Design and Development of Case Studies in

Security and Privacy for Health Informatics

Education
Belal M. Amro Mohanad O. AL-Jabari Hussein M. Jabareen
College of Information College of Information College of Nursing
Technology Technology Hebron University
Hebron University Hebron University Hebron, Palestine
Hebron, Palestine Hebron, Palestine husseinj@hebron.edu
bilala@hebron.edu mohanadj@hebron.edu
Yousef S. Khader Adel Taweel
College of Medicine College of Engineering & Technology
Jordan University of Science & Technology Birzeit University
Irbid, Jordan Ramallah, Palestine
yskhader@just.edu.jo adel.taweel@outlook.com

Abstract – Health informatics has been reported to be a
vital sector for the last decade. Many efforts have been
implemented to better utilize advancements in health
informatics in real life. Educational institutions have
worked hard to enhance their programs to develop or
incorporate health informatics. However, in Palestine,
this field is not widely deployed in health care delivery
institution or in educational institutions. One key
element of Health Informatics is electronic health
records, for which privacy and security are very
important factors. The paper proposes a case based
learning method in teaching privacy and security issues
for Information Technology students. The paper
proposes the use of mini case studies instead of a single
cases study, each of the mini cases studies concentrates
on a set of learning outcomes. Hence, these mini case
studies will enable us to better fulfill learning outcomes.
The paper firstly describes the selected mini case studies
for Privacy and Security issues in health informatics,
then, it deeply details the development of a complete case
study called applying data security techniques over
sensitive Drug management/traceability data, which
enables students to gain essential skills to protect the
privacy of patients and security of drug data. These case
studies will be evaluated once they are implemented and
results will be reported after that.
Index Terms – Privacy, Security, Health Informatics.
1. INTRODUCTION
Health Informatics (sometimes called healthcare informatics
or medical informatics) includes a set of methodologies used
for data (data, information, and knowledge) management, in
healthcare sector. [1][2]. Health informatics relies on the use
of health records and managing them using technology. The
management includes processing a health record, storing it,
and sending it over a network, each of them is considered to
be a state of the health record. Electronic Health Records
(EHRs) improve quality of health care services while
reducing their cost. It also enhances user mobility and makes
the health care system more reliable [3],.
Like any other critical information system, EHRs convey
very sensitive data about both patients and users of the
systems. The transition process from paper-based model to
an electronic health record model in health informatics
raised many challenges including privacy, and security [4].
According to [5], addressing privacy issues in electronic
health records is critical to clinical care, public health, and
health research. Privacy breaches of electronic health
records have economic, social, ethical, and legal
implications and consequences. [6][7].
This paper presents a case-study based model to teach
addressing privacy issues in health care institutions, and how
to follow standard guidelines – in this case: ISO TS_25237
privacy standard for Health records - to protect the privacy
of affected persons in health care institutions – in this case:
diabetes healthcare delivery centre -.
The rest of the paper is organized as follows: a background
is provided in section 2. Section 3 describes case study
development. A discussion is provided in section 4 and the
paper is concluded in section 5.

978-1-5386-9120-5/18/$31.00 ©2018 IEEE


2. BACKGROUND
2.1. HICURE
1
HICURE project , is an Erasmus+ project funded by
European Union. The aim of the project is to develop health
informatics by integrating pathways within undergraduate
health and Information technology degrees.
In HiCure, a topics-based integrated curricula approach has
been adopted and driven by the competences required within
defined pathways. It adopts three categories of the topics: 1)
health-oriented topics that are taught only to health students,
2) IT-oriented topics that are taught only to information
technology students, 3) and common topics that aree taught
to both students from health and Information technology.
The privacy and security issues in Health informatics is a
topic that targets Information technology students and aims
to introduce different electronic data privacy, confidential
and security challenges, as well as methods, types, and
mechanisms for protecting health data. The objectives of the
topic are:
1. Recognize security threats and cyber attacks
2. Recognize privacy and its importance in health
informatics
3. Recognize actions required to protect computer
systems against attacks
4. Recall security techniques and their effect in
securing data
5. Recall the importance of privacy in the digital era
6. Recognize privacy-preserving techniques
7. Recognize the effect of data mining tools over
privacy
8. Comply with international techniques used in data
security and privacy
The subtopics of the security and privacy issues in health
informatics are listed below:
1. Introduction to Privacy and Security
2. Security and privacy standards for health
informatics
3. Security techniques and their effect in securing data
(a. Encryption (symmetric and asymmetric), b.
Non-repudiation (digital signatures), c.
Steganography, d. Access rights)
4. Importance of privacy, confidentiality, and
accountability in electronic data and systems .
5. Privacy-preserving techniques (k-anonymity, l-
diversity, pseudonyms)
6. Effects of data mining tools over privacy
The course is enriched with four case studies that students
have to carry out to better achieve the goals and objectives
of the course. Details about case study development are
provided in Section 3.
1
http://sites.birzeit.edu/hicure/
2.2. DEVELOPING SECURITY AND PRIVACY COURSES
IN HEALTH INFORMATICS CURRICULA
As mentioned above, HiCure aims to develop health
informatics by integrating pathways within health and IT
undergraduate curricula. Similar efforts have been carried
out for the same purpose in different regions.
In [11], a project aimed to analyse the implementation of a
computerized physician order entry (CPOE) system in a
Dutch university medical centre. Developers realized that
both social and technical issues are necessary for the success
of the implementation; the social impact might be gained by
training.
In North Carolina A&T State University, researchers have
developed an Interdisciplinary Health Informatics Security
and Privacy Concentration [12]. Students are supposed to
carry out some mini-case studies to understand standards
and HIPPA regulations.
In [13], the authors emphasized the necessity of sharing
responsibilities among different stackholders in the health
sector including- providers, healthcare organizations, health-
IT departments, and public and private agencies. The authors
detailed the requirements from each stackholder and their
responsibilities where security and privacy are required on
different levels and from all stakeholders.
A small trial of introducing healthcare security issues to
sophomore students was conducted by [14]. Different issues
were presented to students including Medical services,
Malware, Programming, Forensics, and Interoperability.
Ghazvini and Shukur [15], studied the challenges of success
factors of electronic healthcare systems. They reported that
human errors are one of the most challenging issues that
might be addressed by specialized training. They
recommended to set up the security of the system as well as
auditing logs to trace illegal or unauthorized breach.
In [16], the authors concluded that cyber-situational
awareness is fundamental in combating adversaries on the
Internet as well as taking proactive steps to avoid unwanted
privacy and security leaks. Camara et. al. [17] conducted a
comprehensive survey about security problems of
Implementable Medical Devices – IMDs- and showed that
the patient’s health can be seriously threatened by a
malicious adversary even with the newest IMDs.
Kumar and Samuel [3] reported that inadequate
identification and authentication of users, unauthorized
access by users, inadequate monitoring of user activity,
inappropriate disclosure and reporting requirements, and
poor security are chief sources of privacy breaches.
Implementation of ISO standards can easily address these
problems.
In their proposal of integrating medical informatics into
computer science curriculum at the University of Texas-
Brownsville [ 18], Zaim et. al. proposed a plan that includes
teaching security basics to students, however, they depended
on a single case study of designing, building and
implementing a biometric system for human identification
using iris features.
However, teaching privacy and security and their specific
technical concepts for health informatics can be challenging,
and may not be easily comprehended and applied in complex
health environments by interdisciplinary-degree students
using traditional teaching and learning techniques. . Thus to
teach privacy and security for heath informatics, in IT and
health courses or curricula effectively, case studies,
designed at suitable-level, must be coherently integrated at
appropriate teaching points that enable students to digest and
practice complex concepts. In this work, we propose the use
of several mini case studies, opposed to fewer large case
studies, to be carried out by IT students in the course of
security and privacy for health informatics. The inclusion of
several, in this case four, short mini case studies would help
better achieve the learning outcomes of the above noted
subtopics more effectively.
3. CASE STUDY DEVELOPMENT
As mentioned in section 2, four case studies were developed
to enrich students’ knowledge and enhance their skills in the
aim of achieving the objectives of the selected topic. The
following subsections detail the mini case studies approach
and fully describe the development of one of the four case
studies, called the Drug management/traceability data.
3.1. OVERVIEW OF THE CASE STUDIES
To best achieve the goals of the topic, four case studies are
introduced to students. Each case study is provided within
the subtopics after acquiring the required knowledge
necessary to carry out the case study. These cases studies are
briefly described below:
Diabetes case study
ISO-TS_25237-2008 is a standard for privacy-preserving for
Health informatics [8]. The standard addresses principles
and requirements for privacy protection of electronic health
records using pseudonymization. Following such a standard
is a must for institutions to protect the privacy of their
customers. It is worth mentioning that health data contain
very sensitive information about patients and thus must be
protected accordingly. The case study aims to answer the
following questions:
1. Are Diabetes Healthcare centres required to protect
patient’s privacy?
2. Do they deploy ISO-TS_25237-2008 or any similar
standard?
3. If the previous answer is No, are they planning to
implement such a standard?
Colorectal cancer case study
ISO 27799:2016 specifies detailed controls for managing
Health Informatics security and best practice guidelines [10].
It specifies which data to be protected and shows how and
what Information Security Management System ISMS
should be composed of. Besides, it addresses the steps of
establishing, operating, maintaining and improving the
ISMS. The case study aims to answer the following
questions:
1. Are Colorectal cancer treatment Healthcare centres
required to employ data security?
2. Do they deploy ISO 27799:2016 or any similar
standard?
3. If the previous answer is No, are they planning to
implement such a standard
Drug management/traceability case study
Drug management/traceability data conveys very sensitive
data that might invade the privacy of related entities. Such
data should be well secured to protect the privacy of related
entities. Due to the sensitivity of the data and its huge
influence on corresponding patients, the drug management
and traceability system must be highly secured to maintain
the proper function of drug delivery system and the trust of
the people in that system. The case study aims to answer the
following questions:
1. Are drug management centre /pharmacy required to
employ data security?
2. Do they deploy policies and techniques according
to standards?
3. If the previous answer is No, are they planning to
implement a security standard?
Healthcare delivery case study
Healthcare delivery systems gather data about healthcare
services. This data contains very sensitive information about
patients and other healthcare delivery users. On the other
hand, this data might be very useful for research purpose,
which might lead to a significant contribution to the human
being wellness. The case study aims to answer the following
questions:
1. How can we measure the privacy level of a dataset?
2. Once we decide to use k-anonymity, how to apply
k-anonymity over the dataset?
3. In case we need to apply l-diversity over the data
what steps should be taken?
4. Which privacy metric should we use, k-anonymity
or l-diversity?
3.2. DESIGN AND DEVELOPMENT OF DRUG
MANAGEMENT CASE STUDY
This subsection details the design and development of one of
the four mini case studies called Drug
management/traceability data. The development includes a
scenario, the duty of the team, status report, and case study
problems:
3.2.1. SCENARIO
A drug dispensing company with only one dispensing centre
called PharmaWorld is willing to establish centres in all
Palestinian cities. They want all these centres to work
together with the aim of the benefit of PharmaWorld. All
centre in cities must work in accordance with the regulation
of the centralized centre. To avoid any conflicts in
establishing new centres, PharmaWorld would first make
sure that the central centre meets the requirements of drug
dispensing centres including the regulation of drug
management and traceability. They use an electronic system
to manage drugs in their centres. The system traces the
amounts of drugs in the store and some other data related to
the drugs.
PharmaWorld received a generalization letter from
authorities indicating that dispensing centres should also
keep track of the owner of the drug after dispensing. This
requires that PharmaWorld tocollect information about
clients and the drugs they buy and store data in their system.
PharmaWorld knows that collecting such data might have
privacy issues for their customers, hence they planned to
design a secure and privacy-preserving system to handle all
these issues. Therefore, they referred to an academic
institution – in this case, Hebron University – for
consultation purposes. Hebron University established a team
from the IT department who are experts in security. The
architecture of their company is shown in Fig 1.
Pharma Pharma
World World
Branch Branch
Pharma
World
Central
Branch
Pharma Pharma
World World
Branch Branch
FIGURE 1
STRUCTURE OF PHARMAWORLD WITH DISTRIBUTED BRANCHES
The scenario above is discussed with students and they are
now ready to have their duties.
3.2.2. DUTY OF THE TEAM
After discussing the scenario with students, they are ready to
understand what are their duties for this case study, these are
listed below. It is worth mentioning here that students are
familiar with ISO 27799:2016 standard as it is introduced in
one of their lectures, and extra details are left to students to
study and understand related aspect of the standard by their
own:
1. Study the security situation at PharmaWorld centre.
2. Analyse to what extent do they apply security and
privacy preserving techniques
3. Study the ability to deploy a better security
architecture according to (1)
4. Report their findings in a formal technical report
5. The duties in this case study assist to achieve the
course objectives, specifically objectives 2, 3, and 8
listed in Section 1.
To achieve that, students will be asked to conduct one or
more visits to a drug management store (PharmaWorld) to
gather the following information:
1. Are employees aware of security issues related to
drug management data
2. Does PharmaWorld have policies regarding the
security of data?
3. Does PharmaWorld apply security techniques to
preserve data security?
4. Does the Pharma World follow a security standard?
5. Are they willing to apply better security
techniques?
6. What problems might arise when applying security
techniques at PharmaWorld
Based on the answers to the above-mentioned questions, a
complete view of security as a matter of fact for
PharmaWorld will be described. And the challenges of
applying /enhancing security techniques can then be
addressed
3.2.3. CASE STUDY PROBLEM:
Based on their visit(s) to the drug management centre and
the information students gathered by interviews and
observation, and after reading and understanding the
scenario of our case study, students have to address the
following points:
1) Whether they found any security flaw in the
workflow of PharmaWorld centre?
2) If a security flaw was found, show how can you
mitigate this flaw by following the guidelines
provided in ISO 27799:2016 and ISO TS_25237.
(Students may not apply the standard, just provide
general guidelines on how to mitigate the problem.)
3.2.4. STATUS REPORT
Based on the above, and following a decision-making
process, a solution based on the challenges and findings may
be proposed for PharmaWorld by students, drawn from ISO
27799:2016 [10] and ISO-TS_25237-2008 [9].
Options might include:
• Enhance some security techniques on part of
sensitive data
• Apply some security techniques on part of sensitive
data
• Completely apply a new secure drug management
system
The preferred solution would depend on the privacy and
security findings of PharmaWorld made by students, and
according to the common way and procedures used in drug
dispensing companies in Palestine. Students may propose a
complete re-engineering process for all assets and
procedures in the drug management centre where security is
considered relevant in each procedure.
4. DISCUSSION
According to our literature survey, it was obvious that a
health informatics course development requires sharing
responsibilities from different stakeholders of the domain as
well as conducting specialized training for all participants in
the field.
Having this in mind, and being aware of the importance of
security and privacy in the health sector, as well as taking
the healthcare situation in general. The proposed approach of
using mini-case studies to teach the topics of privacy and
security issues in health informatics, would provide a more
effective teaching approach for students to comprehend
difficult concepts of both privacy and security in complex
health environments. This approach will also make it easier
to implement and integrate at different teaching points
within a course.
The design of several mini case studies aimed to better
prepare the IT student for the best practices of privacy and
security in health sector. By several mini or short case
studies, students will be develop sufficient awareness of
challenges and related issues in the health sector and will be
able to tackle these problems especially in privacy and
security.
Employing more complex case studies may generate several
issues, especially in implementation, particularly in non-
mature and health informatics less developed health
environments, e.g. Palestine, where learners may not be able
to realise or perform sophisticated case studies.
5. CONCLUSION AND FUTURE WORK
Health informatics is vital for better healthcare delivery in
terms of time, quality, and budget. Different stackholders
have to share responsibilities in the development and usage
of health informatics. A key issue in the success of the
development and deployment of health informatics system is
training that should be done on different levels of health
informatics system usage and roles of the participants.
Universities – as part of stakeholders – are required to
develop their curricula and prepare their students ( health
and IT students ) well to better use and develop health
informatics tools. In this work, the process of designing case
studies as part of the topic called privacy and security issues
in health informatics has been proposed. A detailed case
study named Drug management/traceability data that aims to
provide the student with practical skills required to secure
the data and leverage the privacy of related persons.
As a future work, the implementation of case studies will
consider additional issues including roles of students and
evaluation criteria. In addition, challenges that may face
students during conducting the case study and how to avoid
them for larger scale will be considered. Feedback from
students and health institutions must also be addressed.
ACKNOWLEDGMENT
This study, part of the HiCure project, has been funded with
support from the European Commission. This paper reflects
the views only of the authors, and the Commission cannot be
held responsible for any use which may be made of the
information contained therein. The authors would like to
thank the HiCure members who contributed to this study.
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AUTHOR INFORMATION
Belal Amro is an assistant professor at Faculty of
Information Technology in Hebron University - Palestine,
where he has been working since 2003. From 2003 to 2004,
he was a research assistant at Hebron University. From 2005
to 2007, he was an instructor in the Computer Science
Department at Hebron University after having his MSc.
degree in complexity and its interdisciplinary applications
form Pavia- Italy. During 2008-2011 he received an
ERASMUS PhD grant at Sabanci University-Turkey. From
2011-2012 he worked as research assistant at Sabanci
University. In 2012, Mr Amro has received his PhD in
Computer Science and Engineering From Sabanci
University- Istanbul, turkey. From 2012 till now, Mr Amro
has been working as an assistant professor at Faculty of
Information Technology – Hebron University. From 2014 to
2017 Mr Amro has worked as chairman of Computer
Science Department at Hebron University. Mr Amro has
served as technical program committee member for different
international conferences and journals, and reviewed more
than 50 papers in the field of information technology
including privacy and security. Currently, Mr Amro is
conducting research in network security, wireless security,
privacy preserving data mining techniques and has published
more than 10 papers in international journals and
conferences in the field of computer security and privacy.
Mohanad O. AL-Jabari is an assistant Professor at college of IT
at Hebron University - Palestine. He has finished his B.Sc. degree
in computer science from Bizeit University (2001), master degree
in Computer Information System from Arab Academy for Banking
and Financial Sciences (2004), and PhD in computer science –
Semantic Web & Web 2.0 Adaptation from University of Namur,
Belgium (2010). He is currently conducting research in software
engineering, interactive Web 2.0 and Education 2.0, and Health
Informatics. Currently, he is the dean of IT College at Hebron
University.
Hussein Jabareen hold a Ph.D. in Management and Development
of Health Services, Master Degree in Development Studies from
University of Glasgow, Scotland-UK, Master Degree in
Community & Public Health from Birzeit University, and B.Sc. of
Nursing Sciences from Bethlehem University. Currently working
as Dean of College of Nursing at Hebron University since 2011 and
supervisor and examiner of master theses for students at Hebron
and Al-quds Universities. His research interests cover areas of
change management and administrative reformation, public health
and health system administration, community institutions
improvement, social equity and development.
Yousef Khader is a professor of Epidemiology and Biostatistics at
Jordan University of Science and Technology (JUST). He has
doctoral degree in Biostatistics from Tulane University. He is a
fellow of Faculty of Public Health of the Royal Colleges of
physicians of the United Kingdom through distinction. In last 15
years, he published more than 320 papers in highly reputable
journals including The Lancet, JAMA, and New England Journal of
Medicine. He received many national and international awards and
he currently leads six projects funded by IDCR, NIH, WHO,
UNICEF, Share-net. He is the world lead of "Revised Focal
Infection Theory".
Adel Taweel is a faculty member and scientist in software
engineering and medical informatics at Birzeit University. Dr.
Taweel has led and managed several EU, USA & UK funded
projects, and is a PI of three current EU-funded health informatics
projects (IMI, EHR4CR, HiCure and Diet4Elders). He is a health
informatics fellow, a charted engineer, a member of several
professional institutions (IET, BCS, IEEE), and an IMIA Health
Informatics Fellow. Dr. Taweel has published more than 100 peer-
reviewed scientific research papers and is a reviewer, an editorial
board member and a PC member of numerous international
journals and conferences .