Running head: BLOCKCHAIN CYBERSECURITY 1

White Paper, Blockchain Technology

Christopher Manaois

University of San Diego

HCIN 559

Professor Kathleen Stacy

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Cybersecurity Risks in Home Healthcare Environments

With technology continually evolving in healthcare, home healthcare and monitoring are

being used more and more because of the increased capabilities of medical devices and

equipment. Such capabilities include the ability to connect to devices and equipment through

networks that enable providers to connect and monitor them remotely. Remote monitoring

provides convenience and comfort to both patients and providers. It can be easier for providers to

keep an eye on patients by conserving more manpower and resources from travel. At the same

time, patients and families are also able to stay in their home environments, which can increase

morale. These advances, however, hold significant cybersecurity risks and are included as one of

the Emergency Care Research Institute’s (ERCI) top 10 patient safety concerns (ECRI, 2020).

The medical devices connected to a network can be hijacked or interrupted, which can affect its

performance, and consequently affecting the patient’s care. For instance, a network can be

invaded and access to encrypted data can be restricted until a fee (ransom) is paid. Fairly recently

Hollywood Presbyterian Medical Center suffered a ransomware attack and payed $17,000 to

regain access to their medical files (Kruse et al., 2017). These attacks are real threats that can

debilitate a healthcare organization and restrict or limit patient care.

Because medical institutions increasingly use medical devices that are connected to

networks to provide care to patients, it is vital to identify and address cybersecurity threats.

These threats could potentially leave institutions compromised and put patients in great danger.

This is especially important for patients who are under home healthcare since there is no in-

house technician available to physically assist patients and family members if these attacks do

happen. The purpose of this paper is to explore the real threats of cybersecurity in home
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healthcare settings and propose a possible solution to address or mitigate the problem to ensure

safety of patients.

Cybersecurity Hazards and Potential Solutions

Healthcare has developed enabling providers efficient ways to remotely treat and monitor

patients, especially those with chronic diseases. These remote capabilities keep focus on patient

monitoring even outside of the clinical setting. But these efficiencies give cyber-criminals

opportunities to exploit and carry out attacks. Some motivations for attacks include financial or

political gain, or to further expose an organization’s vulnerabilities (Coventry & Branley, 2018).

Home health medical devices are no less vulnerable. This paper will analyze articles identifying

hazards and potential solutions to improve home healthcare delivery. Such solutions include,

institutional funding and system updates, personnel and institutional practices, the use of

blockchain technology and the recommendation of virtual private network (VPN) and

manufacturing firmware compliance.

Medical devices utilized to monitor and treat patients can be exposed to cybercriminals.

It was suggested that insufficient funding for cybersecurity causes problems for institutions since

most efforts are centered on integration rather than software updates and system security

(Coventry & Branley, 2018). Organizational workflow changes are needed to manage

cybersecurity threats. Measures like regular system backups, software updates keep security

patches in place (Coventry & Branley, 2018). Buying into systems and processes that enable and

support secure data transferring also protects an organization (Coventry & Branley, 2018).

Although investing in increased cybersecurity is vital to a healthcare organization, internal

practices can greatly ensure protection from attacks.

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Continuous training and education for user recognition, avoidance and reporting of

phishing attacks is vital (Wright et al., 2016). By providing everyday users the information on

flagging and acting against security threats, a line of defense is put into place. A two-factor

authentication is the most important step in security risk reduction (Wright et al., 2016). These

extra steps provide substantial security benefits. In addition to workspace personnel and user

compliance, new emerging technology can also be utilized to defend the integrity of

interconnected healthcare organizations and homes employing home health.

With Smart Home ecosystems widely developing, home healthcare is enabled and

supported. Smart Home is having information technology (IT) capabilities at home that meet

user demands essentially improving comfort, security, entertainment and convenience (Safavi et

al., 2018). Security is a key concern in Smart Home ecosystems because information can be

infiltrated by outsiders (Safavi et al., 2018). It was suggested that blockchain technology be used

to ensure privacy and security, which includes smart healthcare protection. Blockchain

technology appeals to health data because of its capabilities on sharing, distributing and

encrypting information (Agbo et al., 2019). Safavi et al. (2018) suggests blockchain technology

can improve audit logging, give patients more access to their personal health records (PHR),

improve health IT application deployment, and provide abilities to connect databases. Having

user or provider distributed keys can safeguard transmission and transactions with blockchain

technology. In addition, manufacturers can also provide default capabilities that ensure security

for its customers. This will make it hard for criminals to access devices right off the market.

Finally, it was noted that approximately 500 million Americans have internet capable

devices like smartphones, tablets and other internet connected devices (McGee, 2016). It was

added that wireless networks are the source of the greatest security risk because attackers can
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gain access to personal data and even manipulate medical care appliances to pose physical safety

risks to patients (McGee, 2016). McGee (2016) recommends homes utilizing virtual private

network (VPN) to decrease vulnerability from cyber-attacks. A VPN provides users privacy by

creating a private network from a public internet connection (Symanovich, 2020). VPNs provide

tunnels enabling users to connect to the internet without leaving information for hackers to grab.

Some things VPNs are able to hide browsing histories, IP addresses and locations and devices

connected to that network (Symanovich, 2020). In addition to VPNs, McGee (2016) suggests

that manufacturers of medical appliances and devices with connecting capabilities require to

install security compliant firmware. Cyber-attackers are able to access and compromise medical

devices though its firmware without the user’s knowledge. By letting the manufacturers produce

equipment that is security compliant to begin with, patients and medical institutions will be less

vulnerable to attacks.

Healthcare is only one field that reaps the benefits of the conveniences provided by

technology. It enables providers to monitor patients who are in locations other than the hospital

or clinical setting. These benefits come with vulnerabilities to attacks that can cause

organizational and individual (patient) harm. In order to prevent and mitigate these hazards, it

was pointed out that organizations need to invest in cybersecurity measures as well as implement

workflow changes. Cybersecurity measures can be addressed at user, organizational and

production levels. At a user level, individuals can perform safe and secure practices allowing

defense against threats. Users can also utilize VPNs to increase network safety. Second,

healthcare organizations need to invest more to protect data- including additional training or

buying into additional cybersecurity measures. Lastly, manufacturers can also do their part by

ensuring security compliance of their medical devices to protect their customers from potential
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invasion and attacks. These solutions can help healthcare organizations protect patients from

cybersecurity threats and provide the best care possible.

Solution Description

For this paper, I believe blockchain technology is the best solution that will help mitigate

cybersecurity risks for healthcare in home settings. As mentioned previously, blockchain

technology has been greatly appealing to the healthcare industry due to its capabilities of sharing,

encrypting and distributing data. Blockchain technology was proposed by Satoshi Nakamoto

with the idea to provide protection against data failure and exposure with a decentralized

architecture to record information (Srivastava et al., 2018).

A blockchain is defined as a distributed ledger where different individuals are connected

and are able to work together (Hathaliya et al., 2019). In this case, the collaborators can be

doctors, patients, caregivers, etc. There is a digital agreement by the providers, patients and

caregivers that controls information that is added and also protects data from being tampered

with (Hathaliya et al., 2019). Blockchains have key features as displayed in Table 1 below.

Table 1

Key Features of a Blockchain, (Hathaliya et al., 2019).

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The immutable nature of the blockchain makes it pertinent to healthcare systems since

one cannot delete or modify information easily. There is, however, the issue of security and

scalability especially for longer blockchains since there is a significant amount of latency when

new information is added and propagated. Srivastava et al. (2018) talks about a system in which

a GHOSTDAG protocol network is utilized to perform faster computations as opposed to long

blockchains. The 5 entities defined in the system are the patient, the healthcare provider, the

device, the GHOSTDAG protocol network and the insurance company.

The smart devices are utilized by the patient, family or caregivers which transmit raw

medical data through networks or a smart phone. The system also collects health data from the

patient in which patients are the owners of their personal data where they can restrict or grant

access from any third party. Healthcare providers are responsible for administering tests and

treatments for patients where they are able to access previous medical data after gaining access

directly from the patient (Srivastava et al., 2018). The GHOSTDAG protocol network uses two

blockchain based protocols. A private blockchain where patient health data is processed using

smart contracts; and a public blockchain to send alerts to the smart devices and healthcare

facilities to receive the alerts (Srivastava et al., 2018). Lastly, the insurance company are able to

request data from users including health data from devices and past medical treatment to provide

the best medical healthcare or facilities (Srivastava et al., 2018).

Blockchain technology is the best solution to reduce risks for cyberattacks in home

healthcare because data within the network is very difficult to tamper with. By having a

blockchain, only authorized users are able to enter or modify data. This serves as a line of

defense against cyberattacks. To address the security and privacy issue, using GHOSTDAG

blockchain-based smart contracts can further protect patient data from intruders. The
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GHOSTDAG protocol increases propagation speed of new blocks which makes the blockchain

even more secure (Srivastava et al., 2018).

With the use of blockchain technology for medical devices for remote patient monitoring,

the patients can have control over what information is shared to providers and insurance

companies to receive the best care possible. Health data transmission will be faster and more

secure where patients and families can receive alerts when abnormal readings are taken.

Healthcare providers can receive alerts and safely access necessary patient data in order to

deliver the best treatment for the patient, even while monitoring the patient remotely. Healthcare

organizations are also able to confidently transmit and receive pertinent patient data with

blockchain technology. This will make healthcare data is more secure from attacks and intrusion

that can cause both physical and financial harm to both patients and the healthcare organization.
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Failure Mode and Effect Analysis
Steps in the Process
I. User Login Authorized
User (Patient/Provider/Insurance)
 II. Reading of presented
medical information
(measured health data/
provider instructions)
Smart Device
 III. Taking action based on
presented medical information
(provider prescription,
provider prognosis, care
instructions, etc.)
Smart Device
 IV. Entry of medical
information (i.e. charting)
Smart Device
V. Population of the charted
medical information to medical data
EHR
V.I. User Logout
Smart Device
 VI. Medical data Processed,
Modified and Secured according to
smart contract
Blockchain Technology
 VII. Sending of Notification
of new medical information
Smart Device
9
List of All Potential Failure Points
- Stolen login credentials
- Sharing login credentials
- Forgetting login credentials
- Misinterpretation of medical
information
- Wrong medical information was
transmitted
- Device is defective and cannot
communicate medical information 
- Error in carrying out the medical
orders
- Wrong provider diagnosis
- Wrong instructions given to patient
or caregiver
- Wrong medical information entered
- Failing to enter pertinent medical
information
- Device failure to accept medical
information entry
- Error of medical information being
uploaded due to wrong input
- Ineffective transmission due to
network connection
- Hardware defects resulting in failure
to transmit medical data
- Forgetting to logout
- Device failure to logout
- Network failure to logout
- Slow processing of medical data
- Errors in the Smart Contract
established
- Hijacking or breached system
- Network failure in transmitting the
data
- Smart device failure to receive data
due to hardware error
- Loss of smart device power to
receive notifications
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-
Failing to see notification
 VIII. Receiving of
-
Device failure to provide notification
Notification for new Medical
-
Network error resulting in
Information available
notification failure
Failure Mode and Effects Analysis Table

1 Process Step: I. User Login

Authorized User (Patient/Provider/Insurance)
2 Potential Failure Mode Forgetting login Stolen login Sharing login
credentials credentials credentials
3 Potential Cause(s) Human factor Leaving Easier to
credentials in document if
common areas device is left
logged in
4 Severity 2 3 3
5 Probability Frequent Occasional Frequent
Process Step #1

6 Hazard Score 4 3 4
7 Action (Eliminate, Control Control Control
Control, or Accept)
8 Description of Action - Password reset -Incident - Training on
link reporting proper use
- Providing -Immediate - Setting an
copies of login suspension of automatic log
credentials stolen off after an
- Providing credentials idle period
additional -Immediate - Adding
authorized credential initials after
users reset documenting
availability to ensure
consistency
Process Step #2

1 Process Step II. Reading of presented medical information

(measured health data/ provider instructions)
Smart Device
2 Potential Failure Mode Misinterpretation Wrong Device is
of medical medical defective and
information information cannot
was communicate
transmitted medical
information
3 Potential Cause(s) Lack of Human error Wear and tear
understanding/ resulting to of hardware /
medical inaccurate software
knowledge documenting
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4 Severity 7 5 6
5 Probability Frequent Occasional Occasional
6 Hazard Score 12 6 6
7 Action (Eliminate, Eliminate Control Control
Control, or Accept)
8 Description of Action - Training - CDSS to - Regular
sessions for confirm maintenance
users data entry checks
- 24/7 assistance - CDSS to - CDSS to
hotline flag remind of
- Provide abnormal maintenance
handouts for readings checks
common terms - Immediate - Routine swap
for medical alerts to out of
condition dangerous equipment to
parameters ensure
entered optimum
function
Process Step #3

1 Process Step III. Taking action based on presented

medical information
(provider prescription, provider prognosis,
care instructions, etc.)
Smart Device
2 Potential Failure Mode Error in carrying Wrong Wrong
out the medical provider instructions
orders diagnosis given to patient
or caregiver
3 Potential Cause(s) Lack of Erroneous Inaccurate
understanding / medical data medical
medical presented information on
knowledge EHR
4 Severity 7 8 8
5 Probability Occasional Uncommon Uncommon
6 Hazard Score 6 8 8
7 Action (Eliminate, Control Control Control
Control, or Accept)
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8 Description of Action - Providing - CDSS to - CDSS to flag

training to confirm inconsistent
users diagnoses care
- Provide - Verification instructions
supplemental from - CDSS to
information another confirm
(handouts, provider instructions
videos, etc.) - Immediate - Verification
- Help desk for referral to from another
questions specialist provider

1 Process Step IV. Entry of medical information (i.e.

charting)
Smart Device

2 Potential Failure Mode Wrong medical Failing to enter Device failure

information pertinent to accept
entered medical medical
information information
entry
3 Potential Cause(s) Lack of medical Missed Invalid entry of
knowledge / information codes
training due to lack of
awareness
4 Severity 6 7 5
Process Step #4

5 Probability Frequent Occasional Frequent

6 Hazard Score 8 9 8
7 Action (Eliminate, Control Eliminate Eliminate
Control, or Accept)
8 Description of Action - Provided - Training on - Training on
training documentatio common
- Help desk for n code entry
immediate - Routine - Handout or
questions verification manual for
- CDSS of data entry
confirming documentatio - Alert to
entered n notify
medical data - CDSS to flag provider if
readings important
outside medical
normal information
parameters was not
entered
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1 Process Step V. Population of the charted medical

information to medical data
EHR

2 Potential Failure Mode Error of medical Ineffective Hardware

information transmission defects resulting
being uploaded due to network in failure to
due to wrong connection transmit
input medical data
3 Potential Cause(s) Lack of training Insufficient Defective smart
for user network device to
documentation bandwidth to transmit data
support
operation
4 Severity 6 7 6
5 Probability Frequent Occasional Occasional
6 Hazard Score 8 9 6
Process Step #5

7 Action (Eliminate, Control Eliminate Control

Control, or Accept)
8 Description of Action - Provide - Alert to - Routine
training medical checks on
- Help desk for facility of hardware and
immediate connection is software of
concerns disrupted smart device
- CDSS - Providing a - Provide
confirming separate alternative
data entry network for means to
medical transmit data
device and - Alert
smart device healthcare
- Provide facility of
contingencies smart device
(i.e. written is unable to
documentatio connect to
n and back network
up
communicati
on to
healthcare
facility
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1 Process Step V.I. User Logout

Smart Device

2 Potential Failure Mode Forgetting to Device failure Network failure

logout to logout to logout

3 Potential Cause(s) Human factor Malfunction of Interruption to

device network
hardware resulting in not
being able to
log out
Process Step #5.1

4 Severity 3 4 4
5 Probability Frequent Occasional Occasional
6 Hazard Score 4 6 6
7 Action (Eliminate, Control Control Control
Control, or Accept)
8 Description of Action - Automatic -Automatic - Alert sent to
logout after logout after network if
idle time idle time device
- Training for -Smart device disconnects
authorized sleep after - Contingency
users idle time for
- Smart device -Notification emergency
sleep after idle if network
time malfunction connection
is detected on - Routine tests
device on network
integrity
Process Step #6

1 Process Step VI. Medical data Processed, Modified and

Secured according to smart contract
Blockchain Technology
2 Potential Failure Mode Slow processing Errors in the Hijacking or
of medical data Smart Contract breached
established system
3 Potential Cause(s) Accumulation of Insufficient Lack of security
long blockchains and unclear measures
communication
of terms
4 Severity 7 7 9
5 Probability Uncommon Uncommon Uncommon
6 Hazard Score 8 8 8
7 Action (Eliminate, Eliminate Eliminate Eliminate
Control, or Accept)
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8 Description of Action - Routine - Regular - Routine

inspection of reinspection changing of
performance of smart security
speed contract passwords
- Routine cloud - Immediate - Immediate
backup access to reporting for
- Set correct errors security
parameters - End user incidents
and dates for input - Regular
archiving data included security
training
Process Step #7

1 Process Step VII. Sending of Notification of new medical

information
Smart Device
2 Potential Failure Mode Network failure Smart device Loss of smart
in transmitting failure to device power to
the data receive data receive
due to notifications
hardware error
3 Potential Cause(s) Low bandwidth Device Human factor-
or slow network malfunction forgetting to
traffic due to faulty charge smart
hardware device
4 Severity 4 4 4
5 Probability Frequent Occasional Frequent
6 Hazard Score 8 6 8
7 Action (Eliminate, Control Control Control
Control, or Accept)
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8 Description of Action - Alert sent to - Routine -Alert to charge

healthcare quality battery when
facility if checks for reaching
device smart devices critical amount
disconnects - CDSS to -Alert to check
from network check in with battery level
- Providing healthcare every morning
contingency to facility of no -Automatic
transmit notification is battery
medical data received in a conservation
- Sending certain time mode for
notification - Set up device if at
though other protocol to critical amount
means like text follow up
messages or with
emails healthcare
facility if
notifications
are not
received in a
time
Process Step #8

1 Process Step VIII. Receiving of Notification for new

Medical Information available
2 Potential Failure Mode Failing to see Device failure Network error
notification to provide resulting in
notification notification
failure
3 Potential Cause(s) Human factor Hardware or Disconnected or
device insufficient
malfunction network speed
4 Severity 6 6 6
5 Probability Frequent Occasional Occasional
6 Hazard Score 8 6 6
7 Action (Eliminate, Control Control Control
Control, or Accept)
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8 Description of Action - Provide - Routine - Routine check

supplemental inspection of of network
notification to smart device speed and
user - Alternative integrity
- CDSS to notification - Alert sent out
remind user to options to healthcare
check for - Recurring facility if
updates notifications device is
- Snooze feature if “unread” disconnected
on smart from network
device - Providing
alternative
means to
receive
notifications
(email, text,
etc.)

Quality Measurement

In order to maintain the integrity of security in home health settings, measures can be

taken from both end user and administrative standpoints. First, end user security is very critical

since this can be an access point for cybercriminals to enter the network. New user training as

well as routine supplemental training should be part of the security maintenance of the healthcare

organization. This goes for both clinical and non-clinical users (like family members connecting

to the network). This security quality measure can be documented by random phishing attempts

administered and monitored by the healthcare organization’s administrative team. The number of

successful mock-phishing attempts can be documented to reinforce the need for more training

and increased security measures. If the phishing attempt is successful, the user can be prompted

to complete a refresher training course in order to mitigate real breaches in the future.

In addition, the administrative staff, particularly the cybersecurity personnel should be

involved in monitoring the activity of the data and blockchain of the network. Signs of intrusion

attempts should be closely watched since this would be visible by authorized personnel. This
BLOCKCHAIN CYBERSECURITY 18

data could be collected to also identify weak points of the network such as end users, Bluetooth

connectivity, internet or WIFI connections, etc. Daily reports should be collected and based on

the urgency can be addressed accordingly. Less urgent cases can be complied to address during

weekly or bi-weekly meetings to secure holes or leaks in the network. The software can be then

regularly updated based on findings to maintain security since cybercriminals use tactics that

continually evolve.

The integrity of the home health networks should be protected to the best of the

healthcare organization’s ability to protect both their patients and the organization itself. In order

to do so, end user and the networks blockchain technology should be closely monitored by

authorized cybersecurity staff to mitigate and prevent unwanted attacks by criminals wanting to

exploit the patients’ and organization’s resources.

Conclusion

With technology advancing, healthcare capabilities have increased where patients and

providers do not necessarily have to be in the same area to monitor and render treatment. Patients

can remotely receive care which in turn provides a familiar environment that also helps with

morale. Healthcare providers also free up more resources from in person care which can

potentially increase reach and focus on patients who require more medical attention. However,

being connected remotely also poses some threats to the healthcare organization, specifically in

cybersecurity. If not addressed accordingly, cybercriminals can tap into the network and cause

harm to the organization and the patients. Blockchain technology is a great solution to mitigate

cybersecurity risks by protecting data tampering and unauthorized deletion or modifications.

Only authorized users including patients, providers, allowed insurance providers and network
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administrators are able to gain access and input information, while data activities are kept track

of. 

Much of the harm prevention can be performed though user training which is a primary

means to secure the network from unauthorized access. As covered in the Failure Mode and

Effect Analysis, the technology can also be incorporated into the electronic health records to flag

and send out CDSS notifications for abnormal events that occur. Regular software updates are

also essential to keep up with cybercriminals’ evolving tactics to maintain the network’s

integrity.

Through blockchain technology, healthcare data will become more secure. At the same

time, data transmission will be faster providing both physical and financial safeguards to the

healthcare organization and patients. It is encouraged that healthcare organizations who employ

remote monitoring and home health adapt this effective technology in order to protect patients

and the overall organization.  

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