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Type of paper. Academic level. Michelle W. USA, New York. Your writers are very professional. Michael Samuel. USA, California. Eliza S. Australia, Victoria. Why Work with Us. Try it now! Finally, we make some concluding remarks in Section 4. Digital health-care systems that leverage EHRs and use technologies such as IoT and big data are expected to seamlessly connect patients and providers across diverse health-care systems. These systems are also being increasingly connected via the Internet to various types of medical wearable technologies that are being worn for real-time health-care monitoring.

Figure 3 shows the percentage of population in millions adopting the medical wearable technology. However, several challenges need to be addressed before digital health care can develop stable, flexible and interoperable systems. Next we discuss some of the current challenges that are hindering the widespread adoption of digital health care Firouzi et al. Connected gadgets including medical and mobile devices capture, aggregate, process and transfer medical information to the cloud.

The device layer is vulnerable to tag cloning, spoofing, RF jamming, and cloud polling. In cloud polling, traffic is redirected to allow command injections directly into a device through a man-in-the-middle attack. A direct connection attack involves the use of a service discovery protocol such as universal plug and play, or properties of Bluetooth low energy BLE , to locate and target IoT devices.

Denial of service DoS attacks can affect health-care systems and affect patient safety. While a common defense to DoS is redundancy the use of multiple devices on the network , in a health-care environment the duplication of resources may not always be possible because some of the gadgets are implanted life-critical systems. The fast detection of potential security threats remains a challenge because of the number and complexity of emerging software and hardware vulnerabilities.

This issue is getting worse as increasing number of devices are being connected to the Internet. Today, default authentication remains prevalent, and insecure Web-based interface access further increases the attack surface. Additionally, we have also seen a surge in the proliferation of wearable devices including different types of embedded sensors and implanted medical devices in recent years.

The lack of security standards of these devices along with the availability of powerful search engines such as Shodan which enables locating Internet-connected devices Williams and McCauley, , make these wearable devices vulnerable to all kinds of attacks Das et al.

Recently, many wireless networking technologies have also been deployed in the health-care environment and these include Wi-Fi, BLE and ZigBee that are being used to provide connectivity to different types of medical devices and sensors Zeadally and Bello, Security protection of these wireless and sensor technologies against eavesdropping, Sybil attacks, sinkhole attacks, and sleep deprivation attacks must be enforced.

Centralized data sets of personal information, family history, electronic medical records and genomic data, should also be protected from hackers and malicious software to enforce security and privacy Nambiar et al. Confidentiality and privacy are important concerns for physicians as well. Patients may not want to share their medical records because of the sensitive nature of the health data for example, cancer or HIV test results.

Concerns exist that the integration of connected technology into current medical information systems may compromise the confidentiality of health data Sonune et al. These privacy concerns stem from the fear that digital and connected technology may attract hackers.

Furthermore, researchers sometimes argue that connected health technology would be implemented imperfectly, allowing for security vulnerabilities to be exploited Poyner and Sherratt, Low security and misconfigured device and network settings could affect the privacy of patients and their data. Another concern is the use of various providers which are mandated to submit confidential data to law enforcement agencies. This can affect the adoption and use of the technology where patients are concerned about privacy.

The networks which transmit data are often highly heterogeneous and are frequently managed by third parties which makes the protection of security and privacy as well as governance of this data even more challenging Williams and McCauley, Inter-realm authentication is essential for entities operating in different domains to establish trust for carrying out digital health transactions.

Shibboleth is a federated identity solution that facilitates entity authentication both within and between organizational systems Shibboleth, At a country level, Shibboleth, a system that provides inter-realm authentication has been deployed and tested successfully. A typical Shibboleth-based system enables a user of a digital health system to authenticate itself to an identity provider IdP , and subsequently sends a service request for a service hosted on a service provider SP.

Through such a federated arrangement, Shibboleth facilitates single sign-on capabilities for digital health entities as in eHealth, Shibboleth-based systems are secure and provide strong authentication across multiple realms of a digital health system.

However, not all digital health systems have Shibboleth implementations owing to the lack of facilities to host separate Identity and Service Providers in an organization within a nation, and to have these hosted across all similar digital health organizations. The lack of information technology IT skills and necessary funding especially in the third world, hinders the ready adoption of systems such as Shibboleth.

Another aspect that requires attention as a prevailing digital health issue for nations is the lack of interoperability between nations intending to cooperate on digital health ICT infrastructures. This shortcoming is due to not only the limited ICT infrastructures or dearth of IT skills, but also the lack of policy for global cooperation among nations on the exchange of sensitive medical data, which would facilitate telemedicine and provisioning of high-quality medical care remotely.

Projects such as Liberty Alliance Broda, have fostered bringing together disparate platforms and standards for inter-realm authentication under one umbrella. The proposal of the Liberty Alliance Project aims to enable interoperability between standards at the Internet Identity Layer. They have also highlighted the need for collaboration among various stakeholders through public forums and certification programs. The lack of interoperability among the heterogeneous platforms and standards that exist for inter-realm authentication is identified as a potential vulnerability that could lead to loss of data privacy, compliance regulation issues, as well as backward compatibility with legacy systems.

The Liberty Alliance Project also identified that open technology standards, deployment policy guidance and independent third party certification are essential for enabling inter-realm authentication. The lack of proper standards for facilitating seamless digital health transactions among multiple domains, which may span several continents, restricted the widespread adoption of digital health especially in countries where network bandwidths were barely sufficient.

Consequently, digital health applications of telemedicine and of patient data sharing across multiple domains have remained restricted. Inter-judicial boundaries have impeded ready acceptance of standards and policies for data sharing across geographies.

The case study of Catalan digital health system catCert, provides a good example of a federated authentication system that does the following: Authentication of medical doctors against hospital systems is achieved by using a user ID and a password or an X. Pharmacies use X. In addition, the presence of a SAML backend system facilitates the sharing of authentication data between federated digital health systems. The SAML architecture Oasis, allows making statements on user attributes and authorizations for authenticated entities.

Examples of such attributes include medical or financial data. It provides context to the operation being carried out, details on how an authentication transaction is conducted, the type of transaction being carried out and details on the user, including mechanisms used for his or her authentication.

However, some of the shortcomings of SAML are: The level of confidentiality of digital health attribute assertions is entirely dependent on the strength of the cipher being used. Targeted confidential messages cannot be crafted unless a holistic certification mechanism is in place to issue and maintain public-private key pairs to facilitate data encryption and decryption.

Anonymity of subjects is not the same as pseudonymity. Consequently, the ability of the SAML-based digital health authentication system to ensure that users remain anonymous, is restricted, because of the limitation of the SAML standard.

The original SAML specification is vulnerable to collusion-based attacks, wherein two or more malicious system entities cooperate to share information exchanged from previous transactions, and consequently compromise the confidentiality of messages exchanged. In particular, a digital health system that relies on the presence of a CA within a geographical bound such as city or state limits, will not be able to provide authentication services for other entities outside the CA bounds.

Health Information Exchange HIE enhances health-care delivery by providing the ability to electronically share health-care information among diverse health-care organizations in a reliable and secure manner.

Currently, HIE is implemented by using one of the following methods: consumer-mediated exchange, directed exchange, and query-based exchange Williams et al.

Consumer-mediated exchange provides patients with access to their own electronic records, thus allowing them to track their health conditions, determine whether there is erroneous billing or medical data, and update their self-reports. Directed exchange is conducted when a health-care organization transfers such vital information such as laboratory test results and medication dosage to other specialists involved in the care of the same patient.

Query-based exchange usually occurs in unplanned medical care when a health-care organization needs the previous health records of a new patient. This is done by requesting access to these records through the HIE system.

Impediments in the deployment of HIE systems are mainly owing to security and privacy concerns. Some of the issues associated with current HIE systems are as follows: First, abuse of access rights by authorized insiders Szerejko, This usually happens when health-care organizations share medical records of their patients with unauthorized individuals, either out of irresponsibility, for personal reasons, or in exchange for some kind of gain. Second, violation of rules by unauthorized insiders, who may have access to the system itself but not to the records Strauss et al.

For instance, hospital employees who do not provide direct patient care or former employees who have not yet been electronically restricted from data retrieval. Third, unauthorized intruder attempts to enter the system either by attacking it directly or by pretending to be part of the health-care team Saiz et al.

The emergence of health care-related cybercrime is a major concern and an emerging threat to HIMSs Agha, As a result, a total of million patient records were exploited by cyberattacks, which amounted to 45 per cent of the American population iSheriff, as shown in Figure 5.

Furthermore, most data breaches occur in health-care and medical industries as compared to financial, governmental, or educational sectors Gleeson and Friel, One of the major challenges to implementing smart or connected health is communication. Many devices now have sensors to collect data and they often communicate with the server in their own language. Each manufacturer has its own proprietary protocol, which means sensors made by different manufacturers cannot necessarily communicate with each other.

This fragmented software environment, coupled with privacy concerns, frequently isolates valuable information on data islands, undermining the main idea behind IoT Dimitrov, The presence of several devices also opens up concerns related to connecting medical devices using wireless network technologies. For instance, people using a Wireless Personal Area Network WPAN -enabled device are expected to move freely but mobility can result in collisions when WPANs that operate in similar frequency channel are within close range.

Collision in WPANs has several disruptive effects because it reduces performance and may lead to disastrous situations especially when health-care delivery is concerned. Therefore, it is essential to make sure that medical devices operate properly when connected using various types of wireless communication technologies Gawanmeh, Smart health systems are not always easy to use by physicians.

The presence of a large number of features could sometimes make a system complex which in turn demotivates health-care workers in learning how to use it Grood et al. Users and service providers both require interoperability within individual IoT domains and amongst themselves. This creates complex challenges because the various disciplines captured by IoT are regulated by a diverse group of regulatory agencies.

This complexity is further exacerbated in connected health scenarios wherein medical standards require particularly strict regulations. Companies that want to build smart health applications in the medical area must consider the regulations imposed by Food and Drug Administration, the Centers for Medicare and Medicaid Services, and the Federal Communications Commission FCC Firouzi et al.

A truly interoperable connected health system is one in which data flows with both one-to-one and one-to-many connections, leading to the exchange of information among multiple interfaces which require systems to cooperate with one another. In health-care environments, it is important for devices to be compatible with many transmission formats and protocols for authentication and encryption. Digital health care that leverages IoT sensor devices faces several data management challenges.

The data originates from medical sensors, which are worn or implanted inside the human body. Public health records generally give the number of removed per day, per week, or per month.

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