95].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [95]
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
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None of the sources cited for this claim have been checked yet.
In the paper
“Other than personal and financial information, EHR data also contains patient's highly confidential data in the form of physicians' personal notes, neuroimaging data [98], [99], X-rays, ultrasounds as well as lab reports.This data may include lab results of HIV and other sexually transmitted diseases [100], mental disorders [101], personality disorders [102], contagious diseases as well as doctors”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [98]
- Not checked yetcites [100]
- Not checked yetcites [101]
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In the paper
“Criminals sell valuable data taken from EHR to the ''darkweb'' [92] (darkweb refers to the content on the web that is not indexed by search engines and thus remains hidden from the general public) and achieve high financial gain.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [92]
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In the paper
“In case of patients monitored at home, the data from patients is collected through a distributed network of sensors.Securing such data is another big challenge because there are greater chances of spying and skimming [104].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [104]
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None of the sources cited for this claim have been checked yet.
In the paper
“With the increased used of smart healthcare services, e health solutions [107], [108], and digital record systems, EHR data generates sheer volume of data (Alone in US 48% growing annually [109]), therefore, most of the data of EHR database is stored on cloud services [110].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [109]
- Not checked yetcites [110]
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In the paper
“Cloud storage of EHR is beneficial in many ways like it provides cost effective storage, easy access as well as processing and updating of information is achieved with improved effectiveness and efficiency but on the other hand opens new doors for the threats and breaches [111].It is because highly sensitive and confidential patients' information contained in EHR is stored on a third party server”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [111]
- Not checked yetcites [112]
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In the paper
“All such data is stored in the hospital's local database (each hospital may have its own local electronic database), which is connected across other hospitals' or health providers' databases via wired or wireless connections for sharing purposes.Transfer of such confidential data over the internet creates several security risks.It provides a chance to hackers and other harmful attackers to access”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [103]
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
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In the paper
“Different cryptographic, non cryptographic and hybrid access control models have been developed to securely access EHR data [115], [116], but with the advancements in technology, securing data in EHR is more challenging as it was ever before.Therefore, there is a high need of securing data in EHR over the network and on cloud servers [117].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [115]
- Not checked yetcites [116]
- Not checked yetcites [117]
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Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“In order to overcome such deficiencies of cloud based storage, recently blockchain chain technology has been introduced in the healthcare sector [121], [122].Although blockchain technology provides a range of benefits over the cloud computing technology, it does not provide finegrained control of access over EHR.In blockchain technology, only the patient's private key can decrypt the encrypted EHR”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [121]
- Not checked yetcites [122]
- Not checked yetcites [123]
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None of the sources cited for this claim have been checked yet.
In the paper
“Usually consent of an individual is necessary for sharing of data but ambiguity arises when different healthcare organizations have different perspectives on the question of ''who owns the data?''.Does data belong to the patient, his/her physician, health insurance organization, healthcare organization, social security agency or is it jointly owned by all [104], [127]?”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
What the sources say
- Not checked yetcites [104]
- Not checked yetcites [127]
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“For example, disclosing a patient's sensitive private information such as sexually transmitted diseases or mental illness in the public domain can negatively impact an individual's reputation.In extreme cases such individuals can face social boycott as people start avoiding an individual if they know that he/she has sexually transmitted diseases like HIV, chlamydia etc., [128].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
What the sources say
- Not checked yetcites [128]
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
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None of the sources cited for this claim have been checked yet.
In the paper
“Even though, researchers have introduced a few very advanced encryption methods such as Attribute Based Encryption (ABE) [118], Key Policy Attribute Based Encryption (KP-ABE) [119] and Cipher text policy Attribute Based Encryption (CP-ABE) [120] but these are not of much help because the data hosted on clouds is not only vulnerable to external hackers' attacks but also to the internal attacks from”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 1) SECURITY CHALLENGES
What the sources say
- Not checked yetcites [118]
- Not checked yetcites [119]
- Not checked yetcites [120]
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Another dimension to this issue is financial impact on an individual's life as medical insurance companies usually calculate premium/cost of insurance based on medical history and life events.In such cases insurance companies can increase their premium [130], [131].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
What the sources say
- Not checked yetcites [130]
- Not checked yetcites [131]
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These privacy concerns are usually raised due to the fact that when the patients data (which was recorded for the purpose of patient individual care) is being shared or linked without consent or knowledge of a particular individual.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
Strength:plain· not yet calibratedCausal:correlational· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Rests on an assumption: Consent of an individual is necessary for sharing of EHR data.
In the paper
“In order to protect sensitive data many patients try to conceal their sensitive information.It is because of the lack of confidence in the system's security retaining their data.It also shows mistrust of patients' on medical staff (doctors, nurses and the others) because patients think that they might disclose their confidential information to the public that may create embarrassment for them in”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
What the sources say
- Not checked yetcites [135]
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Hiding facts and information from the physicians and the medical staff can lead to treatment failure.Thus, such challenges may have severe consequences for patients, healthcare providers and even for the governments.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
- Rests on an assumption: Hiding facts and information from physicians and medical staff can lead to treatment failure.
None of the sources cited for this claim have been checked yet.
In the paper
“Privacy of patients can be affected when his/her data is used for clinical research or secondary use, refer Section V for discussion on secondary uses of EHR.For example, a blood sample given by a patient is stored in a laboratory and after carrying out requested analysis the same sample is analyzed again for the purpose of clinical research.Even though the sample is returned back to the”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
What the sources say
- Not checked yetcites [127]
- Not checked yetcites [132]
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“If analyzed critically, clauses (b-f) of Article 5 have contradictory nature in the context of EHR data concepts.The regulations mentioned in these clauses (such as data minimization, purpose limitation) limits the quantity of data collection and enforces its deletion soon after the purpose has been achieved.On the other hand, healthcare organizations encourage collecting more and more data and to”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 3) Data minimization (Article 5(1)(c)):
What the sources say
- Not checked yetcites [147]
Load-bearingStrength:plain· not yet calibratedCausal:correlational· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“The privacy of clinical data has been subject to a lot of research and it has been difficult to determine how much of the data belongs to the patient and how much of it may belong to healthcare organizations and whether the consent of the owner of data is needed, in case the data is to be used for the research purpose [127], [132], [133].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 2) PRIVACY CHALLENGES
What the sources say
- Not checked yetcites [127]
- Not checked yetcites [132]
- Not checked yetcites [133]
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“Obtaining explicit consent for every secondary use is a time consuming, costly as well as an exhausting process [149].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 3) Data minimization (Article 5(1)(c)):
What the sources say
- Not checked yetcites [149]
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“According to Spiekermann et al. [151], if individuals knew about today's healthcare business model and how third parties use personal private data, they would be surprised and feel betrayed.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 3) Data minimization (Article 5(1)(c)):
What the sources say
- Not checked yetcites [151]
Load-bearingStrength:hedged· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
Probably not a substantial claim.
In the paper
“Re-identification pulls down the illusion of privacy policies, which are promised by technologists.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 3) Data minimization (Article 5(1)(c)):
What the sources say
- Not checked yetcites [154] source
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passes
Probably not a substantial claim. It may be too vague to check against evidence.
In the paper
“In short, HIPAA with HITEC and Cure regulations have not advanced itself with fast growing technology.It does not completely fulfill patients' expectations of immediate availability of their health data electronically when needed [168] and robustly securing personal data.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > B. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
What the sources say
- Not checked yetcites [168]
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Obviously, under such circumstances, obtaining broad consent is not logical.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 3) Data minimization (Article 5(1)(c)):
Load-bearingStrength:boosted· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passes
Probably not a substantial claim. It may be too vague to check against evidence.
- Rests on an assumption: At present, most patients are not aware (or do not want to be aware) about what happens to their data once it has been taken from them and do not know about the data processing procedures undertaken by healthcare providers.
In the paper
“The conclusive outcome of all such debates is to shift specific consent into a broader consent of data processing that covers the range of its future uses (such as secondary uses of EHR) [150].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > 3) Data minimization (Article 5(1)(c)):
What the sources say
- Not checked yetcites [150]
Strength:boosted· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“After its legislation in 1966, HIPAA has not undergone any major iteration, therefore, its rules have been outdated and cannot provide much help in safeguarding against the vague threats of the present digital age [164].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > B. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
What the sources say
- Not checked yetcites [164] source
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Another major issue with HIPAA regulations is that its protection applies only on covered entities i.e. health care providers, clinicians, pharmacies, health care facilities and healthcare clearinghouses but not on the non covered entities i.e. different types of information sharing platforms like social media posts [166].Therefore, it can cause personal information leak [167].In case of releasing”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > B. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
What the sources say
- Not checked yetcites [166]
- Not checked yetcites [167]
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“Such data elements are not represented in any standard coding scheme such as ICD codes, therefore, their retrieval, reporting and aggregation is not easy like structured data using commonly available database tools[34].”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > VIII. CONCLUSION
What the sources say
- Not checked yetcites [34]
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“One of the methods to convert unstructured data into structured data is manually reviewing EHR by the experts using text charts or data abstraction methods[35].However, these methods are time consuming and not reliable to capture all the structured information.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > VIII. CONCLUSION
What the sources say
- Not checked yetcites [35]
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“Storage limitations refer to the fact that personal data must be deleted after it has been used and no longer further needed.It means data should be collected with a proper predefined time-line and it must be removed after the timeline is reached.”
§ Secondary Use of Electronic Health Record: Opportunities and Challenges > VIII. CONCLUSION
What the sources say
- Not checked yetcites Article 5(1)(e)
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

91 of 91

The paper relies on this without support.
Patients are often unwilling to share their private health data for secondary uses, sharing it only for personal care.
“For all such uses, patients may not be willing to share their information as often patients share their private health data for their personal care and not for the other/secondary uses.”
The paper relies on this without support.
EHR data has not been utilized to its full potential for secondary uses.
“However, EHR data has not been utilized to its full potential for secondary uses”
The paper relies on this without support.
Patients do not always trust a single healthcare organization.
“It is because patients do not always trust a single healthcare organization and may visit several such organizations to get a sense of satisfaction.”
The paper relies on this without support.
Data contained in EHR in the form of clinical notes is often noisy, incomplete and inconsistent as well as contains grammatical errors and misspelled words.
“Data contained in EHR (in the form of clinical notes) is often noisy, incomplete and inconsistent as well as it contains grammatical errors, misspelled words etc.”
The paper relies on this without support.
EHR data is the most vulnerable data to cyber threats.
“EHR data is the most vulnerable data to the Cyber Threats.”
The paper relies on this without support.
Healthcare organizations spend more on increasing their integration but do not spend much on their system protection.
“Healthcare organizations spend more on increasing their integration but do not spend much on their system protection.”
The paper relies on this without support.
At present, most patients are not aware (or do not want to be aware) about what happens to their data once it has been taken from them and do not know about the data processing procedures undertaken by healthcare providers.
“At present, most of the patients are not aware (or do not want to be aware) about what happens to their data once it has been taken from them and also they do not know about the data processing procedures undertaken by the healthcare providers.”
The paper relies on this without support.
Consent of an individual is necessary for sharing of EHR data.
“Usually consent of an individual is necessary for sharing of data but ambiguity arises when different healthcare organizations have different perspectives on the question of ''who owns the data?''.”
The paper relies on this without support.
Hiding facts and information from physicians and medical staff can lead to treatment failure.
“Hiding facts and information from the physicians and the medical staff can lead to treatment failure.”
The paper relies on this without support.
NLP-based machine learning models can convert unstructured data elements of electronic health records into structured codes and extract useful information for further analysis.
“NLP based ML models give meanings to words and phrases in text and convert unstructured data elements of EHR into structured codes.In short, NLP captures unstructured data elements of EHR, analyzes the data elements with respect to their grammatical structures, obtains meanings from grammatical structures, and finally summarizes information to make it useful for further analysis.”

10 of 10

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

Spiekermann attribution points to a different reference
Minor
The text attributes a claim to Spiekermann et al. at reference 151, but reference 151 lists Voigt and von dem Bussche; Spiekermann et al. appear at reference 150.
Article 6 requirements described as both one condition and all clauses
Minor
The paper first says lawful processing requires obeying one of the listed conditions, then says all the listed clauses must be followed.
HIPAA enactment year changes from 1996 to 1966
Minor
The paper says HIPAA was passed in 1996, but later dates its legislation to 1966.

3 of 3

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Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success
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Deep EHR: A Survey of Recent Advances in Deep Learning Techniques for Electronic Health Record (EHR) Analysis
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Structural magnetic resonance imaging of the adolescent brain
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Willyard, C. (2017) · Nature · doi:10.1038/nature.2017.21550 · Cited by 1,230
Broken Promises of Privacy: Responding to the Surprising Failure of AnonymizationPreprint
Ohm, P. (2009) · SSRN Electronic Journal · Cited by 997
Medical Internet of Things and Big Data in Healthcare
Dimitrov, D. V. (2016) · Healthcare Informatics Research · doi:10.4258/hir.2016.22.3.156 · Cited by 975
Health Insurance Portability and Accountability Act
(2007) · Sage eBooks · doi:10.4135/9781412952644.n199 · Cited by 971
Benefits and drawbacks of electronic health record systems
Menachemi, N., & Collum (2011) · Risk Management and Healthcare Policy · doi:10.2147/rmhp.s12985 · Cited by 909

Flagged first, then by citations

Show all 180 references

2 of the 180 references couldn’t be matched to a known paper.

Research works printed but not linked: 9

wheeler, 2019, The Counselor and the Law A Guide to Legal and Ethical Practice
mohammed, 2017, US healthcare industry: Cybersecurity regulatory and compliance issues, Journal of Research in Business Economics and Management, 9, 1771
2015, HIV Positive Couple Face Social Boycott
2012, Former Howard University Hospital Employee Pleads Guilty to Selling Personal Information About Patients
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2017, Global Hepatitis Report 2017
1995, Directive 95/46/EC on the protection of individuals with regard to the processing of personal data and on the free movement of such data
davis, 2018, 3 Phishing Hacks Breach 20 000 Catawba Valley Patient Records
2016, Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46

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Authors: Shah, S. M., & Khan, R. A.
Affiliations: Faculty of Information Technology, Barrett Hodgson University, Karachi, Pakistan
ORCID: Shah, Shahid Munir
Khan, Rizwan Ahmed
Venue: IEEE Access
Publisher: Institute of Electrical and Electronics Engineers (IEEE)
Published: 2020
Volume: 8
Pages: 136947-136965
ISSN: 2169-3536 (ISSN-L)
DOI: 10.1109/access.2020.3011099
OpenAlex: W3002945543
Cited by: 158
References: 180
Citations by year: 2026: 21 · 2025: 44 · 2024: 39 · 2023: 28 · 2022: 12 · 2021: 11 · 2020: 1
FWCI: 12.23
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
creativecommons.org/licenses/by/4.0/legalcode (vor)
Locations: IEEE Access (publishedVersion, cc-by)
arXiv (Cornell University) (submittedVersion)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
arXiv (Cornell University)
Topics: Health Sciences › Health Professions › Health Information Management › Thoreau and American Literature
Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Physical Sciences › Computer Science › Artificial Intelligence › Privacy-Preserving Technologies in Data
Keywords: electronic health records, secondary use of health data, patient privacy, data privacy regulation, GDPR, HIPAA, My Health Record, data breaches, cyberattacks, health data sharing, clinical research, disease surveillance

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Secondary Use of Electronic Health Record: Opportunities and Challenges

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