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com
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ScienceDirect
Procedia Computer Science 00 (2019) 000–000
Procedia
Procedia Computer
Computer Science
Science 17500 (2019)
(2020) 000–000
615–620 www.elsevier.com/locate/procedia
www.elsevier.com/locate/procedia

The 6th International Workshop on Cyber Security and Digital Investigation (CSDI)
The 6th International Workshop on Cyber
August 9-12, 2020,Security
Leuven,and Digital Investigation (CSDI)
Belgium
August 9-12, 2020, Leuven, Belgium
Blockchain
Blockchain and
and Smart
Smart Healthcare
Healthcare Security:
Security: A
A Survey
Survey
Noshina Tariqaa , Ayesha Qamaraa , Muhammad Asimaa , Farrukh Aslam Khanb,∗
Noshina Tariq
a
, Ayesha Qamar , Muhammad Asim , Farrukh Aslam Khanb,∗
National University of Computer and Emerging Sciences, Islamabad 44000, Pakistan
a National University of Computer and Emerging Sciences, Islamabad 44000, Pakistan
b Center of Excellence in Information Assurance (CoEIA), King Saud University, Riyadh 11653, Saudi Arabia
b Center of Excellence in Information Assurance (CoEIA), King Saud University, Riyadh 11653, Saudi Arabia

Abstract
Abstract
The Internet of Things (IoT) has penetrated its roots in almost every domain of life. Smart healthcare is one of the major domains
The
that Internet of Things
extensively (IoT)
uses IoT has penetrated
infrastructures anditssolutions.
roots in almost everysmart
IoT-based domain of life. Smart
healthcare healthcare
systems is one of added
have immensely the major domains
value to the
that extensively uses IoT infrastructures and solutions. IoT-based smart healthcare systems have immensely
healthcare domain with the use of wearable and mobile devices. This leads to a substantial use of health data sharing for added value to the
the
healthcare domain with
improved, accurate, and the usediagnosis.
timely of wearable and mobile
However, smartdevices. Thissystems
healthcare leads toarea highly
substantial use of tohealth
vulnerable data
several sharingbreaches
security for the
improved,
and variousaccurate,
malignantand timelysuch
attacks, diagnosis. However,
as privacy smart
leakage, healthcare
tempering, systems
forgery, etc. are highlythe
Recently, vulnerable to several
blockchain security
technology breaches
emerged as a
and various malignant attacks, such as privacy leakage, tempering, forgery, etc. Recently, the blockchain technology
propitious solution against such breaches and challenges. This paper presents an up-to-date survey on different challenges and open emerged as a
propitious solution
issues faced against
in smart such breaches
healthcare due to theand challenges.
traditional This paper
security presents
measures anwith
along up-to-date surveyrequirements
the security on different challenges and open
of such domains. It
issues faced in smart
also amalgamates the healthcare
potentials due to the traditional
of blockchain security
technology as ameasures
promisingalong withmeasure,
security the security requirements
highlights of challenges
potential such domains. It
in the
also amalgamates the potentials of blockchain technology as a promising security
healthcare domain, and provides an analysis of different blockchain-based security solutions. measure, highlights potential challenges in the
healthcare domain, and provides an analysis of different blockchain-based security solutions.
c 2020

© 2020 The
The Authors.
Authors. Published
Published by
by Elsevier
Elsevier B.V.
B.V.
c 2020

This The
is an Authors.
open accessPublished by Elsevier
article under B.V.
the CC BY-NC-ND
BY-NC-ND license
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
This is an open access article under
Peer-review under responsibility
responsibility of the
ofthe CC BY-NC-ND
theConference
ConferenceProgramlicense
Program (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Chairs.
Chair.
Peer-review under responsibility of the Conference Program Chairs.
Keywords: Blockchain; Smart healthcare; Security; Privacy
Keywords: Blockchain; Smart healthcare; Security; Privacy

1. Introduction
1. Introduction
With the emergence of the Internet of Things (IoT) and wearable technology, many opportunities as well as chal-
Withhave
lenges the emergence
escalated inofthe
thehealthcare
Internet ofdomain.
Things Inter-connectivity
(IoT) and wearableoftechnology, many
smart devices opportunities
(e.g., as welland
wearable devices as chal-
vital
lenges
monitoring sensors) constitutes massive health-related data. Thanks to the cloud computing and big data analyticsvital
have escalated in the healthcare domain. Inter-connectivity of smart devices (e.g., wearable devices and for
monitoring sensors)
deriving valuable constitutes
and massive
useful insights outhealth-related
of these datadata. Thanks todecision
for effective the cloud computing
making. and big data
The extracted dataanalytics for
could also
deriving valuable and useful insights out of these data for effective decision making. The extracted data
be used by hospitals and medical institutions so that they could connect with the existing Electronic Health Record could also
be usedfor
(EHR) by improved
hospitals and medical
health institutions
observation, so that
disease they could
diagnosis, and connect with the existing
timely treatment Electronic
[1]. In addition, it Health
may alsoRecord
help
(EHR) for improved health observation, disease diagnosis, and timely treatment [1]. In addition, it
health insurance companies in making in-depth strategic policies for customers. In 2009, U.S. Health Information may also help
health insurance companies in making in-depth strategic policies for customers. In 2009, U.S. Health
Technology for Economic and Clinical Health (HITECH) Act reserved approximately 36.5 billion dollars to invest in Information
Technology for Economic and Clinical Health (HITECH) Act reserved approximately 36.5 billion dollars to invest in

∗ Corresponding author. Tel.: +966-11-4697341 ; fax: +966-11-4695237.

∗ Corresponding
E-mail address:author. Tel.: +966-11-4697341 ; fax: +966-11-4695237.
[email protected]
E-mail address: [email protected]
1877-0509  c 2020 The Authors. Published by Elsevier B.V.
1877-0509
This c 2020

is an open Thearticle
access Authors. Published
under by Elsevier B.V.
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
1877-0509 © 2020
This is an open Thearticle
access Authors. Published
under by Elsevier B.V.
the Conference
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Peer-review under responsibility of the Program Chairs.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Peer-review under responsibility of the Conference Program Chairs.
Peer-review under responsibility of the Conference Program Chairs.
10.1016/j.procs.2020.07.089
616 Noshina Tariq et al. / Procedia Computer Science 175 (2020) 615–620
2 Noshina et al. / Procedia Computer Science 00 (2019) 000–000

health organizations to use EHR systems instead of the traditional methods to manage data [2]. Nowadays, the EHR
market is highly valued, which may be counted in the figure of tens of billions of dollars [1]. However, sharing health
data needs a secure and trusted infrastructure as there exists many risks related to privacy, security, and interoperabil-
ity. Firstly, health data have huge privacy-sensitivity; particularly as more and more data is being stored on the cloud.
Therefore, the challenges of revelation and leakage of confidential data are increasing. Secondly, the centralized ar-
chitectures are widely used in the current systems as well as in the security mechanisms. Hence, it is challenging to
effectively integrate interoperability among healthcare systems, which are distributed in deployments. In addition, it
is also a major challenge that users have less access to the private health data [3]. Keeping in mind the concept of
self-ownership along with the increased mobile platform adoption and portable computing devices, it is inevitable to
develop a newer release of EHR systems that would ensure control of user access and preservation of security in a
much distributive yet effective way.
It is of much significance that such systems should own the ability to share data in an efficient and secure man-
ner [4] [5] [6]. In addition, they must also provide greater access control, privacy, and anonymity to the respective
individuals. If there is no/less security, privacy, and trust handling, the individuals will become reluctant to provide
their important information or they may avoid seeking the treatment [7]. Currently, many health data systems rely
on a single party for the management of confidential health data, which is highly prone to single-point-of-failure.
However, the technology of blockchain could change this reliance due to its distributive nature. It provides the ability
to overcome failure and attacks (as discussed in later sections) in a distributive and immutable way. In addition, it
also provides a record for the ownership of data and its authenticity [1] [8]. It relates to the pseudo-anonymity in
addition to the public key infrastructure (PKI) while retaining the privacy of the users [7]. The use of blockchain tech-
nology in healthcare as well as in its research is detailed in [9]. The work supports the use of blockchain technology
in the healthcare domain, which also includes preservation of privacy for prediction modeling, increasing large scale
interoperability among institutions, invariability of health history records, improvement of health assurance process,
interchange of health data, artificial intelligence supporting healthcare models, management of identity, strategies of
earning revenue, and data record [10].
This survey provides an integrative study covering security requirements along with challenges and open issues in
patients’ information sharing, loopholes in existing solutions, and privacy pledge regarding blockchain add-on in smart
healthcare as compared to monotonic available state-of-the-art surveys. To provide a baseline for other researchers, it
also filters out the booming trends in the said area. It highlights that apart from other security solutions, blockchain
may provide a decentralized and scalable solution to meet the growing needs of the smart healthcare domain. The main
contributions of this paper include a concise analysis of essential security requirements of smart healthcare systems.
We also discuss the benefits of blockchain adoption in security as well as its efficacy in the smart heathcare domain
by scrutinizing different blockchain-based solutions in securing healthcare data against potential security breaches. In
addition, the survey also highlights different challenges of the usage of blockchain in this domain.
The remainder of the paper is organized as follows: Section 2 details the security requirements of smart healthcare
systems. Section 3 presents blockchain and its applications in the healthcare domain. Finally, Section 4 concludes the
paper with possible future directions.

2. Smart healthcare security requirements

The IoT notion in the medical realm includes validation, automatic information compilation, and discerning. IoT-
enabled smart healthcare systems deal mostly with patients’ personal information and findings. This data is highly
prone to malicious attacks if not secured with advanced and formidable security measures [11]. Unfortunately, some of
the smart devices and sensors used in the smart healthcare domain are resource-constrained (having low processing and
storage capabilities). Consequently, supporting security protocols cannot be integrated in them [12] [13]. Furthermore,
the nature of such devices is mobile and may need public network connections, such as hospitals, homes, offices, etc.,
which further add to its vulnerability. With the exponential increase in connected IoT devices, designing dynamic and
stable security mechanisms is a challenging task [14] [15]. For instance, the development record of patients’ health
situation is confidential, and it needs a safeguarding method to avert the information dispersal to an unsanctioned
group. By functioning in this way, no one can observe and manipulate the data or pass a faulty patient health record.
It also prevents a doctor from performing error in handling the patients. If no safety procedure is adopted, the medical
 Noshina Tariq et al. / Procedia Computer Science 175 (2020) 615–620 617
Noshina et al. / Procedia Computer Science 00 (2019) 000–000 3

practitioners may give incorrect medication or furnish wrong nursing to their patients [16]. For example, modifications
to a blood examination report might aggravate a patient’s situation because of transfusing incompatible blood during
the blood transfusion process. The important security requirements in the IoT-enabled healthcare domain are outlined
in Table 1.

Table 1. Smart healthcare security requirements.

Requirement Description
Confidentiality Ensures that health data is preserved and cannot be accessed by unauthorized entities. In IoT domain, a number of connected devices,
applications, and parties are part of healthcare domain making data hampered to improper diagnostics [13].
Integrity Refers to the correctness of health data, either gathered or disseminated to the authorized entities without any fabrication or modifica-
tion [17]. Modified and fabricated data may also lead to improper diagnosis and hazardous consequences.
Availability For timely diagnosis and treatment, healthcare data must be available as and when required without delays [18].
Ownership Ensures that the health information and data captured belongs to a particular entity (the creator) with all rights. This characteristic restricts
unauthorized access and misuse [19].
Privacy Holds that the health data and information is available to authorized users only. For example, patients’ data and information is not provided
to any third party without their permission. Privacy also ensures that the data will be secure in transit or in storage.
Authenticity Refers to the truthfulness of the requesting entity, which means only the authentic party may access or modify the health data [19].
Non-repudiation Ensures neither user nor patient can deny the provided data. It may be handled by digital signatures and encryption [20].
Auditing Ensures the overall credibility of a healthcare application. It refers to maintain log of all the transactions (captured or modified) [21].
Access Control Ensures controlled and legitimate access to the health data and information either public or private [19].
Data Freshness It makes sure that the data is not inconsistent and is up-to-date. To ensure this property timely, data availability must be ensured. Delays
may make unwanted and calamitous effects on diagnosis and patients’ life [22].
Anonymity Refers to the privacy of patients’ identity, concealing from public and unauthorized entities. It makes sure that the data stored in such a
way ensures anonymity of patients’ identification [23].
Secure Data Transit It makes sure that the data in transit is also safe and is not being altered or observed. It ensures that the adversary will not have access to
the data in transit, nor it can inspect or alter it [14].

3. Blockchain

Blockchain technology has been exhaustively researched in the past few years. Satoshi Nakamoto [24] introduced
the concept of blockchain as the supporting mechanism of the digital cryptocurrency called Bitcoin. The fundamental
concept of the blockchain technology gives a basis for cooperation between unknown and untrustworthy things, while
also corroborating the disseminated features of mobile (smart health) devices, lacking the need of a central security
and authentication authority, as in the current cloud computing architectures [25]. This main technology relies in an
immutable “public ledger”, which is a record of data shared among all the participants. This public ledger contains
blocks of data, linked together with the use of a cryptographic hash key. The linking process (also known as con-
sensus) is called Proof of Work (PoW) [8]. Both the ledger and the consensus mechanism are innately impervious
to data manipulation. The block data cannot be altered post-fact, because this invalidates previous block hashes in
the blockchain and breaks the consensus among nodes. The use of the blockchain technology allows Bitcoin’s public
distributed ledgers to make transactions of digital money inexpensively and securely without a third party that would
verify the transaction and avoid the perennial “double spending” issue [25]. A smart contract is executed as a storage
process whenever a transaction is initiated. The key characteristics of blockchain technology includes decentralized
control, data transparency and auditability, distributed information, and security from malicious actors [8] [25].

3.1. Blockchain and smart healthcare

Serious cyber attack concerns have emerged in healthcare services during the past few years. A record number
of cases have been reported in the year 2019, where Health Insurance Portability and Accountability Act (HIPAA)
breaches reached to 418, and a total of 34.9 million US citizens had their protected health information (PHI) com-
promised in that year [26]. The existing infrastructure is not capable of providing security against such data breaches,
which can ultimately question the privacy and security of patients’ health information. The presently implemented
models of smart healthcare records open another window towards a problematic scenario, i.e., the patients’ data being
in the custody of health organizations, leaving patients’ information at stake, and causing inefficient data delivery
towards patients’ healthcare. For example, just because the information about a patient’s health is not sent from one
service provider to the other in time, the patient’s treatment might get delayed. EHR has such limitations practically,
618 Noshina Tariq et al. / Procedia Computer Science 175 (2020) 615–620
4 Noshina et al. / Procedia Computer Science 00 (2019) 000–000

which can be overcome by using blockchain. Recently, blockchain has been adopted by several government, private,
and public-private partnered projects [27]. Blockchain’s potential benefits in the field of healthcare were witnessed
when the US Food and Drug Administration (FDA) and IBM Watson Health focused on a blockchain framework to
protect data related to oncology [28]. Blockchain allows data collection from various sources and saves that data in the
transaction audit log, which ultimately helps in keeping track of accountability and transparency of data at the time of
data exchange. It is believed by FDA and IBM that blockchain has the capability to support data exchange collected
from various sources with the consensus of patients and the terms mutually agreed on [27]. Presently implemented
models have the dependency on passwords, which may contain secret data that has to be exchanged and usually stored
on unreliable and less secure clouds [14]. This caused numerous well-known cyber accidents, the most famous of
which was the one that took place in 2014, when hackers intruded into US Health insurer Anthem’s servers and the
sensitive information of about 80 million people (patients and employees) got stolen [27]. It is also of great impor-
tance that the healthcare data access must be handled with precautions. Similarly, standardized auditing is inevitable
for guaranteeing data integrity. Blockchain reduces the chances of such disastrous breaches and ensures data integrity,
anonymity, and resilient storage. In addition, single-point-of-failure is also mitigated as this model stores data in a
distributive way.

Table 2. Blockchain-based security solutions in smart healthcare systems.

Reference Issues Addressed Blockchain Solution Advantage
[29] Access control, data obfuscation Ethereum-based smart contracts and cryptography Data ownership, integrity, and scalability
with no monetary-based mining incentives
[30] Privacy leakage, single-point-of-failure, Privacy preserving, data encryption, access control, Privacy, accountability, and on-demand rescission
and sybil attack and key management
[31] Privacy, eavesdrop, and intrusion attacks Distributed web platform, access control Pseudonymity, privacy, integrity, accountability
[32] Privacy issues Private blockchain and consortium blockchain Access control, auditing, privacy preservation, se-
cure search, and time-controlled rescission
[33] Real-time patient monitoring security Permissioned and consortium-managed blockchain Confidentiality, availability, immutability, trace-
ability, privacy, and transparency
[34] Data leakage, malicious operation, and Customised search index-based blockchain Fair analysis, reliable search results, confidential-
dishonest user ity, integrity, anti-tampering, and traceability
[35] Data integrity and repudiation issues Blockchain-based notarization Data integrity, non-repudiation, data versioning
[36] Data sharing, scalability, and Quality of Blockchain-based smart and secure Healthcare sys- Scalabilty, data sharing, QoS, efficient, remote
Service (QoS) issues tem (ssHealth) monitoring
[37] Privacy and anonymous information Two-layer consortium blockchain along with a new Privacy protection, tamper-resistance, high fault
sharing issues consensus algorithm (MBFT) tolerance and efficient transaction handling
[38] Single-point-of-failure, man-in-the- RHM solution based on a public blockchain Privacy preserving, identity management, security,
middle attack, denial of service, and data immutability, efficient message delivery times
sniffing attacks

The information that authenticates a subject is a major challenge in identity as well as in access management.
An example could be a username, password, and thumb-print used for verification of a person. On the other hand,
authentication of an identity based on blockchain technology makes use of private keys, which are used to sign every
transaction. Another issue is the missing data auditing trail. It also covers the area of user preferences and a consent of
his/her data usage. Blockchain supports data auditing trail, i.e., a complete log of electronic data creation, changing,
and removing is maintained. Authorization to perform actions by different stakeholders is also a challenge in smart
healthcare systems. A policy assigns the rights of access to data for each stakeholder. However, mostly, the patients
do not have self-ownership of their data. Thanks to the blockchain technology that supports authorization, legitimate
access to data, and self-ownership of patients on their data. Last but not least, efficiency also plays an important role
in challenges faced in the said domain. Inefficiency in administration, logistics, and in delivery of services results in
cost and time overheads and less advantages are achieved [39]. The reasons could be the inefficient exchange of data
and flaws in policy making. In addition, monitoring and logging of every access to EHR must be ensured to forbid
non-monitoring of access to sensitive healthcare information. However, this milestone is somewhat difficult to achieve
for traditional healthcare systems, as most of the health organizations do not follow the mechanism of strict authorized
access. Moreover, the infrastructure of patients’ databases does not contain good security requirements. Blockchain
can be a solution to these issues that may lead to solving a general problem of privacy and authentication. It also
supports data auditing and time-stamping that could help patients to identify modifications in data with respect to time
as well as identity of the person who modified it. In a blockchain scenario, patients can permit third parties to access
 Noshina Tariq et al. / Procedia Computer Science 175 (2020) 615–620 619
Noshina et al. / Procedia Computer Science 00 (2019) 000–000 5

data, however, third parties cannot store it. To conclude, blockchain-based solutions are higher-ranked than existing
traditional systems. Table 2 summarises some blockchain-based security solutions in smart healthcare systems along
with their advantages.
Although blockchain gives an add-on to EHRs, it still faces certain challenges that contribute to limitations of this
field. However, engaging blockchain in this filed is packed up by educational barriers instead of technical ones [27].
Healthcare providers may face certain roadblocks due to access control and ownership factors that could hinder them
to adopt blockchain. In addition, psychological challenges faced by healthcare organizations should be admitted and
tackled to address issues of security, privacy, trust, and integrity. Traditionally, most of the healthcare providers are
the only owners of the patients’ information within their organizations [40], which needs to be changed. However, it
is a difficult task to change the norm. On the other hand, old people or patients with mental health problems are not
able to manage their medical records, and eventually cannot use blockchain for access control and self-ownership, for
example. Moreover, there exist some privacy laws for IoT-enabled healthcare data, e.g., HIPAA of 1996 that should
be applied strictly in this domain [41]. If proper encryption is applied to patients’ data along with an appropriate
control policy, the two factors can contribute a lot in trust management in this domain. Furthermore, scalability issues
also exist due to increasing size of generated data with time. By adopting blockchain, every participating node in the
network holds the complete medical record of a patient, which could lead to the problems of bandwidth usage and
data storage [42].

4. Conclusion

IoT-enabled smart healthcare systems are prone to critical security threats and challenges. To mitigate these threats
and challenges, it is needful to understand the security requirements of such systems. The traditional security mecha-
nisms do not cater for all the security requirements of the IoT-enabled smart healthcare system due to less scalability,
higher cost, single-point-of-failure, and resource-constrained nature of the IoT devices. Recently, blockchain tran-
spired a new era of security and privacy in the healthcare domain. In this study, we addressed the security requirements
of IoT-enabled smart healthcare systems along with the application of blockchain-based security solutions. We dis-
cussed how blockchain-based solutions can overcome different security issues in an efficient, distributive, and scalable
way. In addition, we also highlighted the challenges of blockchain deployment is this infrastructure. In future, we aim
to expand our study to an in-depth analysis of the authentication mechanisms to design an efficient blockchain-based
identity authentication mechanism.

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