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A Survey on Security and Privacy Issues in Modern Healthcare Systems: Attacks and Defenses
AKM Iqridar Newaz, Amit Kumar Sikder, Mohammad Ashiqur Rahman, A. Selcuk Uluagac
TL;DR
Modern healthcare systems improve automated monitoring and treatment but face serious security and privacy risks from software, hardware, and connectivity weaknesses. This survey organizes healthcare threats and defenses across the system, finding that reported attacks most often target confidentiality or integrity-related properties while existing solutions face hardware and standards limitations.
Problem
Increasingly complex, programmable, and connected healthcare devices lack satisfactory security measures, exposing treatment and patient data to attacks such as malware and ransomware.
Method
The paper surveys healthcare-system components, security and privacy goals, attack categories and impacts, existing defenses, solution limitations, and future research directions.
Results
Reported passive attacks comprise 55.6% of healthcare attacks, while integrity is the most affected security property at 44.0%; non-invasive devices are the most targeted.
Takeaways & Limitations
Securing healthcare requires addressing common vulnerabilities across devices, communications, and healthcare providers while considering the limitations of current mitigation approaches.
Takeaways & Limitations
Healthcare-device security solutions are constrained by the absence of standardized IC manufacturing practices and a baseline for normal device power consumption.
Abstract
from arXiv · showhide
The recent advancements in computing systems and wireless communications have made healthcare systems more efficient than before. Modern healthcare devices can monitor and manage different health conditions of the patients automatically without any manual intervention from medical professionals. Additionally, the use of implantable medical devices (IMDs), body area networks (BANs), and Internet of Things (IoT) technologies in healthcare systems improve the overall patient monitoring and treatment process. However, these systems are complex in software and hardware, and optimizing between security, privacy, and treatment is crucial for healthcare systems as any security or privacy violation can lead to severe effects on patients' treatments and overall health conditions. Indeed, the healthcare domain is increasingly facing security challenges and threats due to numerous design flaws and the lack of proper security measures in healthcare devices and applications. In this paper, we explore various security and privacy threats to healthcare systems and discuss the consequences of these threats. We present a detailed survey of different potential attacks and discuss their impacts. Furthermore, we review the existing security measures proposed for healthcare systems and discuss their limitations. Finally, we conclude the paper with future research directions toward securing healthcare systems against common vulnerabilities.
1 INTRODUCTION
Healthcare technologies increasingly automate monitoring and treatment, but expanding connectivity and system complexity expose devices and applications to serious security and privacy threats. This survey maps those threats, their impacts, existing defenses, limitations, and future directions.
- Technological advances: Modern healthcare applications remotely collect physiological information and can provide automatic treatment through consumer and medical devices.Examples include smartwatches monitoring heart rate and ECG, smartphones tracking activity and sleep apnea, and implanted devices.
- Technological advances: Lightweight communication protocols support small sense-actuate devices that remotely and instantly transmit physiological values for treatment.The surveyed examples include blood pressure and heart-rate measurements.
- Security challenges: Software and hardware defects, open-source platforms, and continuous connectivity create opportunities for malicious attacks against healthcare systems.Reported scenarios include remotely disabling or reprogramming implantable cardiac defibrillator therapies.
- Survey scope: The survey provides a detailed attack taxonomy, evaluates impacts with common vulnerability scoring metrics, reviews mitigations and limitations, and identifies future research directions.It also describes typical healthcare-system components, security and privacy goals, and adversarial models.
- Survey scope: The paper is organized around healthcare-system architecture, security and privacy goals, attack classification and impacts, defenses, limitations, requirements, challenges, and conclusions.The attack impacts are summarized using common vulnerability metrics.
2 RELATED WORK
Earlier healthcare-security surveys commonly address specific devices, attacks, or solution areas. This survey instead analyzes security and privacy across the healthcare system end to end while also comparing attack impacts, solution limitations, and research directions.
- Research gap: The survey addresses a gap because prior works generally concentrate on specific attacks or solutions for specific devices rather than overall healthcare security and privacy.Its stated aim is to synthesize broader system-level issues.
- Existing surveys: Existing surveys often focus on implantable medical devices, including their telemetry interfaces, software, security frameworks, and standards.Other reviewed studies address remote monitoring, wearable biosensors, IoT information flows, and healthcare cyber threats.
- Existing surveys: Prior work includes focused reviews of wearable biosensors, IoT healthcare information flows, emerging healthcare applications, and cybersecurity challenges.These studies examine selected technologies or threat areas rather than the full system scope.
- Differences from prior work: Unlike most prior surveys, this work covers end-to-end components from medical devices and sensors through networks, communication, and healthcare providers.It also presents a formal architecture to identify major components and security and privacy needs.
- Differences from prior work: The survey categorizes attacks, measures their impacts with CVSS, identifies limitations of current solutions, and proposes categorical future research directions.These elements are presented as distinctions from existing surveys.
3 BACKGROUND AND DEFINITIONS
A healthcare system integrates medical devices, sensors, networking, and higher-level computing resources to collect patient data and support treatment. Its components communicate through short- and long-range wireless technologies.
- Healthcare-system architecture: Healthcare systems typically include medical devices equipped with sensors that collect patient vitals and make autonomous decisions for enhanced treatment.The overall architecture is presented as comprising five major components.
- Device and sensor categories: Medical devices include non-invasive, invasive, and active therapeutic types, while sensors may be physiological, biological, or environmental.Examples include infusion-related devices, glucose and alcohol sensors, accelerometers, and gyroscopes.
- Networking: Networking transfers physiological signals from sensors or devices to a central node and aggregated measurements between that node, servers, and healthcare professionals.Short-range and long-range communications serve these two transmission purposes.
- Networking: Bluetooth and Zigbee are commonly used BAN wireless standards; Bluetooth provides low-power, low-cost short-range connectivity in the unlicensed 2.4 GHz spectrum.Bluetooth uses frequency hopping over 79 channels.
- Networking: MICS supports ultralow-power, low-rate communication for diagnostic or therapeutic medical-device functions in the 402-405 MHz band.Its channels are 300 kHz wide.
- Networking: Long-range healthcare connectivity can use WLAN, GSM, GPRS, UMTS, WiMAX, and LoRa, while future 5G advances are expected to support seamless real-time remote-device access.The passage describes these technologies as offering broad coverage and ubiquitous network access.
4 SECURITY AND PRIVACY NEEDS IN EXISTING HEALTHCARE SYSTEMS
Healthcare systems require authentication, confidentiality, integrity, availability, and anonymity across interconnected tiers. The paper frames these needs around patient-related data moving among medical devices, personal devices, health servers, and professionals.
- System tiers: A personal healthcare system has three tiers: medical devices, personal devices such as smartphones and computers, and health servers with healthcare professionals.The first tier includes invasive and non-invasive devices.
- Security goals: Authentication is required across all tiers, while confidentiality and integrity must also protect data and system information at Tiers 2 and 3.Access should be restricted to authorized professionals or hospital authorities, and unauthorized modification should be prevented.
- Privacy goals: Privacy goals include device, data, and communication anonymity, plus unlinkability of transactions between senders and receivers.Patients and doctors should use pseudonyms or temporary identifiers instead of real identities.
- Authentication requirements: Authentication design must account for healthcare environments, single- versus multi-factor access, continuous authentication, and emergency scenarios.One-factor authentication may suffice for basic readings, whereas healthcare-server access may require multiple factors.
- Threat examples: Weak password schemes, eavesdropping, absent integrity checks, modifiable logs, and device availability flaws illustrate risks against the stated goals.Examples include clear-text insulin-pump communications, firmware-update weaknesses, altered Fitbit logs, and ICD sleep-mode flaws enabling denial of service.
5 ATTACK MODEL AND EXISTING SECURITY AND PRIVACY ATTACKS ON HEALTHCARE DEVICES AND APPLICATIONS
The survey organizes healthcare attacks by goals, capabilities, attack surfaces, and effects, covering hardware, software, and communication-channel threats. Reported examples show that insufficient authentication, integrity checks, encryption, and update validation can expose devices, data, and treatment processes.
- Attack Model: Attackers can intercept, modify, interrupt, or generate radio messages and impersonate programmer devices to request information or reprogram medical devices.These capabilities can target communication and device-control functions in implantable medical-device systems.
- Hardware Attacks: Hardware attacks can insert hardware trojans during chip manufacturing, corrupting medical-device data and logic.A BCG-scale attack modified an XOR-gate input-bus function and could evade detection when distributed among thousands of gates.
- Software Attacks: Software attacks exploit weak verification of embedded software and updates, including malware, ransomware, outdated operating systems, counterfeit firmware, and EEG attacks.The survey links these threats to missing or inadequate mechanisms for verifying software functionality and authenticity.
- Software Attacks: Ransomware can block patient data and medical systems, disrupting care and equipment access; one hospital network remained unavailable for ten days until a $17,000 ransom was paid.The survey also reports that ransomware affected about 50 U.K. hospitals in May 2017 and that restoring limited systems took an average of 12 days.
- Software Attacks: EEG attacks can use malicious BCI software to extract private information, including bank-card details, PINs, memories, prejudices, and possible neurological disorders.The attack can increase information leakage by presenting specially designed videos and images to users.
- Device and Communication Attacks: Healthcare devices also face authentication, firmware, and communication weaknesses that enable unauthorized access, firmware exploitation, clear-text interception, and secret-key recovery.Examples include approximately 85% of networked devices allowing unauthorized USB read/write access, remotely exploitable Alaris gateways, DPA against AES-protected heart-rate data, and eavesdropping on insulin-pump communications.
6 CURRENT SECURITY AND PRIVACY SOLUTIONS
The survey organizes healthcare security and privacy defenses across hardware, software, communication, data-protection, and access-control mechanisms, while emphasizing trade-offs and implementation limitations.
- Security measures address healthcare-device trade-offs and counter specific attack types, with some solutions widely used or considered standards.The survey frames these defenses around practical security requirements for healthcare systems.
- Hardware-centric Solutions: Physical separation isolates security applications from a device’s main architecture, using mechanisms such as TPMs and Plug-n-Trust.Plug-n-Trust encrypts transmitted medical data but does not hide data processing and may remain vulnerable to denial-of-service attacks.
- Software-centric Solutions: Static analysis examines source code and execution paths to detect software flaws such as buffer overruns, uninitialized variables, and null-pointer dereferences.Its applicability is constrained because healthcare application source code is not openly available.
- Software-centric Solutions: Formal verification examines a system’s entire state space to establish security properties for all possible inputs.A described approach transforms medical-device software, translates functional specifications into verifiable properties, and uses model checking to detect anomalies.
- Trust Management Framework for Communication Channel Attacks: Close-range communication limits radio-attack opportunities by requiring attackers to approach the healthcare device, increasing the chance of detection.Body-coupled communication uses the human body as a signal-propagation medium through transmission-line or capacitive approaches.
- Data Protection Mechanisms for Communication and System-level Attacks: Data-protection approaches include encryption, symmetric key management, compression, machine learning, blockchain, and access-control mechanisms.Encryption protects wireless transmission but creates energy and implementation costs for resource-constrained devices; Encompression reportedly reduces those costs by 78% with a 6–10x compression ratio.
7 DISCUSSION AND FUTURE RESEARCH DIRECTIONS
Healthcare security measures must balance protection with patient safety and device constraints. Future directions emphasize secure data handling, common communication standards, fault tolerance, and coordinated industry practices.
- Security proposals must account for healthcare devices’ energy, storage, and computing constraints while pursuing security and privacy goals.
- Securing healthcare data: Cryptographic protections can secure wireless communication and stored healthcare data, but existing devices such as IMDs may require replacement or redesign.Emergency communication with unauthorized personnel may also be interrupted by implemented cryptographic mechanisms.
- Communication and development practices: Standards and common communication protocols are needed to support broader protection against threats affecting healthcare communication media and devices.
- Fault-tolerant design: Fault-tolerant designs can sustain operation despite component faults, although redundancy introduces performance or resource overhead.Trip modular redundancy uses three module copies and majority voting, but costs three times more than the original circuit.
8 CONCLUSION
The survey examines how increasing complexity, programmability, and wireless connectivity make healthcare devices and applications more vulnerable to security and privacy issues. It documents threats and defenses to support more proactive security research and awareness.
- The survey reviews existing security and privacy research in healthcare systems.
- Increasing functional complexity, software programmability, and wireless connectivity are identified as trends increasing vulnerability.
- The paper analyzes healthcare threats and how current solutions address them.
- The authors call for aggressive and proactive attention because healthcare devices perform critical tasks.
- The survey aims to document attacks and defenses and facilitate a more aware healthcare security and privacy ecosystem.