A Review on various Cloud-based Electronic Health Record Maintenance

system for COVID-19 Patients

D.Palanivel Rajan1
1
Professor, Dept of CSE, CMR Engineering College, Hyderabad, Telangana, India,
palanivelrajan.d@gmail.com.

Abstract Cloud computing is an evolving technology to maintain the database of any system.
Data collected from any part of the system will be transferred to the cloud, and it will be
retrieved at any point in time. It plays a vital role in biomedical applications, where a huge
number of patient records are needed to be maintained. In recent years we faced an
unexpected pandemic condition due to COVID 19 diseases. Routine human life has turned
upside down due to it. This disease affects the various age groups of people, and the number
of patients affected is also growing exponentially, day after day, across the globe. The
treatment for this critical illness is not the same for patients of different age levels. Aged
people may be already affected by various diseases, whereas middle-aged and children may
not be. COVID 19 is getting more vulnerable, and the death rate is increasing. Diagnosing
this disease is a tedious task for doctors. Symptoms collected from patients of various ages
and the treatment methods offered to them should be appropriately maintained. This may ease
out ways to cure the upcoming affected patients. In this paper, we present an overall review
of various Cloud-based electronic health care recording methods, that are currently available.
Personal Health Records (PHRs) are stored on a remote cloud server using these approaches.
The selective information will be shared when needed by a physician for diagnosis and
treatment. Many new cloud-based systems are developed, which have more secure and safe
data transfer compared to the conventional client-server model. Security is the most
concerned parameter for the emerging cloud technologies as PHRs are to be maintained
confidentially. The various existing cloud-based models are reviewed in the aforementioned
aspect.

Keywords: COVID-19, Electronic Health Record, Cloud, Patient Health record, Security

1. Introduction: Doctors in different parts of the

The world is in the latest situation
with the outbreak of coronavirus disease
2019. Since, December 2019, this disease
is causing serious impairment and threats
in more than 200 countries worldwide.
This condition also reveals that many
patients are asymptomatic, or only have
mild symptoms [1]. Patients with
asymptomatic symptoms caused by covid-
19 have recovered by maintaining
quarantined and taking medicines in some
cases, however, the incidence of morality
has increased due to patients suffering
from serious coronavirus disease with
coagulopathy [2], and often COVID-19
also becomes problematic for patients
suffering from acute pulmonary embolism
and right-sided heart failure [3]
world need to monitor the people affected
with a coronavirus and also need to
provide care to them in different countries.
Because it will assist them to give better
treatment to the patients who are affected
with various severe symptoms. For this,
the physician needs to maintain the health
record of a patient with a history of
whether he/she has already been affected
by any other diseases or only affected by
this disease. To adopt this method
physician needs to create an Electronic
Health Record (EHR) of the patient with
incorporate cloud computing technology
for easy access of a record from anywhere
in the world by the physician, EHR system
which helps to the physicians to monitor
the flow of patient files inside a hospital symptoms, others have ARDS syndrome,
and also retrieve the information about the which is precipitated by a cytokine storm.
diseases around the world and provide
specific care to the patient's for getting
better lifecycle quality to maximize data,
and recovery processes [4]
At the same time, records that are
stored in cloud-based technology need to
be maintained in a secure way, and also
authenticated persons only access that data
whenever they need it. In order to
efficiently store and exchange PHRs and
eradicate patients' concerns about PHR
privacy, the secure cloud-based EHR
approach, ensures the protection and
security of data that is stored in the cloud,
is discussed using various techniques to Figure 1.1 Possibilities of a cause of
rely on cryptographic primitives. Infection

In Section 2 reviews corona 2.1. Possibilities of Transmission

diseases, different types of symptoms, how
they spread to each other, comparison of
diseases in various countries like
developing and developed countries,
treatment given for a disease. In Section 3
discusses the importance of electronic
health record, how it was designed and
implemented in various countries with
help of cloud computing technology, and
also the various security concern
mechanism is used to maintain the data in
cloud computing are discussed.
2 About Corona Virus:
Coronavirus 2019 is a transferrable
disease instigated by extreme ARS
(SARS-CoV-2). This disease is identified
in Wuhan, China during December 2019
and now it has resulted in a current
epidemic. As of now, over 26.6 million in
188 countries and territories have been
registered with over 874,000 deaths, with
over 17.7 million recovered. As in Figure
1, various possibilities like Fever, cough,
fatigue, shortness of breath, and smell and
taste issues are among the most common
symptoms. While most people have mild
This type of disease that spread is
heavily influenced by age as four ranges
have been reported: 0 to 14, 15 to 44, 45 to
64, and => 65 years [5]. Figure 2 shows
the age-wise distribution of cases affected
in Mumbai. Mainly by small coughing,
sneezing, and talking droplets the virus is
transmitted. Usually, the droplets are not
airborne. However, those in the immediate
vicinity can inhale and get contagious.
People may get contaminated by rubbing
and then pressing on their mouths. The
transfer can also be carried out by tiny
droplets, which can be suspended for
longer periods in the air in closed spaces.
There are three possibilities of
transmission as symptomatic, pre-
symptomatic, and asymptomatic where
people can infect.
Figure 2.1 Age-wise distribution
2.1.1Symptomatic transmission
The term "symptomatic
transmission" refers to transmission from a
person who has symptoms. This type of
virus is transmitted from patients who are
infected already to the people in the near
distance by respiratory droplets, contact
with polluted objects and surfaces, and
straight contact with infected persons.
2.1.2Pre-symptomatic transmission
The interval between being
exposed to this type of virus (getting
infected) is on average of 5-6 days but can
be up to 14 days. Some infected people
can be contagious during this phase, which
is also known as the "PR symptomatic"
period. As a result, transmission from a
pre-symptomatic illness might occur prior
to the emergence of symptoms.
2.1.3Asymptomatic transmission
In this, a virus is transmitted from
one person to another, who does not have
any symptoms. This disease is the most
contagious during the first three days after
the beginning stage of symptoms, but it
can spread before and in people who are
asymptomatic.
2.3. Diagnosis Methods
A nasopharyngeal swab is the basic
diagnostic tool by reverse transcription-
polymerase (RT-PCR). Chest CT imagery
will benefit people with elevated fears of
infection based on symptoms and risk
factors to be diagnosed.
2.4 Prevention Methods:
Preventing infection risk
minimizations includes staying in a house,
wearing a mask in public places,
maintaining a distance from others,
avoiding crowded places, regularly
washing the hands for at least 20 seconds
with soap and water, proper respiratory
care, and avoid of touching eyes, nose, or
mouth without washing your hands. Let us
see some reviews on this type of covid19
attack.
2.5 Literature related to Severe
coronavirus disease patients with
coagulopathy
Coagulopathy is a common
complication of severe coronavirus disease
where disseminated intravascular
coagulation (DIC) may cause more
number deaths. Many patients with severe
diseases may be affected due to Third
International Consensus Definitions for
Sepsis for the evidence of virus infection
and respiratory dysfunction (Sepsis-3). In
addition to these severe cases like long-
term bed rest and hormone treatment raise
the risk of venous thromboembolism
(VTE).
Due to these reasons, it is
recommended that individuals with severe
can take anticoagulants (such as heparin)
on a regular basis. The International
Society of Thrombosis and Haemostasis
proposed a new approach known as
“sepsis-induced coagulopathy" (SIC) to
analyze in an earlier stage of sepsis-
associated DIC, and it has been confirmed
that patients who meet the diagnostic
criteria for SIC benefit from anticoagulant
therapy. They used retrospective analysis
for validating the effectiveness of the SIC
score and other coagulation indicators in
the screening of outpatients who could get
benefit from anticoagulants.
3. Implementation of Electronic health
record
The implementation of Electronic
health records with cloud computing
technology is simple and easy. It is a wide
technology that provides less cost for
maintaining records, security, privacy,
scalability, implementation. As listed in
Table 3.1 It is platform-independent with
reduced errors, improved quality,
flexibility, exchange aid sharing ability.
Owing to these features cloud computing
technology can effectively provide the
implementation support for the electronic
health record as shown in Figure 1.[6]
Table 3.1 Advantages of EHR in Cloud
 which already given for him This
S.
Domain Uses electronic health record makes the
No
Reducing software, physician to get opinion from the other
hardware, physician in the form of mode of
1 Cost treatment, medicine, etc.
installation, and
maintenance costs
The EHR technique is particularly
Encryption and
useful in this current pandemic situation
decryption,
Security and Authentication, for the physician to make the decision for
2 Privacy Two-factor the patients affected by a covid-19 because
authentication, some patients are affected by
Confidentiality, asymptomatic symptoms and some have
Audit, other issues such as registration, heart
Provision of disease, hypertension, kidney failure and
resources at the time some of them are affected by a second
3 Scalability of demand, the covid-19. In this section we will examine
possibility of how to incorporate Electronic Health
development Record using cloud technology by
PC, Laptop, Mobile, providing of the patient record with the
Implementati Windows, SQL, various security aspects, such as privacy
4
on ORACLE, open
and confidentiality. Here discussions are
EHR
made on the aspects of privacy preserving-
Use of multiple and
5 Flexibility separate sites, use attribute based, fuzzy keyword search over
for all shareholders encrypted data and attribute-based
Fast transfer, time encryption.
Exchange and dependent,
6
sharing ability permission of file
owners
Reducing takes in
exchanges,
Reducing
increasing access
errors and
7 speed, integrating
improving the
the multiple types of
quality
electronic health
Figure 3.1 Accessing a record in cloud
records
3.1 Attribute Based Encryption
It is otherwise known as fuzzy
Moreover, Electronic Health identity-based encryption. Key-policy
Record is the digital version of patient attribute-based encryption (KP-ABE) and
medical history which overcomes the ciphertext-policy attribute-based
record maintaining in the paper. The main encryption (CP-ABE) were defined as two
objective of creating and maintaining of different and complementing conceptions
EHR is it helps physicians to make of ABE in this method (CP-ABE). A
decision and disease diagnosis about the construction of KP-ABE was provided in
patients. [13] When he arrives with any the same paper [7,8], while the first CP-
disease, the physician needs to check the APE construction supported for tree-based
previous record information such lab access method in a generic group model.
results, scan images and the prescription Subsequently, a number of alternatives of
ABE schemes have been proposed since its
introduction.
Its features are being expanded,
and schemes with stronger security are
being proposed. This scheme is an
example, of accepting any type of access
structure. The common thing in this
approach is to use a technique to delegate
overhead computing with secure
outsourcing for encryption/decryption/key-
issuing to the third parties, which reduces
the amount of the calculation done locally.
This strategy aids us to develop an
outsourcing paradigm for achieving
efficient local decryption. [9]
3.2 Privacy-preserving attribute-based
Mechanism
In this paper, the authors discussed the
extensible access control mark-up
language used in a cloud-based EHR
model for performing the attribute-based
access control which focuses on
performing partial encryption, security,
and using electronic signatures when a
patient’s document is sent to a document
requester. XML encryption and XML
digital signature technology were utilized,
as demonstrated in Figure 2. This method
is effective because it sends only the
information which is required to the
requesters who are authorized to treat the
patient.
Figure 3.2. Accessing records based on
XML encryption
This model provides the
information to the authorized persons who
have access to medical records without
jeopardizing the confidentiality of patients.
The proposed model is categorized into
two stages. During the First Stage, the
access control is performed by using the
XACML language. It determines if the
user has been granted permission to obtain
the medical document. If permission is
granted for the user to access the patient's
records after access control has been
completed. In the second stage, it protects
the patient's privacy by sending the
documents which are requested by the user
in partial encryption and digital signatures.
3.3 Fuzzy based keyword Search in
document
In This method, the query has been
provided over the encrypted data with the
help of keywords. To achieve, this the data
owner needs to encode the keywords and
upload the ciphertexts to the cloud server.
By providing a trapdoor of a keyword
users can able to get the data that is used to
search in the encrypted index in the cloud
server [11]. There are two methods of
searchable encryption namely Symmetric
Searchable Encryption (SSE) and Public
Encryption Keyword Search (PEKS)] [12].
Keyword search in a multi-user
setup is a more prevalent case in a cloud
environment, where the files are shared by
a data owner with a group of authorized
users. The persons who have access rights
are able to create legitimate trapdoors and
search the shared files for keywords.
Through keyword search, a fine-grained
access control method is created with the
help of the ABE method. Through
keyword search, ABE is used to provide
fine-grained access control. The concept of
"multi-key searchable encryption"
(MKSE) is proposed as a conceivable
approach for solving the scalability issue.
To search a trapdoors keyword in
the encrypted document with different
keys the MKSE provides a single keyword
trapdoor to the user for search over in the
server. By using a different keys search
with a keyword trapdoor, it will not
increase the number of trapdoors that
relate to the number of documents. To
overcome this issue the edit distance in the
encrypted keywords has been presented as
a new technique called fuzzy keyword
search over encrypted data is identified.
But it can’t address how the structure
would work in a multi-user system with
changes in searching privileges.
3.4 Dynamic multi-keyword-based
search in Cloud
The storing and searching of data
in the electronic health record is the most
important criteria to perform the task that
needs to do. As shown in Figure 3.3 a
secure way in this Cloud provides
adequate storage facilities for enterprises
to move their precious
information/documents to the Cloud. So,
the user can transfer the valued data to the
cloud. But in this transformation security
is a major concern between the storage
service provider and the user.
Figure 3.3. Cloud data security scheme
In this cryptographic technique is
used for the searchable encryption-based
document because it ensures security. The
Dynamic multi keyword-based search
Algorithm, which includes modified
completely homomorphic encryption and
prims Algorithm, is proposed here. In this
Keywords are sorted and a searchable
index for keywords and files is produced
based on the keyword frequency contained
in the document.
To construct the dynamic tree
based on keywords and a file Prim's
approach is used. By using a two-way hash
table, the encrypted files in the tree are
indexed which provides efficient search
and document retrieval in a better way.
Modified ring-based completely
homomorphic encryption is used to
encrypt the files. This approach delivers 80
to 86 percent throughput for encrypted and
decrypted files respectively with indexing
time in less for indexing the files than
existing approaches.[6]
4. Conclusion:
In this, we investigated the
epidemiological features and preventative
approaches of patients with an
asymptomatic infection of COVID-19 are
identified. However, there is a paucity of
scientific evidence, and the specific
features of silent infections need to be
clarified. Then we discussed the
importance of the design and development
of a novel EHR system that should be
implanted based on cloud technology for
physicians with easy access to records of
patient history with the various security
mechanism. As part of our review, works
need to be taken with the design to provide
an interactive tool in a secure manner to be
taken.
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