IRJET- Comprehensive Study of E-Health Security in Cloud Computing

International Research Journal of Engineering and Technology (IRJET) e-ISSN: 2395-0056
Volume: 06 Issue: 11 | Nov 2019 www.irjet.net p-ISSN: 2395-0072
© 2019, IRJET | Impact Factor value: 7.34 | ISO 9001:2008 Certified Journal | Page 1216
Comprehensive Study of E-Health Security in Cloud Computing
Ravi Bhagyoday1, Chintan Kamani2, Dhrumil Bhojani3, Vivek Parmar4
1,2,3,4B.Tech Cloud Technology and Information Security, Ajeenkya DY Patil University, Maharashtra, India
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Abstract - Cloud movement have driven it to be adjusted in
numerous viewpoints and application that serve human
requests. One of the ongoingpatternsindistributedcomputing
is the e-health administrations, the same number of medicinal
services organizations have started to exchange toward the
digitized form of health records. E-health give simple sharing
of individual social insurance records between numerous
associations and offered real time monitoring forthepatient's
state by means of putting away thisinformationoverthecloud
servers. Notwithstanding, having the information in such a
disseminated setting rises the requirement for having a
verified information imparting to fine-grained get to control,
as the records are put away in a third party service provider.
Additionally, a wide range of parts of security ought to be
taken into check with e-health, for example, the informationis
basic and ought to be just accessible to its proprietors. Various
works have been done to secure the medical data in cloud
environment. This work centersaroundthesecurity difficulties
and answers for on Cloud-based E-health frameworks. In
particular, a best in class is exhibited to safeguard and secure
E-health information, which comprises of two levels:
cryptographic and non-cryptographic methodology. Likewise,
portions of the fundamental issues and open issuesthatcan be
utilized in future investigations are called attention to in this
work.
Key Words: e-health, electronic health record, EHR
cryptographic, non-cryptographic, security, privacy, cloud.
1. INTRODUCTION
The application of information technology in healthcare
(healthcare IT) has become important to an increasing
extent in many countries from the beginning of the 21st
Century. There is a moderate and organized transformation
in healthcare systemsfrompaper basedrecordsto electronic
records, which is the mark of something new in the
healthcare industry. Such growths provide high efficiency
and flexibility on national and international standardization
for interoperability and data exchange to the healthcare
industry by providing a platform that shareshealthcaredata
among different stakeholders. This advancement in
technology has various applications such as Electronic
Medical Records (EMR), Electronic Health Records (EHR),
Personal Health Records (PHR), and Electronic Health Data
(EHD). EHR and EMR are health records of patients handled
by healthcare professionals, whereas PHR carry personal
data, which is handled and monitored by either patient or
their relatives on a regular basis. EHD as electronic health
records or computerized patient records is a systematized
collection of smart health records of patients [2] . These
records are comprised of a wide variety of data, such as
medical histories, demographics, medication, immunization
status, laboratory test reports and other sensitive patient
information. EHD systems have remarkable benefits over
conventional paper based records. Unlike paper-based
records, EHR incurs less manpower, time and physical
storage [3]. Cloud computing is a new digital technology
paradigm and is commonly used in the healthcare sector[4].
It not only offers convenient processing of medical
information, but also enables simple sharing or transfer
between different stakeholders of medical information. The
widespread proliferation of health information in the age of
big data involves the emerging function of cloud networks
not only to host infinite amounts of data, but alsotopromote
their Internet access. [5]. In the healthcare sector, although
the EHRs face various challenges in terms of privacy and
unauthorized access, information privacy and security are
the most prominent of these challenges[6]. Risksrangefrom
ransomware attacks, which jeopardize the security and
privacy of medical data, to Distributed Denial-of-Service
(DDoS) attacks, which are capable of deprivingthe networks
of efficient patient care. Cyber-attacks, such as those
triggered by Ransomware, have more consequences than
financial loss or invasion of privacy [7]. It is the duty of
health care providers to protect the privacy of patient data
[8], according to the Health Insurance Portability and
Accountability Act (HIPAA). Several approaches are already
being used in the cloud environment to protect the security
and privacy of smart health systems.
1.1 Motivation
Current privacy mechanism is not sufficienttoensureproper
security in the e-health cloud computing methods. The
biggest risk faced byhealthrecordshostedincloudisinternal
attacks from people who have access to the credentials
within an organization, which is a lot more worse and
dangerous than the external attacks. This research targets to
provide a full overview of the strengths and weaknesses of
current security mechanisms in e-health environments that
make EHR vulnerable to attacks in the cloud industry. EHR
contains different confidential and important information
varying from patient personal data to financial information,
which in case of leakage not only opens sensitive patient
information but also causes financial loss.
The current propelled encryption methods, for example,
Attribute Based Encryption (ABE) is wasteful to determine
this issue because of its costly calculation [2]. The greater
part of the current answers for Key Policy Attribute Based
Encryption (KP-ABE) and Cipher text Policy AttributeBased
Encryption (CP-ABE) expect that a solitary key
administration focus picks an ace key arbitrarily and

produces unscrambling keys forclientsbasedonacekey. For
the situation where the key supervisor is an aggressor,these
arrangements cannot keep from within assaults. Theinsider
dangers in medicinal services incorporate the burglary of
PHI, for example, Social Security Numbers or individual data
for wholesale fraud and extortion, robbery of Intellectual
Property and damage. Other non-noxious dangers
incorporate the unintentional misfortune/exposure of
touchy data, for example, revealing delicate tolerant data to
other people, sharing login qualifications, recording login
accreditations, or reacting to phishing messages. For
instance, the biggest human services information break in
history is the robbery of 80 million social insurance records
from Anthem Inc. [9]; American Health Insurance Company
is accepted to have been made conceivable because of taken
accreditations. Information encryption, secure stockpiling,
verification, get to control, key administration, effective
client denial and so forth are yet to be tended to and settled.
This paper examinations existing protection safeguarding
approaches, their qualities, downsides, investigate issues
and concocts another worldview bolstered by block chain
innovation that can balance certain weaknesses yet in
addition guarantee a structure for giving proficient
protection saving and security in e-health data.
1.2 Methods
This section starts with the study selection to guarantee the
precision of search and recovery process. Thestudylimits to
publications from various electronic databases related to
health care that attempts to gather relevant experimental
confirmations in a specific field to evaluate the methods
fundamentally and to acquire ends to abridge the
exploration study. This section additionally plays
out security and protection safeguarding investigations of
EHR as a piece of qualitative data analysis that makes it
simple to compare, break and analyze the core of the work.
Table -1: Literature review
Publisher Source Keywords
IEEE
IEEE Journal ofBiomedical
and Health Informatics EHR
IEEE Access e-Health
IEEE International Cloud
Computing Conference
e-Health privacy
and security
IEEE Transactions on
Cloud Computing
Cyber-security
attacks
High Performance
Computing and
Communications
EHR Cryptographic
Approaches
IEEE Transactions on
Information Technologyin
Biomedicine
EHR Non-
Cryptographic
Approaches
IEEE open and big data
conference
Security and
Privacy of EHR in
cloud
IEEE Transaction on
Information Forensicsand
Security
ACM
ACM workshop on Cloud
computing security
ACM International Health
Informatics Symposium
Google
Scholar Journal of Cyber Security
Scopus
International Journal of
Medical Informatics
Journal of Medical systems
Journal of Cloud
Computing
Future Generation
Computer Systems
International Journal of
Security and Networks
Security and
Communication Networks
1.2.1 Literature Review – Study Selection
This study performs a systematized audit of security and
privacy preserving approaches of EHRs in the cloud from
various databases, including IEEE, Google researcher,
PubMed, ACM, Springer and Scopus. The definite summary
and the keywords utilized for searching is shown in Table 1.
This work additionally includes a broad survey of
noteworthy audit papers distributed between 2000 and
2019.
In this research, we havecollected relevantpaperspublished
between 2000 and 2019, and found almost 87 research
papers and articles. Then we reduced those papers based on
quality, title, authors name, relevant abstract and keyword
significance. After this filtration, we were left with 59
relevant papers and articles.
1.2.1 Categorizing Security and Privacy Preserving
Studies
Initially, this review researches the security and privacy
prerequisite of E-health data in cloud arena. On the other
hand, after recapping a brief structure of e-Health system, a
prevailing and updated review of the E-health clouds is
presented using a floristics over privacy preserving
approaches. The survey then discusses the merits and faults
of the updated mechanisms and finally highlights some
future research directionsandopenresearchissues.Therest
of this study is recognized as follows.

In section 2, we discuss the security and privacy
requirements of e-health data in the cloud. Section 3 E-
health Overview, Section 4 reviews an enhanced analysis of
security and privacy preserving mechanisms employed in
the E-health cloud environment. Section 5 describes
research issues and future paths, and Section 6 as
conclusion.
2. Security and PrivacyRequirementsofe-HealthData in
Cloud
In the current Enormous information age, data proliferation
demands re-appropriating of healthcare information to the
cloud servers. Notwithstanding the enormous help given by
the cloud, it additionally involves the potential threats to
security and protection of healthcare data [1]. A portion of
the potential attack incorporate data divulgence, Denial of
Service attack (DoS),cloudmalwareinjectionattack,man-in-
the middle crypto-graphic attack [10],spoofing [11],
collusions attack [12].The cloud service provider and
numerous administration associations have proposed an
assortment of securitymeasuresandguidelinesandimprove
the certainty of patients and organizations. The principal
such administrative measure setforwardbytheUSCongress
in 1996 for the US healthcare industry was the (HIPAA) [8].
There are mostly three classes of cloud servers: trusted
servers, semi-trusted, and untrusted servers. A trusted
server is one that can be totally trusted with no data
exposure and dangers to the healthcare data stored can be
due to internal adversaries [13]. Semi trusted servers are
straight forward however inquisitive servers that get
healthcare data by plotting with malicious clients [14] while
untrusted servers are not trustworthy with no privacy
mechanisms components and are defenseless against
assaults from both interior and outer adversaries [15] as
appeared in Fig 1.
The vital security and privacy requisites in e-health models
are: 1) Data integrity-ensures that the health information
has not been modified by any unauthorized entity. 2) Data
confidentiality guarantees that the delicate health
information is prevented from arriving at unauthorized
clients. Data encryption is the most generous way to deal
with guarantee data confidentiality. 3)Authenticity-ensures
that only the authorized and authentic authorityshouldhave
access to the sensitive health data 4) Accountability- an
obligation to be responsible and to justify the actions and
decisions of individuals or organizations. 5) Audit is a
prerequisite, which guaranteesthatthehealthinformationis
checked and secured by monitoring the action log, and
guarantees affirmation to the clients associated with data
protection and security. 6) Non-repudiation- refers to the
non-denial of authenticity of sender and receiver. For
example, the patients or the specialists cannot revoke after
misappropriation of health information 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.
3. Overview of e-Health System in the Cloud
E-health model is an ongoing medicinal services
advancement using electronic procedures and
correspondence. In an e-health model, EHR or EMR is a
systematized accumulation of electronic health data of
patients [2]. These records includeall thehealthinformation
data including demographics, medical histories, lab reports,
radiology pictures, billing data and any extra delicatepatient
data. The cloud offers incredible support to both healthcare
services providers and patients the same in terms of cost
effective storage, processing and updating of information
with enhanced efficiency and quality. Since this information
is put away in different servers, it very well may be
effectively available to clients from different areas on
request. E-health model guarantee fast, resolute and on-
request access to medicinal records, upgraded social
insurance quality, anyway they similarly uncover
understanding security,by meansofill-advisedapproval and
abuse of EHR information. In this manner, security and
protection are viewedasbasicprerequisiteswhensharing or
getting to persistent information between a few partners. A
review of e-health model is delineated in Fig 1.
Fig - 1: Architecture of electronic health data in cloud
E-health cloud model types can be open, private, hybrid and
community as per the information put away. Since EHR
information is confidential, consists of patient data that are
housed in third-party servers, access control mechanisms
are required. Access control is a security hindrance, which
preserves data privacy byconfiningtheoperationandaccess
of healthcare documents in the healthcare system. The
access control procedures in the healthcare systems are
Role-Based Access Control (RBAC), Attribute-Based Access
Control (ABAC) and Identity-Based Access Control (IBAC)
methods. Role-based models [16] accommodate the task of
assigning roles to the clients for data access. ABAC [17],
which utilizes cryptographic and non-cryptographic
strategies, though IBAC utilizes identity based encryption
mechanism that uses client identity for data encryption.
Information sharing is a particular component of e-health
systems. It very well may be shared among different
stakeholders, for example, healthcare providers, emergency
clinics, medicinal services associations, and so on. Search is
another considerable capacity of an e-Health model. Proxy

encryption and public key encryption are generally utilized
encryption procedures for data search.
3.1 CLOUD COMPUTING SECURITY: STATE OF THE ART
AND RESEARCH CHALLENGES IN E-HEALTH
Cloud computing has seen a colossal development that has
changed the scene of figuring with its storage, flexible
resources and decreased costs to such an extent that, it
prompted numerous associations to move theirinformation
in the cloud. Despite the fact that cloud administrations give
enormous benefits, regardless it experiences a few security
dangers. For example, clients do notknowaboutthemassive
amount of data stored put away with the cloud service
provider [18]. Because of absence of lucidity, it is hard to
know about where, how and when the data is prepared and
subsequently makes it hard to confide in the service
provider, who thus can likewise be an explanation behind
huge data loss. There have been a few plans and
improvements in the area of cloud security.
Some of the advanced privacy-preserving mechanisms that
preserves cloud security can be embraced to e-health, while
some are not because of security concerns. Cloudcomputing
does cloud supplier, whichislesspatient-drivenandisprone
to insider attack, which makes it more vulnerable; own a
centralized mainframe-computing paradigm. This is one of
the significant drawbacks of cloud computing. Despite the
fact that cloud strategies stick to severe safety efforts,it does
not offer a reliable answer for adopted into e-health,
assessed its security issues. Zhu et al. [19] proposes an
efﬁcient privacy preserving biometric identiﬁcationscheme
in which a tremendous volume of biometric information, for
example, fingerprints, irises, voice patterns, facial examples
are encrypted and redistributed to the cloud to evade costly
storage and computation costs. The scheme is safe against
intrigue attacks and gives the greatest degree of data
privacy. This methodology can be applied to e-health cloud
for proficient data storage in whichthehealthrecordscan be
encrypted and put away in the cloud that accomplishes a
specific degree of data protection. Nonetheless,asthehealth
records are very sensitive and the data exposed to the
database owner, this scheme is less satisfactory as far as
security. Likewise, this scheme cannot be considered for
EHRs, as it shows no restraint driven and computationally
infeasible for genuine issues. This work [20] proposes a
powerful and variable half and half multi authority CP-ABE
get to control plot by consolidating (t, n) edge mystery
sharing and multi-authorityCP-ABEconspireforopenpublic
storage with which both security and execution are
improved by overcoming the single point bottleneck issue.
Xu et al. [21] proposes a strong and productive access
control scheme that resolves the single-point execution
bottleneck in a large portion of the current CP-ABE utilizing
an examining instrument. Despite the fact that these
schemes [20], [21] are advanced get to control schemes that
has high security measures, they can't be receivedassuredly
to e-health as these schemes can't ensure protection from
insider attacks since it is constrained by Central Authority
and different Attribute Authorities. A special encryption
procedure named Deniable ABE conspire dependent on
Waters cipher text policy-attribute based encryption (CP-
ABE) scheme was recommended that permits cloud storage
suppliers to create cast client secrets from storedcipher text
from outside coercers [22]. This scheme consolidates the
pros and cons of both ABE and symmetric key encryption a
multi-privileged access control for PHRs by combining the
encryption of data from multi-patients that falls under the
similar access approach [23]. Zhang et al. [24] proposes a
productiveprotectiondiseaseprediction expectationscheme
by utilizing Single layer Perceptron learning algorithm. This
model encrypts the side effect data presented by the patient
and the cloud utilizes the encrypted forecast models
prepared by it to analyze the patient illness without
uncovering the patient privacy.Thesemechanisms[23],[24]
imparts a high level of data privacy, yet at the same time
unrealistic for health records because of its computational
complexity and scalability issues. Another work introduced
an unknown CP-ABE with hidden access arrangement and
provides authentic access to control with consistent key
length [25]. Wei et al. [26] proposed a revocable storage
Identity Based Encryption (IBE) that gives forward and
backward security of cipher text. The greater part of the
current cloud storage frameworks with secure provenance
lacks poor access control, cause extreme performance
overhead and do not support dynamic user management.
This work solves problems bydisplayinganattributedbased
cloud storage framework with secure provenance [27].
Despite the fact that ABE plans are the most effective among
encryption systems and give fine-grained, well-framed
access to health records, it is still impractical for proper
execution on EHRs because of its costly computation [25],
[27], key administration complexity and challenge in
managing access control policies [22] when attributesinthe
access structure develops.
Regardless of the appealing features that cloud offers, the
progress of healthcare field towards cloud condition builds
the worries about privacy, security, access control and
consistency because of the inherent security provokes
identified with cloud technology. Patients losetheirphysical
control by storing health information in the cloud servers,
which can be viewed as a risk to patient privacy. Data
security and data integrity have additionally been a difficult
issue while storing and accessing data in the cloud field[28].
Another drawback is that cloud service provider have an
imperative job in transaction analysis, access control, data
protection, and services integration. With the development
in technology, the riseofcyberthreatshasheightened, which
prevents the privacy and security of EHRs [29]. In this
manner, it is imperative to ensure integrity, confidentiality,
reliability just as authenticity of e-health data in a private,
either open or hybrid cloud environment. Thus, this work
presents the idea of an authorization patient-centric Block
chain for EHRs that takes out a large portion of the current
bottlenecks in the cloud.

4. Classification of Privacy Preserving Mechanisms in e-
Health Records
In this paper, various strategies dependentoncryptographic
and non-cryptographic methodologies are utilized
dependent on their utilization of healthcare system in the
cloud field. Likewise, a few methods are analyzed that
preserve data security, data protection and data secrecy in
the cloud. Besides, some Searchable Encryption (SE)
methods are displayedtoquerytheencryptedinformationin
the cloud. As the information is encoded and put away in
outside cloud servers, ordinary looking plans cannot be
applied. Searching encrypted data is difficult, Searchable
Symmetric Encryption (SSE) has been proposed that enable
keyword searches across encrypted cloud data. Different
from the recent surveys, our research study systematically
covers all aspects and methods of privacy and security of
EHR in cloud.
Numerous approaches have been proposed to preserve the
privacy of the patient health data. However, there is no clear
classification of the privacy preserving approaches.
Therefore, we classify the privacy preserving approaches
used in the e-Health clouds into: (a) cryptographic and (b)
non-cryptographic approaches at top level. The
cryptographic ways to deal with moderate the protection
dangers use certain encryption plans and cryptographic
primitives. The cryptographic plans utilize encryption
methods, to be specific: symmetric key encryption,open key
encryption and a few cryptographic natives, while non-
cryptographic methodologies incorporate access control
systems, for example, RBAC, ABAC, and IBAC and so on.
Fig - 2: Classification of Privacy Preserving Mechanisms in
e-Health Records
4.1 Cryptographic Approaches
Cryptography is a technique for shrouded composing, i.e.
ensuring data and interchanges using conventions with the
end goal that those for whom the data is planned can pursue
and investigate it. Countlessapproacheshavebeenproposed
to defend the protection of the patient’s healthcare
information. Nonetheless, the Cryptographic methodologies
can be characterized into two sorts, symmetric-key
cryptography and Asymmetric-keycryptography(seeFig. 5)
in which the earlier uses a similar key for the encryption and
decoding while the latter utilizes different keys. The
methodologies ordinarily utilized in the e-Health cloud-
based models to secure information, use encryption plans,
for example, Public Key Encryption (PKE) and Symmetric
Key Encryption (SKE). In this area, we quickly characterize
and present the methodologies dependent on the PKE, SKE,
and a few cryptographic natives that are utilized to
safeguard the protection of the e-Health cloud. In PKE, two
diverse arrangement of keys are utilized i.e. open key and a
private key pair for information encryption and decoding
though SKE based methodologies use a solitary shared
mystery key for the equivalent.
Fig - 3: Basic types of cryptography
4.1 SKE Based Approaches
The SKE utilizes the same-shared key for encryption as well
as decryption and it isprofoundlypowerful inEHRstructure.
Yet, it presents unavoidable extra complexity since it
requires additional access control mechanisms for the
effective sharing of EHR. The normally used SKE based
algorithms are Data Encryption Standard (DES), Advanced
Encryption Standard (AES), stream ciphers such as A5/1,
RC4, and Blow Fish and show on.
A secure EMR sharing has been proposed by Li et al. [30] to
move forward the unsinkability between patient and EMR.
EMRs are encrypted using symmetric keyencryptionusinga
one-time key and records arestorednamelessly.Doctors use
digital signatures using a private key to handle electronic
medical records. This approach requires an EMRnumberi.e.
the PID, SID, the identity seed that is stored within the
patients' medical card and the random value R, which was
made by the doctor to get to the EMR of the patient. For
encrypting one EMR, every key is used in this method,which
increases confidentiality of each electronic medical record.
Identity seed SID is based on smart data card and medical
records therefore it cannot be read without permission.
An EHR sharing and integration system has been proposed
by Chen et al. [31] to secure the EHRs in normal and
emergency circumstancesin hybridhealthcareclouds.Inthis
approach, each medical recordusedanindividual symmetric

key using a symmetric encryption scheme in private and
public cloud environments. Here, the specialist makes the
patients' health record and it is scrambled by the symmetric
key alongside a permit License. This license gives an
emergency key to get the encrypted data by thecloudincase
the server is not given with access. The patient needs to give
the smart card to the doctor for the decryption of their EHR.
This plan encrypts all the medical records and decryption is
conceivable as it were by patients' private keys in which the
private key is part into two parts, though the hospital server
will escrow one among the keys and the otherkeywill be put
away on the patient's smart card. The drawback of this
approach is that the permit licensetoooughtto be encrypted
with the hospital's public key as searching encrypted
informationischallenging,SearchableSymmetric Encryption
(SSE) [32] has been proposed that enables keyword search
over encrypted cloud data. This approach presents an
exceedingly efficient and Secure Energetic Searchable
Symmetric Encryption (SEDSSE) in medical cloud data by
leveraging the secure k-nearest neighbor (kNN) and ABE
methods. This approach utilized an AES symmetric
encryption algorithm to encrypt the records and shares the
symmetric secret key asitwerewithauthorizeddoctorswho
fulfill the get to policy related to ABE.
4.2 PKE Based Approaches
In PKE approach, there are two Different keys.
1. Public Key
2. Private Key.
PKE techniques are arithmetically lessefficientbecauseof its
slower Processing and large key sizes. Therefore, PKE
techniques can be highly efficient in combination with SKE
techniques in which SKE techniques is used for encrypting
the Data and public private key pairs are used to secure the
symmetric key.
This structure [33] utilizesPublic KeyInfrastructure(PKI)to
guarantee security necessities, for example, confidentiality,
integrity, access control and non-repudiation, EHR is
encrypted utilizing a shared symmetric key created by
healthcare providers. PKI ties public keys with exceptional
client identities, which comprise digital certificates, a
Registration Authority, a Certificate Authority, a Certificate
Repository Database, and a Certificate Management System.
This proposed design manufacturesa protectedEHRsharing
system that guarantees the compelling sharing of EHRs
among patients and a few healthcare providers.
Authentication between EHR sharing cloud and healthcare
providers is accomplished by marking the archives with the
sender's private key, therefore letting the healthcare
provider confirm the mark signature to recovertheidentical
health records.
Mashima and Ahamad [15] patterned a patient-centered
monitoring system to secure therisk ofstoringandaccessing
e-Health data in the cloud. This work evolved a system that
allows the patients to have explicitorimplicitcontrol related
to when and how the e-Health data is accessed.
4.3 Overview of Alternative Cryptographic Primitive
Approaches
This section addresses an overview of alternative
cryptographic approaches in e-health clouds to protect
confidentiality. The primitives are ABE, SE, homomorphic
authentication, re-encryption of proxies, etc.
4.3.1 ATTRIBUTE-BASED ENCRYPTION (ABE)
APPROACHES
Sahai and Waters [34] attribute-based authentication is
based on public key encryption to secure cloud data where
user attributes are used for encryption and decryption. The
encryption in ABE is based on the access-structure principle
where the cipher text can only be decrypted if the user
attributes match the cipher text attributes. Cipher text
Policy-Based Encryption (CP-ABE) [35] and Key Policy
Attribute-Based Encryption (KP-ABE) are the two main
types of ABE. In KP-ABE, the access policy is encrypted into
the user's secret key and decryption of cipher text is only
possible when the user's attribute matches the access policy
[34], while in CP-ABE [36] each user's private key is linked
to a set of attributes and a cipher text is linked to a universal
set of attributes that can be decrypted when the user's
attributes match the access policy. This approach based on
ABE [37] protects EHR's privacy with PKE for flexible
authorization. The patient's smartcard produces a secret
authorization Transaction Code (TAC) before uploading the
medical data to the cloud server. PKE is used as
identification and for authorization the patient's smart card
and TAC.The health professional has to access the TAC to
decrypt the medical data, and the Encryption / Decryption
feature provides a shared encryption key that is the hash
value of the patient's identity andTAC.Thedecryptioncanbe
done using TAC and authentication from a Private Key
Generator (PKG). Yu et al. [14] lists the problem of
confidentiality, scalability, and fine-grained access to
outsourced data in the cloud. This method solves problems
by incorporating strategies such as ABE, KP-ABE, Proxy Re-
encryption (PRE) and lazy re-encryption as a hybrid
encryption scheme to secure fine-grained access control.
Through key distribution, the information encrypted by a
single user will be exchanged among different users.Re-
encryption of data files and secretkeyupdatesareconsigned
to cloud servers in this method. Cloud servers keep a copyof
user’s secret key to update secret key components and re-
encrypt data files. Lazy re-encryption is used in cloud
servers to reduce overhead computing. It can stop the
revoked users from collecting the updated informationonce
the file contents and keys have been changed after the
revoke of the client.

4.3.2 SEARCHABLE ENCRYPTION
Because of the enormous development of huge data, there
exists huge scale re-appropriating of data intocloudservers.
As medical data and EHRs are redistributed to remote cloud
servers that are presented to cloud services, this prompts
different attacks, for example, eitherDoSattack oradversary
attack that annihilates the data confidentiality in the cloud.
For security of data and prevention of data leakage, cloud
data will be encrypted. Since the health data is encrypted
and put away in outside Cloud servers, ordinary looking
through plans cannot be applied. It requires someaccessible
encryption usage to question the data as appeared in Fig. 6.
As searching encrypted data enable keyword searches
across, it is challenging. SSE has been suggested that cloud
information. These stances difficulties, for example, (1) how
the data owner grants search consents to the data client?
(2)How the verified data clients search the encryptedstored
data? One of the arrangements is SE. SE is a cryptographic
primitive that licenses search tasks over encrypted data
without uncovering the data to untrusted servers. These
search activities are performed on encrypted cipher text
with the help of a trapdoor function from client. The
fundamental two sorts are symmetric searchableencryption
and asymmetric searchable encryption.
Fig - 4: Searchable Encryption
Fig - 5: Classification of SE techniques.
4.3.2.1 Searchable Symmetric Encryption (SSE)
SSE is a symmetric key encryption procedure, which
outsources the information confidentially from one party to
another by giving particular look capabilities. This model
uses proxy re-encryption[58]thatoffersmedical information
within the cloud with end-to-end information encryption
that cones information get to as it were to confirmed
beneficiaries. This approach [39] conserves the privacy and
security in e-Health models with a modern cryptographic
procedure named as a conjunctive keyword search with
assigned analyzer and timing subordinate SE plans named
intermediary re-encryption work (Re-dtPECK). The EHR
reports are encoded by symmetric encryption calculations
and a symmetric key is summarized with the patient's open
key-by-key embodiment. This makes utilization of an
assignment work to perform operations and employ a
conjunctive watchword look instrument. This approach
proposes a novel SSE conspire [40] which gives looking
concurring to the interesting watchwords put away on the
server. The look time is logarithmic and the client can look
and overhaul the record at whatever point required.
4.3.2.2 Public Key Encryption with Keyword Search
(PEKS)
PEKS is a cryptographic approach that uses an open key
model to look over scrambled information. Boneh et al. [41]
proposed PEKS as an introductory scheme, which does not
uncover any data relating to user’s searching within the
public-key setting and with lesser communication
complexity. This strategy [42] proposes a powerless key
unsinkability that supply a broader view on trapdoor
protection in asymmetric encryption for IBE. The reason of
this model is to construct a mysterious IBE scheme that
fulfills both key unsinkability and upgraded useful security.
This approach [43] addresses three fundamental issues of a
PEKS scheme vise evacuation of secure channel, reviving
keywords, and processing different keywords. The thought
of PKE with keywords search (PERKS)hasbeendisplayed by
Tang and Chen [44]. This model gives adaptability in such a
way that the sender is able to enroll a catchphrase with the
receiver prior to the sender producing a tag to construct
searchable content. This makes the model more proficient
and secure against offline keyword-guessing attacks.
4.3.2.3 Attribute Encryption with Keyword Search
(ABKS)
ABKS is a cryptographic search approach that uses data
encryption based on attributes.This searchtechniqueallows
users whose attributes fulfill the access policy to scan
keywords over encrypted EHR information. Yang [45] has
suggested a multi-sender and client scenario that improves
fine-grained accesscontrol andfacilitatesaccountrevocation
by using a robust keyword search technique and
authentication based on attributes. This scheme
implemented a fundamental novel with Synonym Keyword
search method (SK-ABSE) called attribute-based searchable
encryption. An ABE scheme defined by Li et al. [46]
integrates keyword search functions with key outsourcing
and decryption (KSFOABE) outsourcing. The cloud service
provider undertakes partial decryption tasks assigned by
data users in this scheme without providing any knowledge
about the plaintext that is secure and resilient against

selected plaintext attacks. Verifiable Attribute-Based
Keyword Search (VABKS) solution[47] allows a data user to
search only the outsourced encrypteddata ofthedata owner
whose credentials suit the access control policy of the data
owner. Liu et al. [48] introduced a new approach called Key
Policy Attribute-Based Keyword Search (KP-ABKS), which
removes from the cloud a secure channel for validating the
searched result, which reduces the computational
complexity of VABKS.
4.3.2.3 Proxy Re-Encryption with keyword Search
(PRKS)
Proxy Re-Encryption with keyword Search (PRKS)PRKSisa
cryptographic fundamental that uses a proxy re-encryption
system for searching encrypted data. An authenticated user,
which gives permits to other clients by re-encrypting the
outsourced data, permits by PRKS [38]. The proxy re-
encryption with keyword search functions (PRKS) as the
union of two schemes, Proxy Re-Encryption(PRE)andPEKS.
This approach [49] gives two security concepts for
bidirectional PRES (Intermediary Re-encryption Plot):
privacy for keyword and privacy for message. In keyword
privacy, the adversary is allowed to get the plaintext of any
cipher text, and about all trapdoors, barring those,which are
associated with the two particular keywords. Overall, it
cannot decide which keyword matchestoa given ciphertext.
This security thought ensures that the individual who has
the trapdoor or token can as it were do the test. For message
security, the opponent is allowed to get the plaintexts of
about all cipher texts, excluding all the trapdoors, but it
cannot decide which message matches with the specific
plaintext. This security concept guarantees thattheonewho
holds the private key can decrypt the cipher texts. We have
discussed a study of Searchable encryption techniques for
healthcare applications. Be that as it may, all existing multi-
user SE schemes are not practical with regard to the
execution required by basic real-world applications and
don't scale well for broad databases. We categorize and
compare the diverse SE schemes in terms of their security,
efficiency, and functionality. However, SSE is not a favored
strategy [43] for querying the search in EHR due to key
administration issues. Overall, PEKS and PRKS exhibit way
better execution in terms of security, privacy, and are
commonly received to EHR that supports search
functionality.
4.3.3 PROXY RE-ENCRYPTION
Proxy Re-encryption may be a cryptographic approach that
grants a semi trusted proxy server to re-encrypt the cipher-
text, which is encrypted by one user’s public key, into
another cipher text i.e. encrypted by the public key of
another client [50]. For illustration, Alice sends a message
(RK) to Bob through a semi-trusted proxy server, without
sharing Alice’s private key to either the proxy or Bob, and
without disclosing the secret message totheproxyappeared
in Fig. 8. Yang and Ma [39] presented a novel cryptographic
approach called as Conjunctive Keyword Search with an
assigned tester and a timing enabled proxy re-encryption
function, RedtPECK that uses an assignment pointer θ to
perform operations and uses conjunctive keyword for
searching mechanism. This scheme proposes a proxy re-
encryption instrument [51] for ontheroad emergenciesthat
permits an emergency medical center to decrypt a patient’s
health records with the help of cloud servers and client
credentials without disclosing the secret key.
Timing enabled proxy re-encryption systems over
conjunctive keyword search have been proposed [52] that
permit clients to get to the patient records beneath a
predefined time interim, T. This strategy accomplishes
objectives such as Time based disavowal, Effective Access
Control, User revocation, Efficiency.
Fig - 6: Proxy Encryption
4.3.4 HOMOMORPHIC ENCRYPTION
A Homomorphic Encryption is the change of data intocipher
text that can be analyzed and worked with as if it were still
in its original shape. Homomorphic encryption plays a
critical portion in cloud computing, permitting patients to
store encrypted PHR (Patient Health Record) records in a
public cloud and take advantage of the cloud provider’s
analytic administrations. The scheme avoids rebel insiders
from violating privacy and avoids accidental leakage of
private data. Homomorphic Encryption systems are utilized
to perform operations on encrypted data without knowing
the private key (i.e. without decryption); the client is
the holder of the secret key. When the resultoftheoperation
is decrypted, it is the same as if it had carried out the
calculations on the raw data. The homomorphic encryption
scheme algorithm consists of four steps: 1. Key Generation -
creates two keys i.e. the privacy key sk and the public pk. 2.
Encryption - encrypts the plaintext m with the public key pk
to yield cipher text C. 3. Decryption - decrypts theciphertext
C with the privacy key sk to retrieve the plaintext m 4.
Evaluation - outputs a cipher text C off (m) suchthatDecrypt
(skip) = f (m) [59].

4.2 NON-CRYPTOGRAPHIC APPROACHES
Non-cryptographic approaches primarily use policy-based
authorization infrastructure such as policies on access
control to enforce data privacy control. In EHR systems
where access to data is highly confidential and data isstored
on third-party servers. Mechanisms of access control are
necessary and vital as approaching towards encryption.
Access control in a health care information system provides
fundamental data privacy and security barriers by limiting
document access and operation in the EHR system. Some of
the main access control techniques are shown in Fig.10.
Comparison of a few non-cryptographic mechanisms that
protect privacy is shown in the table 8.
Discretionary access control (DAC) is a form of control of
access in which the owner of the object has completecontrol
over the programs. DAC is based on making objects
accessible based on the identity of the subject [83].Access
policy decisions in MAC are not made by an object's
individual owners, but by a central authority, and the owner
cannot change access rights [53].RBAC determines access
decisions based on their job functions in which tasks are
delegated to subjects, and the roles are combined with
permissions to determine which activities can beperformed
on which objects.
ABAC is an authentication-based access control in which
access decisions are made in accordancewiththesetofuser-
defined attributes and requesters are given accesstoobjects
in accordance with attributes that comply with the policy
rules.IBAC is a way of regulating access based on an
individual's authenticated identity.
Khan and Sakamura [54] suggested, through discretionary
access control and RBAC models, a context-sensitive, fine-
grained access control system for personal health data. This
approach uses eTRON architecturewhereencryptionisdone
using public-key cryptography, and the Diffie-Hellman
algorithm establishes stable key sharing.
Pussewalage and Oleshchuk [55]proposeda patient-centred
attribute-based approach in which each PHR file is
encrypted and stored in an e-health cloud with an attribute-
based access policy, which regulates access to the particular
resource and uses a proxy re-encryption technique, which
helps authenticated users, decrypt correct PHR files. This
scheme can withstand attacks mounted via collusion
attribute and can provide client revocation on-demand.This
research introduced a BiLayer Access Control (BLAC) to
combine attributes with roles and to analyse an access
request against pseudo-roles before testing the rules in the
law. Sandhu et al. [56] proposedRBACinwhichthefunctions
are allocated to subjects and roles are correlated with
permissions specifying what behaviour over which objects
can be controlled. There are several disadvantages to this
scheme. Defining and structuring the functions is an
expensive process, and it only supports policies that are
stable and pre-defined. It is also unable to support rapidly
evolving environments[57], and the coarse-granularity of
RBAC also triggers internal attacks[58].Yuan and Tong[17]
proposed ABAC to use specific attributes of each subject to
explain access permissionpolicies. ABACsolvesRBACissues,
but it has two issues.
Initially, ABAC is challenging due to the large number of
rules that need to be examined for access decisions, and
secondly, ABAC may require 2n rules for n attributes [17].
5 RESEARCH ISSUES AND FUTURE DIRECTIONS
This section talks about the research issues and future
directions identified with privacy and security in EHR. Since
EHR, data is delicate, confidential, and housed in third-party
servers, which involves serious risks as far as data privacy
and security goes. A portion of the issues includes:
1. How to verify and safeguard the security of data in
the cloud?
2. Which access control system will be increasingly
effective for the protected exchange of EHR?
3. Which encryption plan could be utilized for
preserving data security?
4. How to actualize security preserved in health care
data storage?
5. How the health data can be successfully shared
against various healthcare providers?
6. How to keep up with integrity of health records?
7. Who will have the option to get to the patient
information with healthcare providers during a
crisis circumstance?
8. How to deal with key administrationintricacywhile
sharing healthcare data between different
healthcare providers?
This audit featured different research issues relating to the
protection and security of e-health data. Along these lines,
we found that there is an inevitable need to strengthen the
security foundation in e-health models assured towards
patients' to guarantee the privacy and security of
information accordingly verifying patient privacy and
sovereignty. Along these lines, we deliver some future
research directions:
 From the discussion, we have inspected a few
cryptographic and non-cryptographic components.
Despite the fact that ABE is generally productive
among encryption plans, Yi et al. [2] investigated
and proved that despite the fact that ABE is
generally proficient among encryption plans,
regardless it experiences costly computation and
complexity in bi-linear pairing tasks. Along these
lines, perceiving new systems for reducing the

multifaceted nature of bi-linear operations or
discovering approaches to re-appropriating
calculations will be a fascinating researchdirection.
 Integrity of health data in the cloud can be another
enthusiasm in research direction
 We have watched a few access control systems that
guarantee security wherein ABAC is the most
adaptable and advantageous giving fine-grained
access. Along these lines,ABACwill beproductiveto
bring greater adaptability into authorizations,
which can likewise be consideredasanexamination
bearing.
 A blend of encryption instruments and access
control systems to save big data security and
privacy can also be considered as a future research
direction for maintaining a reliable security
mechanism in e-healthcare.
6. Conclusion
Since most of the information is put away in cloud servers,
which is exceptionally weak toattacksandbreaches,thereby
leading to an upcoming need to safeguard them. Current e-
health solutions equip us with a certain level of security,
which is not all-around, a foolproof mechanism. In this
specific circumstance, a research to support the certainty
and validity of patients is essential forthewide-scaleuse and
accomplishment of the computerized medical services. This
survey features a comprehensive study of existing e-health
cloud protecting cryptographic and non-cryptographic
systems to verify security and privacy in the cloud and their
vulnerabilities in the quick changing era. Besides, our work
likewise furnishes and recognizes key research areas vise
models, encryption techniques, access control systems and
has additionally distinguished some wonderful research
issues and future research directions tobringupona forceful
action for ensuring secure data privacy in shrewd health
arrangements.
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9830
[60] https://slideplayer.com/slide/10511425/
BIOGRAPHIES
Ravi Bhagyoday is pursuing his
B.Tech in Cloud technologies and
Information security at ADYPU,
Pune India. He is also researching
new technologies in Cloud
technology and working on
different cloud platformslikeAWS,
Google Cloud, Azure, etc.

Chintan Kamani is currently
pursuing his B.Tech degree in
Cloud Computing and Information
Security at Ajeenkya DY Patil
University, PuneIndia andpassout
in the year 2021.Currently
following his passion about the
world.
Dhrumil Bhojani is a cyber-
security enthusiastic currently
pursuing his B.Tech in Cloud
technologies and Information
security at ADYPU, Pune India.
Currently researching on new
technologies in cyber securityfield
and Penetration testing.
Vivek Parmariscurrentlypursuing
his B.Tech degree in Cloud
Computing and Information
Security at Ajeenkya DY Patil
University Pune. Currently
interested in machine learningand
Artificial Intelligence.

IRJET- Comprehensive Study of E-Health Security in Cloud Computing

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