Received April 19, 2019, accepted May 20, 2019, date of publication May 30, 2019, date of current

version June 19, 2019.

Digital Object Identifier 10.1109/ACCESS.2019.2919982

Security and Privacy-Preserving Challenges of

e-Health Solutions in Cloud Computing
SHEKHA CHENTHARA , KHANDAKAR AHMED, (Member, IEEE), HUA WANG ,
AND FRANK WHITTAKER
School of Engineering and Science, Victoria University, Melbourne, VIC 3011, Australia
Corresponding author: Shekha Chenthara ([email protected])

ABSTRACT A systematic and comprehensive review of security and privacy-preserving challenges in

e-health solutions indicates various privacy preserving approaches to ensure privacy and security of elec-
tronic health records (EHRs) in the cloud. This paper highlights the research challenges and directions
concerning cyber security to build a comprehensive security model for EHR. We carry an intensive study
in the IEEE, Science Direct, Google Scholar, PubMed, and ACM for papers on EHR approach published
between 2000 and 2018 and summarized them in terms of the architecture types as well as evaluation
strategies. We surveyed, investigated, and reviewed various aspects of several articles and identified the
following tasks: 1) EHR security and privacy; 2) security and privacy requirements of e-health data in the
cloud; 3) EHR cloud architecture, and; 4) diverse EHR cryptographic and non-cryptographic approaches.
We also discuss some crucial issues and the ample opportunities for advanced research related to security and
privacy of EHRs. Since big data provide a great mine of information and knowledge in e-Health applications,
serious privacy and security challenges that require immediate attention exist. Studies must focus on efficient
comprehensive security mechanisms for EHR and also explore techniques to maintain the integrity and
confidentiality of patients’ information.

INDEX TERMS e-health, electronic health record, EHR cryptographic and non-cryptographic, security and
privacy, systematic review.

I. INTRODUCTION comprised of a wide variety of data, such as medical histories,

The beginning of the 21st century has witnessed great leaps demographics, medication, immunization status, laboratory
in digital technology that are changing the landscape of test reports and other sensitive patient information. EHD
healthcare system across the world. There is a gradual and systems have remarkable benefits over conventional paper
systematic transformation in healthcare systems from paper based records. Unlike paper-based records, EHR incurs less
based records to electronic records ushering in a revolution in manpower, time and physical storage [3]. The advantages of
the healthcare industry [1]. Such developments provide high EHRs include easier and swift clinical data access, ability
efficiency and flexibility to healthcare services by providing to maintain effective clinical workflows, mitigation of med-
a platform that efficaciously shares healthcare data among ical errors, enhanced patient safety, reduced medical costs
different stakeholders. This evolution converts paper based and better and stronger support for clinical decision-making.
records into digitalized electronic records such as Electronic Realizing the benefits offered by EHD systems more than
Medical Records (EMR), Electronic Health Records (EHR), 90% of healthcare institutions in Australia have adopted this
Personal Health Records (PHR), and Electronic Health Data system to facilitate effective medical resource allocation and
(EHD). EHR and EMR are health records of patients handled efficient healthcare [3]. The ability of EHDs to provide better
by healthcare professionals, whereas PHR carry personal data management of healthcare has been ascertained and testified
which is handled and monitored either by patient or their by various users. However the transition from conventional
relatives on a regular basis. EHD as electronic health records healthcare systems to e-health care throws unique challenges
or computerized patient records is a systematized collection with respect to privacy, confidentiality, and security of medi-
of smart health records of patients [2]. These records are cal information.
Cloud computing is a recent paradigm in digital tech-
The associate editor coordinating the review of this manuscript and
nology and is being extensively used in the healthcare
approving it for publication was Kaiping Xue. industry [4]. It not only provides convenient storage of

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 S. Chenthara et al.: Security and Privacy-Preserving Challenges of e-Health Solutions in Cloud Computing

medical information but also facilitates the easy exchange A. MOTIVATION

or transmission of medical data among various stakeholders. The existing privacy-preserving mechanisms are not adequate
The large scale proliferation of health information in the to ensure foolproof security in the e-health cloud. Contrary to
age of big data necessitates the burgeoning role of cloud most beliefs, the main risk faced by health records hosted in
networks not only for hosting unlimited amounts of data but cloud servers is internal attacks from people who have autho-
also for its easy access across the Internet [5]. It facilitates the rized credentials to access data within organizations, where
creation, storage and retrieval of healthcare information by database administrators or key managers are attackers, which
all stakeholders viz healthcare providers, doctors and patients is significantly worse than the external attacks. This paper
with ease irrespective of the barriers posed by time and space. aims to provide a wide review of the strengths and draw-
Cloud services provide immense benefits in terms of cost backs of existing security and privacy preserving mechanisms
effective storage, access, processing and updating of infor- in e-healthcare environments that make electronic health
mation with improved efficiency and effectiveness. Since the records vulnerable to threats in the cloud arena. E-health
data is running on a wide network of remote servers, which data contains various sensitive and confidential information
are integrated and operated as a single ecosystem accessed ranging from patient data to financial information including
from different locations by multiple users, it is susceptible to social security number, credit card details, whose leakage not
intrusion or compromise, thereby posing a threat to privacy only throws open sensitive patients’ information and cause
and security. Moreover the majority of medical data is highly financial losses but also infringes the most fundamental right
sensitive and strictly confidential, its storage on third party of a citizen in any country i.e. right to privacy.
servers naturally increases these vulnerabilities [6]. Gener- The existing advanced encryption techniques such as
ally, a patient may have several healthcare providers viz Attribute Based Encryption (ABE) is inefficient to resolve
primary care physicians, therapists, specialists and several this issue due to its expensive computation [2]. Most of the
insurer providers for medical, dental, vision etc [7]. Consider- existing solutions for Key Policy Attribute Based Encryption
ing the susceptible nature of health information in the public (KP-ABE) and Cipher text policy Attribute Based Encryption
domain there is an imminent need to devise a more secure, (CP-ABE) assumes that a single key management center
efficient and effective mechanism for sharing and accessing chooses a master key randomly and generates decryption keys
data among stakeholders. for users on the basis of master key. In this case where the key
In the healthcare sector, although the EHRs are subjected manager is an attacker, these solutions cannot prevent from
to various challenges with respect to privacy and unau- the inside attacks. The insider threats in healthcare include
thorized access, the most prominent one is pertaining to the theft of PHI such as Social Security Numbers or personal
data privacy and security [6]. Risks vary from the malware information for identity theft and fraud, theft of Intellectual
attack, that compromises the integrity and confidentiality of Property and sabotage. Other non-malicious threats include
medical data, to the Distributed Denial-of-Service (DDoS) the accidental loss/disclosure of sensitive information, such
attacks, which are capable of depriving the systems ability as disclosing sensitive patient information to others, sharing
to provide efficient patient care. Cyber-attacks, such as those login credentials, writing down login credentials, or respond-
caused by Ransomware, have greater ramifications that go ing to phishing messages. For example, the largest healthcare
beyond financial loss or privacy breach [8]. In the USA, data breach in history is the theft of 80 million healthcare
hackers broke [9] into the database of Community Health records from Anthem Inc [12], American Health Insurance
Systems (CHS) of a prominent hospital group and accessed Company is believed to have been made possible because of
a great deal of personal health information, including the stolen credentials. Data encryption, secure storage, authen-
social security numbers of more than a million patients. In a tication, access control, key management, efficient user
similar incident, Anonymous, an internet vigilante group, revocation etc. are yet to be addressed and resolved. This
targeted several hospitals and launched a DDoS attack on paper analyses existing privacy-preserving approaches, their
their websites crippling medical services [10]. These inci- strengths, drawbacks, research issues and comes up with a
dents highlighted an imminent need to protect and secure new paradigm supported by blockchain technology that can
the confidentiality, integrity, availability, security and pri- offset certain shortcomings but also ensure a framework for
vacy of Protected Health Information (PHI) as a primary providing efficient privacy preserving and security in e-health
priority in EHR. In this context, the role of cyber security data.
is paramount in preventing, detecting, and acting on unau-
thenticated access to health data, and its impact towards
social, economic, political and cultural conflicts. According B. METHODS
to the Health Insurance Portability and Accountability Act This section begins with study selection to ensures the
(HIPAA), it is the responsibility of healthcare providers to accuracy of search and retrieval process. The study selec-
maintain the confidentiality of the health data [11]. Sev- tion narrows down to search for publications from different
eral techniques are already being in use to secure the electronic databases related to computer science and health-
security and privacy of smart health systems in the cloud care that attempts to collect relevant empirical evidences in
environment. a particular field to assess the techniques critically and to

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TABLE 1. Literature review - study selection.

obtain conclusions to summarize the research study. This quality review. The literature search study selection is showed
section also performs a categorical study related to security on Fig. 1
and privacy preserving studies of EHR as a part of qualitative
data analysis that makes it easy to compare and analyze the 2) CATEGORIZING SECURITY AND PRIVACY PRESERVING
crux of the work. STUDIES
The Objective of this review is three fold. Initially, this study
1) LITERATURE REVIEW- STUDY SELECTION investigates the security and privacy requirements of smart
This study performs a systematized review of security and health data in cloud arena. Secondly, after summarizing a
privacy preserving approaches of EHRs in the cloud envi- brief architecture of e-Health system, a prevailing and up-to-
ronment from different databases, including IEEE, Google date review of the e-Health clouds is presented using a tax-
scholar, PubMed, ACM, Springer, Elsevier, Scopus and onomy over privacy preserving approaches. The survey then
Science Direct. The detailed summary of the selected studies discusses the merits and drawbacks of the furnished mecha-
and the keywords used for searching is shown in Table 1. This nisms and finally highlights some future research directions
work also involves an extensive review of significant review and open research issues. The rest of this study is catego-
papers published between 2000 and 2018. rized as follows. In section II, we discuss the security and
This review limited its search to relevant papers published privacy requirements of e-health data in the cloud. Section III
between 2000 and 2018 and found more than 200 arti- summarizes E-health Overview and Section IV reviews an
cles. We filtered those by de-duplication based on titles and intensive analysis of security and privacy preserving mecha-
authors, then conducted a topic relevant article study based on nisms employed in the e-health cloud environment. Section V
abstract and keyword significance. 150 articles remained after describes research issues and future directions and Section VI
de-duplication, 120 after relevant article study and 103 after is a discussion of the research gaps in the existing literature

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servers are not trustable without any privacy preservation

mechanisms and are vulnerable to attacks from both internal
and external adversaries [18] as shown in Fig 3.
The vital security and privacy requirements in e-health
systems are 1) Data integrity-ensures that the health informa-
tion has not been altered by any unauthorized entity. 2) Data
confidentiality-ensures that the sensitive health data is pre-
vented from reaching unauthorized users. Data encryption is
the most substantial approach to ensure data confidentiality.
3) Authenticity- ensures that only the authorized and authen-
tic authority should have access to the sensitive health data.
4) Accountability- an obligation to be responsible and to jus-
tify the actions and decisions of individuals or organizations.
5) Audit- is a requirement which ensures that the health data
is monitored and protected by keeping track of the activity log
and ensures assurance to the users associated of data privacy
and security. 6) Non-repudiation- refers to the non-denial of
authenticity of sender and receiver. For instance, the patients
or the doctors can’t repudiate after embezzlement of the
FIGURE 1. Literature search study selection. health data 7) Anonymity- ensures that the identity of the
subject can be made anonymous so that the cloud servers fails
to access the identity of the stored health data.
and Section VII as conclusion. A sketch of categorizing
studies is portrayed in Fig. 2 III. OVERVIEW OF e-HEALTH SYSTEM IN THE CLOUD
E-health system is a recent healthcare innovation utilizing
electronic processes and communication. In an e-health sys-
tem, EHR or EMR is a systematized aggregation of electronic
health information of patients [2]. These records involve all
the health data information including demographics, medical
histories, medications, laboratory reports, radiology images,
billing information and any additional sensitive patient infor-
FIGURE 2. Categorizing studies to sections. mation. The cloud offers great service to both healthcare
providers and patients alike in terms of cost effective stor-
age, processing and updating of information with enhanced
II. SECURITY AND PRIVACY REQUIREMENTS OF efficiency and quality. Since all this data is stored in multiple
e-HEALTH DATA IN CLOUD servers, it can be easily accessible by users from various
In the current Big data epoch, data proliferation demands locations on demand. E-health systems promise rapid, stead-
outsourcing of healthcare information to the cloud servers. fast and on-demand access to medical records, fewer medical
Regardless of the tremendous boons provided by the cloud, flaws, enhanced healthcare quality, however they equally
it also entails perilous threats to security and privacy of the expose patient privacy, via improper authorization and misuse
healthcare data [1]. Some of the potential attacks include of EHR data. Therefore security and privacy are considered
information disclosure, Denial of Service attacks (DoS), to be critical requirements when sharing or accessing patient
cloud malware injection attack, man-in-the middle crypto- data between several stakeholders. An overview of e-health
graphic attack [13], spoofing [14], collusion attacks [15].The architecture is depicted in Fig 3.
cloud service providers and many government organizations E-health cloud architecture types can be public, private,
have suggested a variety of security measures and guidelines hybrid and community according to the data stored. Since
to ensure and enhance the confidence of patients and orga- EHR data is strictly confidential, carries sensitive patient
nizations. The first such legislative measure put forward by information and housed in third party servers, access con-
the US Congress in 1996 for the US healthcare industry was trol mechanisms are required. Access control is a secu-
the (HIPAA) [11]. There are mainly three categories of cloud rity barrier which preserves data privacy by restricting
servers: trusted servers, semi-trusted, and untrusted servers. the operation and access of healthcare documents in the
A trusted server is one that can be entirely trusted without healthcare system. The predominant access control tech-
any information disclosure and threats to the health data niques in the healthcare systems are Role-Based Access
stored can be due to internal adversaries [16]. Semi trusted Control (RBAC), Attribute-Based Access Control(ABAC)
servers are honest but curious servers that acquire health data and Identity-Based Access Control (IBAC) techniques. Role
by colluding with malicious users [17] whereas untrusted based systems [19] provide for the assignment of certain roles

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attacks and provides a maximum level of data privacy. This

approach can be applicable to e-health cloud for efficient
data storage in which the health records can be encrypted
and stored in the cloud that achieves a certain level of data
protection. However, as the health records are extremely
sensitive and the data is exposed to the database owner,
this scheme is less acceptable in terms of security. Also,
this scheme cannot be considered for EHRs as it is not
patient-centric and computationally infeasible for real scale
problems. This work [23] proposes a robust and verifiable
FIGURE 3. Architecture of electronic health data in cloud. hybrid multiauthority CP-ABE access control scheme by
combining (t, n) threshold secret sharing and multi-authority
CP-ABE scheme for public cloud storage with which both
to the users for data access. ABAC [20], which employs cryp- security and performance are improved by overcoming the
tographic and non-cryptographic techniques, whereas IBAC single point bottleneck problem. Xue et al. [24] proposes a
uses identity-based encryption mechanisms that utilizes user robust and efficient access control scheme that resolves the
identity for data encryption. Data sharing is a distinctive single-point performance bottleneck in most of the existing
feature of e-health systems. It can be shared among various CP-ABE using an auditing mechanism. Even though these
stakeholders such as healthcare providers, hospitals, health- schemes [23], [24] are advanced access control schemes that
care organizations etc. Search is an alternate substantial func- has high security measures, they cannot be adopted directly to
tion of an e-Health system. Proxy encryption and public-key e-health as these schemes cannot guarantee protection from
encryption are widely used encryption techniques for data insider attacks since it is controlled by Central Authority
search. and multiple Attribute Authorities. A special encryption tech-
nique named Deniable ABE scheme based on Waters cipher
A. CLOUD COMPUTING SECURITY: STATE OF THE ART text policy-attribute based encryption (CP-ABE) scheme was
AND RESEARCH CHALLENGES IN E-HEALTH proposed that allows cloud storage providers to create forged
Cloud computing has seen a tremendous growth that has user secrets from stored cipher text to prevent the data from
reformed the landscape of computing with its storage, elastic outside coercers [25]. This scheme combines the advantage
resources, easy and fast deployment and reduced costs such of both ABE and symmetric key encryption as it supports
that, it instigated many organizations to move their data in the a multi-privileged access control for PHRs by combining
cloud. Even though cloud services provide massive benefits, the encryption of data from multi-patients that falls under
it still suffers from several security threats. For instance, users the similar access policy [26]. Zhang et al. [27] proposes
are not aware of the massive amount of data stored with the an efficient privacy preserving disease prediction scheme by
cloud service provider [21]. Due to lack of transparency, it is using Single layer Perceptron learning algorithm. This model
difficult to be aware of where, how and when the data is encrypts the symptom information submitted by the patient
processed and therefore makes it difficult to trust the service and the cloud uses the encrypted prediction models trained by
provider, who in turn can also be a reason for huge data it to diagnose the patient disease without revealing the patient
loss. There has been several schemes and developments in the privacy. These mechanisms [26], [27] imparts high level of
area of cloud security. Some of the advanced cloud security data privacy, but still impractical for health records due to
techniques are discussed and the pros and cons are outlined its computational complexity and scalability issues. Another
in Table 2. work presented an anonymous CP-ABE with hidden access
Some of the advanced privacy-preserving mechanisms that policy and provides authorized access control with constant
preserves cloud security can be adopted to e-health, while key length [28]. Wei et al. [29] proposed a revocable storage
some are not due to security concerns. Cloud computing is a Identity Based Encryption (IBE) that provides forward and
centralized mainframe computing paradigm owned by cloud backward security of ciphertext. Most of the existing cloud
provider which is less patient-centric and is prone to insider storage systems with secure provenance lacks poor access
attacks that makes the health records more vulnerable. This is control, incur excessive performance overhead and do not
one of the major downsides of cloud computing. Even though support dynamic user management. This work solves the
cloud techniques adhere strict security measures, it does not problem by presenting an attribute-based cloud storage sys-
offer a fool proof solution to be adopted into e-health, taken tem with secure provenance [30]. Even though ABE schemes
into account of its security issues. Zhu et al. [22] proposes an are most efficient among encryption techniques and provide
efficient privacy preserving biometric identification scheme fine-grained, well-formed access to health records, it is still
in which a huge volume of biometric data such as finger- impractical for proper execution on EHRs due to its expen-
prints, irises, voice patterns, facial patterns are encrypted sive computation [28], [30], key management complexity and
and outsourced to the cloud to avoid expensive storage and challenge in managing access control policies [25] when
computation costs. The scheme is resistant against collusion attributes in the access structure grows.

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TABLE 2. Cloud computing security techniques.

Despite the attractive features that cloud offers, the transi- compliance due to the inherent security challenges related
tion of healthcare field towards cloud environment increase to the cloud technology. Patients lose their physical control
the concerns about privacy, security, access control and by storing health information in the cloud servers which can

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be seen as a threat to patient privacy. Data security and data

integrity has also been a challenging issue while storing and
accessing data in the cloud arena [31]. Another downside is
that cloud service providers have a vital role in transaction
analysis, access control, data protection and services inte-
gration. With advancement of technology, the emergence of
advanced cyber threats has escalated, which hinders the pri-
vacy and security of EHRs [32]. Therefore, it is very impor-
tant to guarantee integrity, confidentiality, reliability as well
as authenticity of the e-health data in either a private, public or
hybrid cloud environment. Consequently, this research intro-
duces the concept of a permissioned patient-centric Block
chain for EHRs that eliminates most of the existing bottle-
necks in the cloud.

IV. CLASSIFICATION OF PRIVACY PRESERVING

FIGURE 4. Classification of privacy preserving mechanisms in electronic
MECHANISMS IN ELECTRONIC HEALTH RECORDS health records.
In this work, different techniques based on cryptographic
and non-cryptographic approaches are considered based on
their application of healthcare systems in the cloud arena.
Furthermore, some techniques are analyzed that preserves
data security, data privacy and data anonymity in the cloud.
In addition to this, some Searchable Encryption (SE) tech-
niques are presented to query the encrypted data in the
cloud. Since the data is encrypted and stored in third-party
cloud servers, normal searching schemes cannot be applied.
Searching encrypted data is arduous, Searchable Symmetric
Encryption (SSE) has been proposed that enable keyword
searches across encrypted cloud data. Different from the FIGURE 5. Basic types of cryptography.
recent surveys, our research study has systematically covers
all aspects and methods of privacy and security of EHR in
cloud. Moreover, the survey also reveals the advanced cloud as Symmetric Key Encryption (SKE), Public Key Encryp-
computing security techniques and their research challenges tion (PKE) and a few alternative cryptographic primitives.
and at the same time incorporating the potential benefits of In PKE schemes, two different set of keys are employed
Block chain technique to offset those shortcomings. Apart ie public key and a private key pair for data encryption
from that we also conclude the discussion with open research and decryption whereas SKE based approaches utilizes a
problems and future directions that expands the scope of single shared secret key for the same. Alternative crypto-
further research in data security and privacy. graphic primitives include several encryption schemes viz
There are several research investigations conducted for Attribute Based Encryption(ABE), Searchable Encryption
preserving e-health data privacy in the cloud. The two main (SE), proxy re-encryption, homomorphic encryption, Identity
types are Cryptographic and Non-Cryptographic. The cryp- Based Encryption (IBE) etc.
tographic schemes employ encryption techniques, namely: Non-cryptographic approaches mainly associates with pol-
symmetric key encryption, public key encryption and sev- icy based authorization infrastructure labeled as access
eral cryptographic primitives, whereas non-cryptographic control mechanisms viz RBAC, ABAC, Mandatory Access
approaches include access control mechanisms such as Control (MAC), IBAC etc. This section gives a detailed sur-
RBAC, ABAC, IBAC etc. Classification of the privacy pre- vey of significant research works based on SKE, PKE and
serving mechanisms is portrayed in Fig. 4 alternative cryptographic primitives that enforce the security
and privacy of electronic health solutions.
A. CRYPTOGRAPHIC APPROACHES
Cryptography means hidden writing that analyses and con- 1) SKE BASED APPROACHES
structs protocols to prevent third parties from reading The SKE employs the same shared secret key for encryption
secret messages. Cryptographic approaches can be symmet- and decryption and it is highly effective in EHR systems. But
ric key cryptography as well as asymmetric key cryptog- it introduces inevitable additional complexity since it requires
raphy (see Fig. 5) in which the prior uses the same key additional access control mechanisms for the effective shar-
for the encryption and decryption whilst the latter uses dif- ing of EHR. The commonly used SKE based algorithms
ferent keys. This study includes encryption schemes such are Advanced Encryption Standard (AES), Data Encryption

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TABLE 3. SKE based approaches.

Standard (DES), stream ciphers such as RC4, A5/1, and Blow symmetric key encryption using a one-time key and records
Fish etc. Some of the SKE based approaches are described are stored anonymously. Doctors use digital signatures using
below and the comparison is shown in Table 3. a private key to process electronic medical records. This
Lee and Lee [33] proposed a cryptographic key manage- approach requires an EMR number i.e. the PID, SID, the iden-
ment protocol based on symmetric cryptosystems to meet tity seed which is stored in the patients’ medical card and the
HIPAA regulations. The three entities used are government random value R, which created by the doctor to access the
healthcare office (SG), server of a healthcare provider (SH), EMR of the patient. Each key used in this process is used
and patients. The main three phases of the scheme include for encrypting one EMR, increasing the confidentiality of
registration, encryption and decryption. Initially, the patient each electronic medical record. Since the identity seed SID
needs to register with SG to avail a healthcare card that makes is based on smart data card, medical records cannot be read
him appropriate for the medical services offered by SH. The without authorization.
encryption phase involves encrypting PHI through enabling An EHR sharing and integration system has been proposed
the health data card by entering the user PIN or by biometric by Chen et al. [35] to protect the EHRs in normal and emer-
verification. This can be done by generating a session key gency situations in hybrid healthcare clouds. This approach
and cryptographic checksum by concatenating the hash value encrypts each medical record using an individual symmet-
of patients’ master key and the session key of healthcare ric key ck using a symmetric encryption scheme in public
provider. The decryption conducted is two fold, one with and private cloud environments. Here, the doctor creates the
patient consent and the other with emergency cases. This patients’ health record and it is encrypted by the symmetric
can be done by computing the master key and session key key ck along with a license L. This license provides an
of the healthcare provider. A secure EMR sharing scheme emergency key to access the encrypted data by the cloud
has been proposed by Li et al. [34] to improve the unlinka- even if the server is not provided with direct access. The
bility between patient and EMR. EMRs are encrypted using patient has to provide the smart card to the doctor for the

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decryption of their EHR. This design encrypts all the medical From Table 3, it is evident that even though most of the
records and decryption is possible only by patients’ private SKE based approaches satisfies IN and CO, but still lacks
keys in which the private key is split into two parts, whereas AN, UN, AC and NR due to the following reasons. In SKE
one among the keys will be escrowed by the hospital server approaches, both the sender and the receiver are required
and the other key will be stored on the patient’s smart card. to trust each other as they will be sharing the same secret
The downside of this approach is that the license file also key for encryption and decryption that makes anonymity
need to be encrypted with the hospital’s public key. A new almost impossible. In SKE techniques, non-repudiation and
dynamic access control scheme for PHR is proposed by unlinkability would be violated if the user-credentials such
Chen et al. [36] under the cloud computing environment. This as passwords or smart cards were lost, shared or stolen.
scheme uses Lagrange interpolation polynomial to establish Moreover, the use of shared user IDs and passwords destroys
a secure PHR information access that ensures security which accountability. Most of the methods in SKE fails to mention
is suitably scaled for large number of users. The approach the procedure to restore anonymity or the key. Moreover,
adopted cryptography based on Lagrange multipliers for these schemes are unable to operate in dynamically changing
encrypting the health records ensuring that every patient has cloud environment because of its inflexible access control and
maximum control over their medical records. By allowing inability to manage multiple user roles.
every patient to generate his/her own related keys, users can
choose with whom to share their health records. This reduces 2) PKE BASED APPROACHES
key management complexity, and at the same time allows The PKE approaches entails two separate keys; one public
users to not only retain access control of PHR, but also per- key and one private key. Autonomous PKE schemes are
mits issuance of limited access rights to other users, such as computationally inefficient because of its slower operations
doctors, pharmacists, nurses, researchers etc. This approach and large key sizes. Therefore, PKE schemes can be more
carries computational overhead. To reduce the complexity efficient in combination with SKE schemes in which SKE
of key distribution, this method overhaul past hierarchical schemes can be used for encrypting the contents and public
models and created partial order relation to manage users. private key pairs can be used to secure the symmetric keys.
This is a very flexible approach for multi-user dynamic access This framework [39] used Public Key Infrastructure (PKI) to
control in coordinating the needs for immediate addition, address diverse security requirements such as authentication,
or removal of user access, and also for the addition and confidentiality, integrity, access-control, non-repudiation etc
modification of PHR, making it more suitable for PHR cloud whereas the EHR are encrypted using a shared symmetric
application. key generated by healthcare providers. PKI binds public keys
Zhang et al. [37] presents a role-based and time-bound with unique user identities which consist of digital certifi-
access control (RBTBAC) model which is an integration of cates, a Registration Authority, a Certificate Authority, a Cer-
RBAC and a time-based access control model that ensures the tificate Repository Database and a Certificate Management
security and privacy of EHRs on untrusted cloud servers. This System. This proposed architecture builds a secure EHR
model is a logorithmic composition of RBAC and time-bound sharing framework that ensures effective sharing of EHRs
hierarchical key management in which an authorized user of between patients and several healthcare providers. Authenti-
the EHR system who is alloted a time period can access the cation between EHR sharing cloud and healthcare providers
data on the basis of his role. This model extends greater flex- are achieved by signing the documents with sender’s private
ibility in spatial and temporal capabilities to restrict access key so that only the targeted healthcare provider can ver-
to sensitive data. The EHR are encrypted through SKE. This ify the signature to retrieve the equivalent health records.
work developed a role-based privacy aware access control and PHR privacy is ensured in this framework [40] by creating
management of EHR data and also utilized a time tree method a security model called Online Referral and Appointment
which offers time bound access control and authorization. Planer (ORAP) in which medical information is encrypted
In this approach, a user requires to work in several roles at the client side. In ORAP model, EHR are cached in a
and also owns and administers multiple keys. It is requisite trusted environment, i.e. at physicians’ practice locale. EHRs
to encrypt the sensitive medical healthcare records prior to are encrypted by the public key of the receiving entity and
uploading to the semi-trusted cloud servers. As searching signed before being transmitted to the cloud and decryption
encrypted data is arduous, Searchable Symmetric Encryp- is restricted to authenticated entities only. This framework
tion (SSE) [38] has been proposed that enables keyword used the Amazon S3 cloud for temporary storage and German
searches across encrypted cloud data. This approach presents healthcare telematics infrastructure components for provid-
a highly efficient and Secure Dynamic Searchable Symmetric ing secure and strong encryption and signatures for all docu-
Encryption (SEDSSE) in medical cloud data by leveraging ments transferred to the patients’ health record. Comparison
the secure k-nearest neighbor (kNN) and ABE techniques. of a few PKE based approaches is portrayed in Table 4.
This approach used an AES symmetric encryption algorithm Mashima and Ahamad [18] designed a patient-centered
to encrypt the documents and shares the symmetric secret key monitoring system to safeguard the risk of storing and access-
only with authorized doctors who satisfy the access policy ing electronic health information in the cloud. This work
related to ABE. developed a system that allow the patients to have explicit

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TABLE 4. PKE based approaches.

or implicit control regarding when and how the medical not required. This prevents any server and collusion of up to
information is accessed. Health records are encrypted through n − 1 servers and therefore can succeed from internal and
Public Key Encryption with associated hash values [41]. Uni- external attacks and also achieves n server joint authentication
versal Designated Verifier Signatures (UDVS) that generates over only one database. Narayan proposed a cloud based
a designated verifier signature is also introduced as part EHR system by integrating [16] symmetric key cryptog-
of this work to ensure patient record usage is restricted to raphy, public key cryptography and attribute based encryp-
authorized entities. The main drawback with this system is tion. In this approach, medical data will be encrypted by a
that the confidentiality of the record is compromised as the patient’s symmetric key and the metadata file which describes
health data is initially built by an issuer who has information information regarding access policy. Location information
about the details of record, hash values, and signatures. One is encrypted using broadcast CP-ABE before storage in the
of the prominent works mentioned in the literature is that cloud. This approach supports direct revocation without data
of Yi et al. [2] that provides a multiparty framework which re-encryption but entails additional costs on the patient side
ensures patient privacy in which all the EHRs are encrypted since re-encryption and updating of access policies are borne
with a common public key and decryption needs the coopera- by them. Another drawback is that all the encrypted files can
tion of all concerned parties. This approach is constructed on be accessible by the trusted authority.
PKI based on the ElGamal Threshold public key encryption A solution to address the security issues is by using a
scheme [2]. This scheme uses modular exponentiation which security architecture on Trusted Virtual Domains (TVDs) in
is less computationally expensive and where re-encryption is e-health infrastructure. This work [42] make use of TVD to

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establish access control by employing three privacy domains; are designed to protect against insider attacks, other schemes
trusted, e-Health and untrusted domains. TVDs are a collec- focus on patient centered PHR in which the records are
tion of different Virtual Machines that have common security first created by record issuers who knows the content of
policies and trust each other. TVD systems have the advan- records, corresponding hash values and signatures. Conse-
tage of flexibility when integrating with legacy systems. This quently, inside attacks can happen when an issuer himself
approach make use of PKE encryption for storing and trans- misuses health records created by him, forfeits data integrity.
mitting e-health data in external storage. The main drawback Compromising secret keys Sk of the patient and Monitoring
associated with this approach is the complexity to deploy by third party loses the data confidentiality. In addition, some
the TVD based solutions and scalability issues where these other schemes have also discussed that PKE technique has
domains are executed on a host computer. Pecarina et al. [43] a slightly higher computational cost due to re-encryption of
described a PKE-based framework to enhance privacy by records when updating access policies.
providing anonymity in data storage and efficient access
control to authorized collaborators in a semi-trusted health 3) OVERVIEW OF ALTERNATIVE CRYPTOGRAPHIC PRIMITIVE
cloud [44]. PHRs will be encrypted by the patient using the APPROACHES
public key of a CSP (Cloud Service Provider) prior to storage This section discusses an overview of alternative crypto-
in the cloud. Decryption of the patient records is carried out graphic approaches for securing privacy in e-health clouds.
by CSP using its private key. After storing PHR at a location, The primitives include ABE, SE, IBE, homomorphic encryp-
the location is finally encrypted through the SKE of CSP. This tion, proxy re-encryption etc.
work [45] proposed an efficient homomorphic encryption for
the encryption of medical data images without hindering the a: ATTRIBUTE-BASED ENCRYPTION (ABE) APPROACHES
data confidentiality. A Probabilistic algorithm is used for both Attribute based encryption introduced by
key generation and encryption. This approach stored images Sahai and Waters [47] is based on public key encryption
in a standard format, namely Digital Imaging and Com- to protect cloud data where the encryption and decryption
munications in Medicine (DICOM), and converts the input is on the basis of user attributes. In ABE, the encryp-
image into a matrix followed by performing key generation tion is based on the access-structure policy in which the
based on the homomorphic property and encryption using cipher text can be decrypted only when the user attributes
homomorphic public key encryption before transmitting to match with the ciphertext attributes. The two main types
the cloud. Efficiency of the data is performed by using Peak of ABE are Cipher Text Policy Attribute-Based Encryption
Signal to Noise ratio (PSNR) and Mean Square Error (MSE) (CP-ABE) [48] and Key Policy Attribute-Based Encryption
analysis, histogram analysis, and correlation analysis etc. (KP-ABE). In KP-ABE, the access policy is enciphered in the
An efficient key word search mechanism which employes user’s secret key and decryption of cipher text is possible only
public key encryption has been proposed by Ma et al. [46] for when the user attribute matches with the access policy [47],
a flexible healthcare system in cloud servers. This approach whereas in CP-ABE [49] the private key of each user is
constructs an encrypted keyword index with users public key tied to a set of attributes and a cipher text is associated
attached to encrypted health data prior to uploading to the with a universal set of attributes which can be decrypted
cloud server. It makes use of a trusted key generation center when the user attributes match the access policy. This ABE
to generate the master key, public parameters and the user’s based approach [50] preserves the confidentiality of EHR
partial private key. This work addressed key management by using PKE for scalable authorization. The smartcard of
problems and key escrow problems with minimum compu- the patient generates a Transaction Code (TAC) which is
tational cost and complexity. the authorization secret, before the medical data is uploaded
From the discussion, indisputably PKE schemes in the to the cloud server. PKE is used for authentication and the
cloud are computationally inefficient to some scenarios due patient’s smart card and TAC as authorization. The health
to their larger key sizes. Some of the existing PKE tech- professional needs to enter the TAC to encrypt the medical
niques fails on the confidentiality of health data as it is data and the Encryption/Decryption function generates a
compromised by an authorized entity who exploits the data public key for encryption which is the hash value of the
ownership. In some PKE techniques, authenticity is not sat- patient’s identity and TAC. The decryption can be performed
isfied considering all the encrypted files are accessible by using TAC and authentication from a Private Key Generator
the trusted authority who exploits the trust. Many of the (PKG). The problem of achieving confidentiality, scalability,
Public key systems use a third party called a Certification and fine-grained access of outsourced data in the cloud
authority (CA) to digitally sign their public key, turning into are enumerated by Yu et al. [17]. This approach resolves
a digital certificate to make it safe. However, if the CA gets problems, including key distribution and data management
compromised, the attacks can happen by masqueraders so that issues, by combining techniques such as ABE, KP-ABE,
the data will be sending to a wrong destination. Furthermore, Proxy Re-encryption (PRE), and lazy re-encryption as a
public key cryptography can encrypt data only up to the key hybrid encryption scheme to secure fine-grained access con-
size hence the distribution of public keys are troublesome in trol. The data encrypted by a single user will be shared
environments to handle large data sets. While some schemes among different users by key distribution. In this approach

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TABLE 5. ABE based approaches.

re-encryption of data files and updates of secret keys are borne by the patient. An additional drawback exists with
consigned to cloud servers. A copy of users secret key is the internal vulnerability of access to encrypted files by the
kept with the cloud servers for updating of secret key com- trusted authority without referenced to a permissioned user.
ponents and re-encryption of data files. Lazy re-encryption The comparison of a few ABE based approaches with its
is used to reduce computational overhead in cloud servers. strength and weakness is shown in Table 5.
It can restrain the revoked users from capturing the updated Efficient and Secure Patient-centric Access Control
information once the file contents and keys are modified Scheme (ESPAC) [52] for the cloud using CP-ABE ensures
post user revocation. A patient centered cloud based EHR PHI privacy permitting data requesters to access the health
system that integrates symmetric key cryptography, public data in accordance with role based access privileges. For
key cryptography and an attribute based broadcast cipher secure communication between remote patient and e-health
text policy Attribute-Based Encryption (bABE) architecture cloud provider, IBE is employed, wherein the access con-
is proposed [16]. This method allows for the encryption of trol is handled by CP-ABE. A novel technique by Ruj
health data using a symmetric key and metadata files that et al. [53] presented an ABE-based access control mechanism
include a description of the file, attribute based access policy. that maintains user anonymity for storing PHRs in the cloud.
Location based information is encrypted using broadcast The user identity is unknown to the cloud but the verification
CP-ABE by the patient and enables them to store within of user credentials and communications between users and
a cloud platform. This approach also includes a key word the cloud are secured by Secure Shell Protocol, SSH. This
search functionality by amalgamating bABE and PKE with approach is collision resistant and is resistant to replay attacks
Keyword Search (PEKS) [51] to carry out private searches in and has a decentralized key distribution. To facilitate flexible
encrypted data without unveiling the matches to the cloud. and effective access control for PHR, this scheme suggests
Even though this approach facilitates direct revocation with- an efficient patient centric framework [48] which employs
out data re-encryption it entails additional computational ABE to encrypt a patient’s PHR file before uploading to the
costs as re-encryption and updating of access policies are cloud. This scheme provides several data owner settings and

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also categorizes the PHRs into two different sub-domains viz

public and private to address key management hurdles. This
approach [54] instigates hierarchical attribute based encryp-
tion with a keyword search scheme that ensures confidential-
ity of EHRs in the cloud environment. This scheme encrypts
a single access structure in which the trusted authority will
issue public and private key pairs.The access policy and time FIGURE 6. Searchable encryption.
period is set by the information owner before outsourcing
the data to the cloud. A proxy re-encryption scheme is also
implemented to deny access after the predefined time period
defined by the information owner. This work assures fine
grained access control, versatile client revocation and lesser
storage and encryption time costs compared to other systems.
Even though ABE provides dynamic access control and
key management, it still experiences some drawbacks. One
of the limitations with ABE is that the data owner needs to
use the authenticated users’ public key for encryption [21]. FIGURE 7. Classification of SE techniques.
The drawback with KP-ABE is that the owner of the data
cannot decide who can decrypt the encrypted data as the data
owner has to trust the key issuer and also suffers with poor This approach is initially introduced based on symmetric
scalability issues. Consequently, the Non-repudiation can’t cryptography [56] that facilitates controlled searching where
be guaranteed. In CP-ABE, attribute management and key the untrusted server is unable to retrieve the original plaintext.
distribution are managed by a trusted authority. ABE schemes Here we discuss SE and categorize its use cases into
are most efficient among encryption techniques and provide four schemes viz Searchable Symmetric Encryption (SSE),
fine-grained and well-formed access to health records but still Public Key Encryption with Keyword Search (PEKS),
infeasible for proper execution on EHRs due to its expen- Attribute-based Encryption with Keyword Search (ABKS),
sive computation [28], [30], key management complexity and Proxy Re-encryption with Keyword Search (PRKS) as shown
challenge in managing access control policies [25] when in Fig. 7 and their comparison is presented in Table 6 and
attributes in the access structure grows [26]. Another down Table 7. A searchable encryption service contains three types
side is that since most of the ABE schemes use a semi trusted of entities: a data owner, a data user (data users), and the
entity who manages the servers and provide cloud services, untrusted cloud [57]. The data owner is a cloud service user
and for this reason become a threat to data integrity. who outsourced the original data to a third-party cloud.
Different healthcare application scenarios require different
b: SEARCHABLE ENCRYPTION searchable encryption schemes. We can characterize exist-
Due to the massive growth of big data there exists large scale ing healthcare application scenarios into four categories: (1)
outsourcing of data into cloud servers. As medical data and When the outsourced data are searched only by the data
EHRs are outsourced to remote cloud servers that are exposed owner, where the data owner is the only authorized data user
to cloud service providers, this leads to various attacks such as to search the encrypted data, SSE schemes can be applied in
either DoS attacks or adversary attacks that destroys the data this scenario. (2) When the outsourced data are shared with
confidentiality in the cloud. For protection of data and pre- another user, i.e. there is only one authorized data user who
vention of information leakage, cloud data will be encrypted. can create the search tokens and search the encrypted data,
Since the health data is encrypted and stored in third-party PEKS schemes are suitable for this one-to- one scenario. (3)
Cloud servers, normal searching schemes cannot be applied. When the outsourced data are shared with several users, i.e.
It requires some searchable encryption implementation to more than one authorized user have the permission to search
query the data as shown in Fig. 6. As searching encrypted the encrypted data, ABKS schemes can be used in this one-
data is arduous, SSE has been proposed that enable keyword to-many scenario. (4) When the data owner is unavailable
searches across encrypted cloud data. This poses challenges and cannot directly grant the search authorization upon emer-
such as (1) How the data owner permits search permissions gency, it needs an authorized delegate user to re-authorize the
to the data user? (2)How the authenticated data users search search permission to other user(s) on behalf of the data owner.
the encrypted stored data? One of the solutions is SE. SE PRES schemes are applicable to this authorization-delegation
is a cryptographic primitive that permits search operations scenario [57].
over encrypted data without disclosing the information to • Searchable Symmetric Encryption (SSE) SSE is a
untrusted servers. These search operations are performed on symmetric key encryption technique which outsources the
encrypted ciphertext with the support of a trapdoor func- data confidentially from one party to another by provid-
tion from user. The main two types are symmetric search- ing selective search capabilities. This model uses proxy
able encryption and asymmetric searchable encryption [55]. re-encryption [58] that shares medical data in the cloud

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TABLE 6. Comparison of SE techniques (SSE and PEKS) based on server set Ups.

TABLE 7. Comparison of ABKS and PRKS techniques based on security new cryptographic technique named as a conjunctive key-
facets.
word search with designated tester and timing dependent SE
schemes named proxy rencryption function (Re-dtPECK).
The EHR documents are encoded by symmetric encryption
algorithms and a symmetric key is encapsulated with the
patient’s public key by key encapsulation. This makes use
of a delegation function θ to perform operations and uses
a conjunctive keyword search mechanism. This approach
proposes a novel SSE scheme [60] which provides searching
according to the unique keywords stored on the server. The
search time is logarithmic and the client can search and
update the document whenever required. This makes use of
two variant schemes in which the first one is an interactive
scheme and the second one is non-interactive in which the
former needs two rounds of communication for the index
generation, updates, and search whereas the latter can be
deployed using a hash chain. This method [61] states an SSE
procedure which supports conjunctive search and Boolean
queries on stored data which is symmetrically encrypted and
focus on a single keyword search mechanism. This model
provides higher security and scales to very large databases.
By preserving keyword privacy, this approach [62] validates
and resolves the issue regarding fuzzy keyword searches
across encrypted data in the cloud. Fuzzy keyword searches
enrich system utility by providing matching files or nearest
possible matching files for the user input with the prede-
fined keywords based on keyword similarity semantics, oth-
with end-to-end data encryption that confines data access erwise. This solution precomputes fuzzy keyword sets with
only to authenticated recipients. This approach [59] pre- edit distance to evaluate keyword similarity and also mini-
serves the privacy and security in e-Health systems with a mizes the storage and representation overheads by developing

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an advanced mechanism on constructing fuzzy keyword provides two security concepts for bidirectional PRES (Proxy
sets. Re-encryption Scheme): privacy for keyword and privacy for
• Public Key Encryption with Keyword Search (PEKS) message. In keyword privacy, the opponent is permitted to
PEKS is a cryptographic approach that uses a public key obtain the plaintext of any ciphertext, and nearly all trapdoors,
system to search across encrypted data. Boneh et al. [63] pro- excluding those which are connected to the two specific
posed PEKS as an initial scheme which does not uncover any keywords. Nevertheless, it cannot determine which keyword
information pertaining to user’s searching in the public-key matches to a given ciphertext. This security idea ensures that
setting and with lesser communication complexity. This the test can only be done by the person who has the trapdoor
technique [64] proposes a weak key unlinkability that pro- or token. For message privacy, the opponent is permitted
vides a broader view on trapdoor privacy in asymmetric to obtain the plaintexts of nearly all ciphertexts, excluding
searchable encryption for IBE. The main purpose of this one and all the trapdoors, but it cannot determine which
scheme is to build an anonymous IBE scheme that fulfills message matches with the particular plaintext. This secu-
both key unlinkability and enhanced functional privacy. This rity concept ensures that the one who holds the private key
approach [65] addresses three main issues of a PEKS scheme can decrypt the ciphertexts. A new cryptographic approach
viz removal of secure channel, refreshing keywords, and pro- described by Fang et al. [72] called Conditional Proxy
cessing multiple keywords. The idea of PKE with registered Re-Encryption with Keyword Search (C-PRES) is an asso-
keyword search (PERKS) has been presented by Tang and ciation of C-PRE and PEKS. This approach offers various
Chen [66]. This scheme provides flexibility in such a way that benefits over previous schemes, such as chosen-ciphertext
the sender is able to register a keyword with the receiver prior security, non-interactivity keyword-anonymity, unidirection-
to the sender generating a tag to build searchable content. This ality, and collusion-resistance. Shi et al. [73] presented an
makes the scheme more efficient and secure against offline approach in which the encrypted data will be outsourced to
keyword-guessing attacks. the cloud by the data owner to perform the keyword search
• Attribute Encryption with Keyword Search (ABKS) on encrypted data with the specified search token. The idea
ABKS is a cryptographic searching approach which uses is to combine ABE and PRE in which the data owner permits
attribute-based encryption for data encryption. This search- keyword searches over encrypted data to authenticated users
ing technique permits keyword searches over encoded EHR in accordance with access control policies.
data by authorized users whose attributes fulfill the access We have discussed a survey of Searchable encryption
policy. Yang [67] proposed a multi sender and user sce- techniques for healthcare applications. However, all existing
nario that enhances fine grained access control and supports multi-user SE schemes are not practical with respect to the
flexible user revocation using a flexible keyword search- performance required by critical real-world applications and
ing technique and attribute based encryption. This scheme do not scale well for extensive databases. We categorize and
introduced a novel fundamental named as Attribute Based compare the different SE schemes in terms of their security,
Searchable Encryption with Synonym Keyword search func- effïciency, and functionality. However, SSE is not a preferred
tion (SK-ABSE). An ABE scheme described by Li et al. [68] method [65] for querying the search in EHR due to key
implements keyword search functions with outsourcing management issues. Nevertheless, PEKS and PRKS exhibit
key-issuing and outsourcing decryption (KSFOABE). In this better performance in terms of security and privacy and are
scheme, the cloud service provider undertakes partial decryp- commonly adopted to EHR that supports search functionality.
tion tasks assigned by data user without having any infor-
mation regarding the plaintext which is secure and robust
against chosen plaintext attack. Verifiable Attribute-Based c: PROXY RE-ENCRYPTION
Keyword Search (VABKS) [69] solution permits a data user Proxy Re-encryption is a cryptographic approach that per-
to only search over the data owner’s outsourced encrypted mits a semitrusted proxy server to re-encrypt the cipher-
data whose credentials match with the data owner’s access text, which is encrypted by one user’s public key, into
control policy. Liu et al. [70] presented a new approach called another ciphertext i.e. encrypted by the public key of another
Key Policy Attribute-Based Keyword Search(KP-ABKS) that user [74]. For example, Alice sends a message (M) to
removes secure channel for validation of the searched result Bob through a semi-trusted proxy server, Without shar-
from the cloud that reduces the computation complexity on ing Alice’s private key to either the proxy or Bob, and
VABKS. without disclosing the secret message to the proxy shown
• Proxy Re-Encryption with keyword Search (PRKS) in Fig. 8. Yang and Ma [59] introduced a novel cryptographic
PRKS is a cryptographic fundamental that uses a proxy approach called as Conjunctive Keyword Search with a
re-encryption system for searching encrypted data. It per- designated tester and a timing enabled proxy re-encryption
mits an authenticated data user who permissions the function, Re-dtPECK, that uses a delegation indicator θ to
search capability to other users by re-encrypting the out- perform operations and uses conjunctive keyword for search-
sourced data [57]. The proxy re-encryption with keyword ing mechanism. This scheme proposes a proxy re-encryption
search functions (PRKS) as the union of two schemes, mechanism [75] for on the road emergencies that permits
Proxy Re-Encryption (PRE) and PEKS. This approach [71] an emergency medical center to decrypt a patient’s health

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FIGURE 10. Classification of access control mechanism.

multiplications over the encrypted data, whereas, Some-

FIGURE 8. Proxy re-encryption.
what Homomorphic Encryption(SwHE) executes restricted
numbers of homomorphic operations by evaluating cir-
records wth the aid of cloud servers and user credentials cuits of specified depth. Fully homomorphic encryption
without disclosing the secret key. based approaches are impractical because of their inef-
Timing enabled proxy re-encryption systems over conjunc- ficacy. Naehrig et al. [80] presented SwHE to perform
tive keyword search have been proposed [76] that allow users computations over the encrypted data. This approach [81]
to access the patient records under a predefined time inter- implements a hybrid architecture that uses homomorphic
val, T. This technique achieves objectives such as Efficient encryption and RSA (Rivest-Shamir-Adleman) to enhance
Access Control, User revocation, Efficiency, and Time based e-health data security in private cloud OpenStack platforms.
revocation. This architecture enables cloud clients to take control of their
cryptographic operations and key management rather than the
d: HOMOMORPHIC ENCRYPTION
cloud provider. Carpov et al. [82] designed a privacy preserv-
ing diagnosis model using homomorphic encryption which
Homomorphic encryption is a type of encryption which
processes data without allowing any information breach to
performs computation on ciphertexts in which the data is
the cloud provider. Data will be encrypted with the private
acquired in an encrypted format, when decrypted returns
key of the user before uploading to cloud servers and data
the result of operations if they had been performed on the
evaluation will be done on encrypted data in which the results
plaintext. A simple example for homomorphic encryption is
are oblivious to the cloud. This approach integrates state-of-
shown in Fig. 9.
the art components such as, trans-ciphering, automatic com-
pilation, parallelisation, and message packing, to preserve
user privacy.

B. NON-CRYPTOGRAPHIC APPROACHES
Non-cryptographic approaches mainly use policy-based
authorization infrastructure such as, access control policies,
to enforce privacy control to the data. In EHR systems where
data access is of a highly confidential nature and data is
housed on third party severs. Access control mechanisms are
inevitable and vital as encryption approaches. In a health
care information system access control offers fundamental
security barriers to data privacy whereby it limits the access
FIGURE 9. Example of homomorphic encryption. and operation of documents in the EHR system. Some of
the main access control techniques are depicted in Fig. 10.
Barni et al. [77] introduced a multiparty approach for Comparison of a few privacy preserving Non-cryptographic
processing the encrypted Electrocardiogram (ECG) using mechanisms is shown in Table 8.
homomorphic encryption to preserve patient privacy. Privacy Discretionary Access Control (DAC) is a form of access
Preserving Attribute based authentication systems have been control in which the object’s owner has whole control over the
introduced [78] for e-health networks which contribute users’ programs. DAC is based on giving access to objects based on
verifiable attributes to authenticate users in an e-health sys- the subject’s identity [83]. In MAC, access policy decisions
tem. The proposed scheme relies on homomorphic encryption are not made by the individual owners of an object but by
to guarantee data security, which preserves the privacy a central authority and also the owner cannot change access
of attributes but the computation cost is extremely high. rights [84]. RBAC defines access decisions on basis of their
Gentry [79] proposed the idea of fully homomorphic encryp- job functions in which roles have been allocated to subjects,
tion which permits a random number of additions and and the roles are associated with permissions that defines

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TABLE 8. Comparison of privacy preserving non-cryptographic mechanisms.

which actions can be operated over which objects. ABAC is within the policy. Sandhu et al. [88] proposed RBAC in
an authentication based access control in which the decisions which the roles have been assigned to subjects and roles
for access are performed according to the set of user defined are also associated with permissions that define which
attributes and requesters will be given object access according actions can be operated over which objects. This scheme
to attributes that satisfy the policy rules. IBAC is an approach has several drawbacks. It is an expensive process to define
to regulate access based upon the authenticated identity of an and structure the roles, and it only supports policies that
individual. are static and defined in advance. Furthermore it can-
Khan and Sakamura [85] proposed a context sensitive not support dynamically changing environments [89], and
fine-grained access control mechanism of personal health also RBAC’s coarse-granularity causes internal attacks [90].
information by means of discretionary access control and Yuan and Tong [20] proposed ABAC in which specific
RBAC models. This approach uses eTRON architecture in attributes of each subject are used to explain access policies
which authentication is performed using public key cryp- for access permission. ABAC resolves issues of RBAC but
tography and secure key sharing is established through it has two problems. Initially, ABAC is arduous because of
the Diffie-Hellman algorithm. Pussewalage and Oleshchuk the large number of rules that are required to be examined for
[86] presented a patient-centric attribute based method in access decisions, and secondly for n attributes ABAC may
which each PHR file is encrypted and stored along with require 2n rules [20].
an attribute based access policy in an e-health cloud that A secure attribute based access control technique for EHR
controls the access to the particular resource and also uti- has been presented by Pussewalage and Oleshchuk [91] using
lizes a proxy re-encryption technique that aids the authen- selective disclosure of the attributes in which the access
ticated users to decrypt the appropriate PHR files. This decisions are made in such a way that the user must acquire
scheme can resist attacks mounted via attribute collusion the same attribute set that satisfies the defined access policy
and is also capable of provisioning on-demand user revo- to the requested resource. This approach employed a Public
cation. Alshehri and Raj [87] presented a framework which Key Infrastructure (PKI) for establishing a secure channel to
eliminates the limitations of RBAC and ABAC. This work authenticate with the health center. This model [92] integrates
proposed a BiLayer Access Control (BLAC) in which several mechanisms such as RBAC and ABAC to provide
attributes are integrated with roles and an access request confidentiality for Electronic health records. A framework
is examined against pseudo-roles before checking the rules that introduces the concept of a provenance based access

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control combines with RBAC with a distributed rule-based 3. Which access control mechanism will be more efficient
mechanism is proposed [93] to enhance the security of cloud for the secure transfer of EHR?
data. Bahga and Madisetti [94] proposed an EHR architecture 4. Which encryption scheme can be used for preserving
that attains semantic interoperability between stakeholders. data security?
This framework adopts a two level modeling that provides 5. How the health data can be effectively shared against
better security and addresses the key requirements of HIPAA multiple healthcare providers?
and HITECH (Health Information Technology for Economic 6. How to maintain integrity of health records?
and Clinical Health act). For secure data storage and secure 7. Who will be able to access the patient data with health-
access a cryptographic model for EHR systems has been care providers during an emergency situation?
proposed [95]. Location awareness and biometric authentica- 8. What kind of access can be given to Administrative staff
tion techniques are used for user authentication and steganog- to offset inside attacks?
raphy techniques are used to conceal EHR data in the cloud 9. How to handle user revocation when an authorized user
by embedding in ECG signals. leaves the system?
Gajanayake et al. [96] presented a new access control 10. How to handle key management complexity while shar-
technique to preserve patient privacy and confidentiality ing healthcare data between disparate healthcare providers?
for EHR by combining three prevalent techniques such as This review highlighted various research issues pertaining
MAC, DAC, RBAC along with a purpose based access to the privacy and security of e-health data. Therefore we
control. This work [97] adopted an XACML (Extensible found that there is an imminent need to strengthen the security
Access Control Markup Language) ABAC mechanism for infrastructure in e-health systems aiming towards patients’
the protection of EHR against unauthorized intruder access, to ensure the privacy and security of data thereby securing
which supports interoperability. This approach makes use of patient confidentiality and sovereignity. Thus, we bring forth
semantic technologies and an inference engine which uses some future research directions as follows:
attributes as classes and rule based policies for decision mak- • From the discussion, we have examined several cryp-
ing. Seol et al. [98] proposed an EHR model that combines tographic and non-cryptographic mechanisms. Even though
ABAC using XACML to preserve patient privacy and ensure ABE is most efficient among encryption schemes, Yi et al. [2]
security in the cloud environment. This work makes use of investigated and proved that even though ABE is most
partial encryption based on XML and XML digital signature efficient among encryption schemes, it still suffers from
technology for authentication purposes. An attribute based expensive computation and complexity in bi-linear pairing
access control scheme [99] for an e-health environment, inte- operations. Therefore, recognizing new techniques for reduc-
grated with controlled access delegation, has been proposed. ing the complexity of bi-linear operations or finding ways
This approach also performs multilevel access delegation to outsourcing computations will be an interesting research
with on-demand attribute revocation mechanisms. An authen- direction.
tication algorithm and RBAC to preserve patient privacy • we have observed several access control mechanisms
in smart health systems [100] has been proposed. It makes that ensure privacy in which ABAC is the most flexible and
use of three parties, namely Health Authority, Healthcare convenient providing fine grained access. So, ABAC will
Professionals, and the Information Consumer. Liu et al [101] be efficient to introduce more flexibility into authorizations
introduced an RBAC scheme for EHR on the basis of two which can also be considered as a research direction.
roles. One for patients and another for medical staff. Patients • Introducing secure Provenance for tracking information
are identified by their identity whereas medical staff will flow for e-health data would be another interesting area to
be recognized by their roles and access will be given per work on.
access policies. This approach also supports user revocation • Integrity of health data in the cloud can be another interest-
mechanisms. ing research direction.
• Privacy is a crucial aspect in healthcare. Maintaining
V. RESEARCH ISSUES AND FUTURE DIRECTIONS privacy and tracking privacy violations by means of account-
This section discusses the research issues and future direc- ability mechanisms in healthcare records is essential for fraud
tions related to privacy and security in EHR. Since EHR data detection and prevention. Keeping track of provenance for
is sensitive, confidential, and housed in third party servers both data and programs is advisable.
entails serious risks in terms of data privacy and security. • The great leaps in digital technologies characterized by
Higher levels of security is utmost needed to prevent, detect, Social networking, IoT, Big Data Analytics and Cloud com-
and act on unauthorized access to healthcare system and is puting calls for the immediate attention of all stakeholders
required to mitigate social, economic, political and cultural to ensure stricter norms of privacy and security with respect
conflicts. Some of the main research issues include: to big data. Therefore, combinations of Data Analytics and
1. How to secure and safeguard security of stored data in Artificial Intelligence will be a better research focus to ana-
the cloud? lyze, examine, and prevent threats in healthcare.
2. How to implement privacy preserved health care data • A combination of encryption mechanisms and access
storage? control mechanisms to preserve big data security and privacy

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S. Chenthara et al.: Security and Privacy-Preserving Challenges of e-Health Solutions in Cloud Computing

can also be considered as a future research direction for

maintaining a foolproof security mechanism in e-healthcare.
VI. DISCUSSION
From the comparitive review of existing cryptographic
and non-cryptographic approaches, we have discussed
how several privacy and security mechanisms can be
applied to e-health data efficiently. For the comparison,
we have examined several crucial factors including the
strengths and weakness of existing techniques and char-
acterized each method using several privacy preserving FIGURE 11. Challenges in cloud.

requirements such as IN (Integrity), CO (Confidentiality),

AU (Authenticity), NR (Non-repudiation), AC (Accountabil-
ity), AN (Anonymity), UN (Unlinkability).
The comparison results are indexed in Table 1 to Table 5 in
which the symbols ‘‘X’’, ‘‘7’’ denotes whether the specific
privacy preserving requirement is accomplished or not and ‘‘-
’’ denotes that a specific requirement is not discussed. From
the detailed survey it is evident that most of the techniques
are adhere to the privacy preserving requirements but none
adhere completely.
From the discussion, it is apparent that most of the existing
cryptographic approaches suffer from higher computational
cost, complexity in key management and distribution, in addi- FIGURE 12. Secure blockchain based EHR System in cloud.
tion to vulnerability to a wide range of intruder attacks
due to the nature of design, portability and scalability. The achieve security, privacy and integrity of health data in an
review provides a detailed study of cryptographic approaches e-health deployment. From Fig. 11 it is obvious that security
such as SKE, PKE, ABE, SSE, Proxy Re-encryption and is a crucial concern in the cloud environment as cyber threats
Homomorphic Encryption in which the SKE suffers from are increasing exponentially. Therefore, there is an imminent
inflexible access control which further entails user pres- need to preserve security of EHRs against security breaches
ence for every smart card access. SKE schemes are unable and to stregthen the security infrastructure in healthcare to
to operate in a dynamically changing cloud environment ensure patient confidentiality.
because of its inability to manage multiple user roles. It is One of the solutions to overcome all these limitations in
evident that PKE schemes are computationally inefficient the existing system is to introduce patient centered elec-
due to larger key sizes. Even though existing ABE based tronic health system namely, Personally Controlled Elec-
mechanisms have the advantage of defining access structures tronic Health Record System, in which the patient will be
and are superior in preserving privacy levels, the computation the universal consent provider of their data (except in emer-
of bilinear pairing in ABE is very expensive. One of the gency situations) to all stakeholders viz doctors, pharmacists,
main limitations found in the existing techniques is that nurses, scientists etc. Blockchain technology [102] can be
they are administered and controlled by a central trusted used as an underlying access control tool to support this dis-
entity. Moreover, among the access control mechanisms, tributed ledger mechanism in the cloud. A secure Blockchain
RBAC is inflexible in dynamically changing environments based EHR system in cloud is depicted in Fig. 12. Smart
and the task of defining structure and roles in RBAC is quite contracts are intelligent permission contracts or codes that
expensive too. ABAC is significantly efficient in handling are written which verifies data ownership, permissions and
access control, but it requires a large number of rules for integrity of data [103]. This approach will be a tamper proof
decision making. The non-cryptographic approaches have mechanism as every health transaction information will be
several limitations on their expensive processes to define and stored as hash values in the blockchain. It has immense poten-
structure roles, policies, and are inefficient operating with in tial to ensure security, privacy, confidentiality, availability
a dynamic environment. From the review, it is also evident and integrity of the e-health information. The introduction of
that SE schemes are not extensively used for handling health- this technological advancement that integrates cryptograph-
care data in the cloud environment due to computational ical aspects provides a secure and efficient framework for
limitations and an inability to withstand intruder attacks. efficient storage, transfer and access of electronic health
The majority of the approaches described are incapable to records in the cloud environment.
withstand internal and external attacks due to the lack of
proper privacy preserving mechanisms. However, we have VII. CONCLUSION
discussed several mechanisms and pointed out the advantages Smart health care services are a great boon and are dom-
and disadvantages, but these existing techniques still fail to inantly used by patients, doctors and other healthcare
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[82] S. Carpov, T. H. Nguyen, R. Sirdey, G. Constantino, and SHEKHA CHENTHARA the M.Tech. degree in
F. Martinelli, ‘‘Practical privacy-preserving medical diagnosis using computer science from Mahatma Gandhi Univer-
homomorphic encryption,’’ in Proc. IEEE 9th Int. Conf. Cloud Comput. sity, India. She is currently pursuing the Ph.D.
(CLOUD), Jul. 2016, pp. 593–599. degree in computer science from the School
[83] K. Punithasurya and S. Jeba Priya, ‘‘Analysis of different access control of Engineering and Science, Victoria University,
mechanism in cloud,’’ Int. J. Appl. Inf. Syst., vol. 4, no. 2, pp. 34–39, 2012. Melbourne, VIC, Australia. She has good expe-
[84] V. C. Hu, D. Ferraiolo, and D. R. Kuhn, Assessment of Access Control rience in teaching and was a Full-Time Lecturer
Systems. Gaithersburg, MD, USA: Nat. Inst. Standards Technol., 2006. in computer science with the Cochin University of
[85] M. F. F. Khan and K. Sakamura, ‘‘Fine-grained access control to medical Science and Technology, India. Her research inter-
records in digital healthcare enterprises,’’ in Proc. Int. Symp. Netw., Com-
ests include cloud computing, big data security and
put. Commun. (ISNCC), May 2015, pp. 1–6.
privacy, visual cryptography, cyber security, and block chain technology and
[86] H. S. G. Pussewalage and V. Oleshchuk, ‘‘A patient-centric attribute based
their applications in the e-health domain.
access control scheme for secure sharing of personal health records using
cloud computing,’’ in Proc. 2nd Int. Conf. Collaboration Internet Comput. KHANDAKAR AHMED (M’11) the M.Sc. degree
(CIC), Nov. 2016, pp. 46–53. in Networking and e-Business Centred Comput-
[87] S. Alshehri and R. K. Raj, ‘‘Secure access control for health information ing (NeBCC) under the joint consortia of Uni-
sharing systems,’’ in Proc. IEEE Int. Conf. Healthcare Inform., Sep. 2013, versity of Reading, U.K.; Aristotle University of
pp. 277–286. Thessaloniki, Greece; and Charles III University
[88] R. Sandhu, D. Ferraiolo, and R. Kuhn, ‘‘model for role-based access of Madrid (UC3M), Spain, in 2011, and the Ph.D.
control: Towards a unified standard,’’ in Proc. ACM Workshop Role-Based
degree from RMIT University, Australia, in 2014.
Access Control, Jul. 2000, pp. 1–11.
He is currently a Lecturer with the Discipline of
[89] D. R. Kuhn, E. J. Coyne, and T. R. Weil, ‘‘Adding attributes to role-based
access control,’’ IEEE Comput., vol. 43, no. 6, pp. 79–81, Jun. 2010.
IT, School of Engineering and Science, Victo-
[90] E. Chickowski. (May 2012). ‘‘Healthcare unable to keep up with insider
ria University, Melbourne, VIC, Australia. During
threats,’’ Dark Reading, 2012. Accessed: May 12, 2018. [Online]. his Ph.D., he was an Active Scholar with the Network Research Group,
Available: https://www.darkreading.com/vulnerabilities—threats/ School of Engineering, where he explored Data-Centric Storage (DCS)
healthcare-unable-to-keep-up-with-insider-threats/d/d-id/1137610? in Wireless Sensor Network (WSN). Before joining Victoria University,
[91] H. S. G. Pussewalage and V. A. Oleshchuk, ‘‘An attribute based access he was a Full-Time Lecturer with the School of IT and Engineering (SITE),
control scheme for secure sharing of electronic health records,’’ in Proc. Melbourne Institute of Technology (MIT), Melbourne, and a Researcher
8th Int. Conf. E-Health Netw., Appl. Services (Healthcom), pp. 1–6, with Australia–India Research Centre for Automation Software Engineering
Sep. 2016. (AICAUSE), RMIT University, from 2016 to 2017. He was with AICAUSE
[92] M. Sicuranza and A. Esposito, ‘‘An access control model for easy manage- as a Postdoctoral Researcher, before he takes the full-time position at MIT,
ment of patient privacy in EHR systems,’’ in Proc. 8th Int. Conf. Internet from 2015 to 2016. He serves as a member of the Editorial Board of the Aus-
Technol. Secured Trans., Dec. 2013, pp. 463–470. tralian Journal of Telecommunications and the Digital Economy (AJTDE)
[93] J. Lacroix and O. Boucelma, ‘‘Trusting the Cloud: A PROV + RBAC and the TPC Chair for ITNAC 2017. He has also been serving as a Reviewer
Approach,’’ in Proc. IEEE 7th Int. Conf. Cloud Comput., Jul. 2014, for several international A* journals and conferences.
pp. 652–658.
[94] A. Bahga and V. K. Madisetti, ‘‘A cloud-based approach for interoperable HUA WANG received the Ph.D. degree in com-
electronic health records (EHRs),’’ IEEE J. Biomed. Health Informat., puter science from the University of Southern
vol. 17, no. 5, pp. 894–906, Sep. 2013. Queensland (USQ), in 2004. He was a Professor
[95] U. Premarathne, A. Abuadbba, A. Alabdulatif, I. Khalil, Z. Tari, with USQ, from 2011 to 2013. He is currently a
A. Zomaya, and R. Buyya, ‘‘Hybrid cryptographic access control for Full-Time Professor with the Centre for Applied
cloud-based EHR systems,’’ IEEE Cloud Comput., vol. 3, no. 4, pp. 58–64, Informatics, Victoria University. He has authored
Aug. 2016. [Online]. Available: http://ieeexplore.ieee.org/abstract/ or coauthored over 150 peer-reviewed research
document/7571083/ papers mainly in data security, data mining, access
[96] R. Gajanayake, R. Iannella, and T. Sahama, ‘‘Privacy oriented access con- control, privacy, and web services, as well as
trol for electronic health records,’’ Electron. J. Health Inform., vol. 8, no. 2, their applications in the fields of e-health and
p. 15, 2014. [Online]. Available: http://www.ejhi.net/ojs/index.php/ejhi/ e-environment.
article/view/265
[97] J. Calvillo-Arbizu, I. Román-Martínez, and L. M. Roa-Romero, ‘‘Stan- FRANK WHITTAKER received the master’s
dardized access control mechanisms for protecting ISO 13606-based elec- degree in international business and the Ph.D.
tronic health record systems,’’ in Proc. IEEE-EMBS Int. Conf. Biomed. degree. His thesis was entitled Electronic Commu-
Health Inform. (BHI), Jun. 2014, pp. 539–542. nities of Care—Measuring the Benefits.
[98] K. Seol, Y.-G. Kim, E. Lee, Y.-D. Seo, and D.-K. Baik, ‘‘Privacy- At the forefront of digital care solutions for
preserving attribute-based access control model for XML-based electronic more than two decades, he has been working
health record system,’’ IEEE Access, vol. 6, pp. 9114–9128, 2018. closely with providers, government, and research
[99] H. S. G. Pussewalage and V. A. Oleshchuk, ‘‘Attribute based access con- institutions to transform the delivery of coordi-
trol scheme with controlled access delegation for collaborative E-health
nated care services and facilitate provider—client
environments,’’ J. Inf. Secur. Appl., vol. 37, pp. 50–64, Dec. 2017.
collaboration. Over this time, he has been involved
[100] P. Tasatanattakool and C. Techapanupreeda, ‘‘User authentication algo-
in the design and implementation of a range of innovative solutions, gained
rithm with role-based access control for electronic health systems to
prevent abuse of patient privacy,’’ in Proc. 3rd IEEE Int. Conf. Comput. an extensive understanding of the challenges faced by community ser-
Commun. (ICCC), Dec. 2017, pp. 1019–1024. vice providers, and demonstrated the impact that personalized technologies
[101] W. Liu, X. Liu, J. Liu, Q. Wu, J. Zhang, and Y. Li, ‘‘Auditing and revo- can have on care outcomes. He is involved in a number of postdoctoral
cation enabled role-based access control over outsourced private EHRs,’’ research projects. He is an Industry Relationship Manager with the Centre
in Proc. 17th Int. Conf. High Perform. Comput. Commun., pp. 336–341, for Applied Informatics, Victoria University. He is an experienced Project
Aug. 2015. Manager with an accounting/IT background. For his Ph.D., he investigated
[102] M. Zhang and Y. Ji, ‘‘Blockchain for healthcare records: A data perspec- the impact of technology on the delivery of three health care programs
tive,’’ PeerJ Preprints, vol. 6, May 2018, Art. no. e26942v1. using a five-perspective evaluation model to measure: access, participation,
[103] A. Ekblaw, A. Azaria, J. D. Halamka, and A. Lippman, ‘‘A case study for health outcomes, safety and quality, and resource efficacy. His research and
blockchain in healthcare:‘MedRec’ prototype for electronic health records evaluation framework were published, in 2013 and have since been utilized
and medical research data,’’ in Proc. IEEE Open Big Data Conf., vol. 13, and cited in many projects.
Aug. 2016, p. 13.

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