Health Care and Cybersecurity: Bibliometric Analysis of the Literature

Evaluating EHR-Integrated Digital Technologies for Medication-Related Outcomes and Health Equity in Hospitalised Adults: A Scoping Review

The purpose of this scoping review is to identify and evaluate studies that examine the effectiveness and implementation strategies of Electronic Health Record (EHR)-integrated digital technologies aimed at improving medication-related outcomes and promoting health equity among hospitalised adults. Using the Consolidated Framework for Implementation Research (CFIR), the implementation methods and outcomes of the studies were evaluated, as was the assessment of methodological quality and risk of bias. Searches through Medline, Embase, Web of Science, and CINAHL Plus yielded 23 relevant studies from 1,232 abstracts, spanning 11 countries and from 2008 to 2022, with varied research designs. Integrated digital tools such as alert systems, clinical decision support systems, predictive analytics, risk assessment, and real-time screening and surveillance within EHRs demonstrated potential in reducing medication errors, adverse events, and inappropriate medication use, particularly in older patients. Challenges include alert fatigue, clinician acceptance, workflow integration, cost, data integrity, interoperability, and the potential for algorithmic bias, with a call for long-term and ongoing monitoring of patient safety and health equity outcomes. This review, guided by the CFIR framework, highlights the importance of designing health technology based on evidence and user-centred practices. Quality assessments identified eligibility and representativeness issues that affected the reliability and generalisability of the findings. This review also highlights a critical research gap on whether EHR-integrated digital tools can address or worsen health inequities among hospitalised patients. Recognising the growing role of Artificial Intelligence (AI) and Machine Learning (ML), this review calls for further research on its influence on medication management and health equity through integration of EHR and digital technology.

Vulnerability to Cyberattacks and Sociotechnical Solutions for Health Care Systems: Systematic Review

BACKGROUND

Health care organizations worldwide are faced with an increasing number of cyberattacks and threats to their critical infrastructure. These cyberattacks cause significant data breaches in digital health information systems, which threaten patient safety and privacy.

OBJECTIVE

From a sociotechnical perspective, this paper explores why digital health care systems are vulnerable to cyberattacks and provides sociotechnical solutions through a systematic literature review (SLR).

METHODS

An SLR using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was conducted by searching 6 databases (PubMed, Web of Science, ScienceDirect, Scopus, Institute of Electrical and Electronics Engineers, and Springer) and a journal (Management Information Systems Quarterly) for articles published between 2012 and 2022 and indexed using the following keywords: "(cybersecurity OR cybercrime OR ransomware) AND (healthcare) OR (cybersecurity in healthcare)." Reports, review articles, and industry white papers that focused on cybersecurity and health care challenges and solutions were included. Only articles published in English were selected for the review.

RESULTS

In total, 5 themes were identified: human error, lack of investment, complex network-connected end-point devices, old legacy systems, and technology advancement (digitalization). We also found that knowledge applications for solving vulnerabilities in health care systems between 2012 to 2022 were inconsistent.

CONCLUSIONS

This SLR provides a clear understanding of why health care systems are vulnerable to cyberattacks and proposes interventions from a new sociotechnical perspective. These solutions can serve as a guide for health care organizations in their efforts to prevent breaches and address vulnerabilities. To bridge the gap, we recommend that health care organizations, in partnership with educational institutions, develop and implement a cybersecurity curriculum for health care and intelligence information sharing through collaborations; training; awareness campaigns; and knowledge application areas such as secure design processes, phase-out of legacy systems, and improved investment. Additional studies are needed to create a sociotechnical framework that will support cybersecurity in health care systems and connect technology, people, and processes in an integrated manner.

Hacking Acute Care: A Qualitative Study on the Health Care Impacts of Ransomware Attacks Against Hospitals

STUDY OBJECTIVE

Cyberattacks are an increasing threat to health care institutions which potentially impair patient outcomes. Current research is limited and focuses mainly on the technical consequences, whereas little is known about health care staff experiences and the effect on emergency care. This study aimed to explore the acute care effect of several large ransomware attacks against hospitals that occurred in Europe and the United States between 2017 and 2022.

METHODS

This interview-based qualitative study assessed the experiences of emergency health care professionals and information technology (IT) staff and investigated the challenges during the acute and recovery phase of hospital ransomware attacks. The semistructured interview guideline was based on relevant literature and cybersecurity expert consultation. Transcripts were anonymized, and traceable information regarding participants and/or their organizations was removed for privacy purposes.

RESULTS

Nine participants were interviewed, including emergency health care providers and IT-focused staff. Five themes were constructed from the data: effects and challenges regarding patient care continuity, challenges during the recovery process, personal effect on health care staff, preparedness and lessons identified, and future recommendations.

CONCLUSIONS

According to the participants of this qualitative study, ransomware attacks have a significant effect on emergency department workflow, acute care delivery, and the personal well-being of health care providers. Preparedness for such incidents is limited, and many challenges are encountered during the acute and recovery phase of attacks. Although there was profound hesitancy among hospitals to participate in this study, the limited number of participants provided valuable information that can be used to develop response strategies for hospital ransomware attacks.

Evaluating Staff Attitudes, Intentions, and Behaviors Related to Cyber Security in Large Australian Health Care Environments: Mixed Methods Study

BACKGROUND

Previous studies have identified that the effective management of cyber security in large health care environments is likely to be significantly impacted by human and social factors, as well as by technical controls. However, there have been limited attempts to confirm this by using measured and integrated studies to identify specific user motivations and behaviors that can be managed to achieve improved outcomes.

OBJECTIVE

This study aims to document and analyze survey and interview data from a diverse range of health care staff members, to determine the primary motivations and behaviors that influence their acceptance and application of cyber security messaging and controls. By identifying these issues, recommendations can be made to positively influence future cyber security governance in health care.

METHODS

An explanatory sequential mixed methods approach was undertaken to analyze quantitative data from a web-based staff survey (N=103), with a concurrent qualitative investigation applied to data gathered via in-depth staff interviews (N=9). Data from both stages of this methodology were mapped to descriptive variables based on a modified version of the Technology Acceptance Model (TAM; TAM2). After normalization, the quantitative data were verified and analyzed using descriptive statistics, distribution and linearity measures, and a bivariate correlation of the TAM variables to identify the Pearson coefficient (r) and significance (P) values. Finally, after confirming Cronbach α, the determinant score for multicollinearity, and the Kaiser-Meyer-Olkin measure, and applying the Bartlett test of sphericity (χ2), an exploratory factor analysis (EFA) was conducted to identify the primary factors with an eigenvalue (λ) >1.0. Comments captured during the qualitative interviews were coded using NVivo software (QSR International) to create an emic-to-etic understanding, which was subsequently integrated with the quantitative results to produce verified conclusions.

RESULTS

Using the explanatory sequential methodology, this study showed that the perceived usefulness of security controls emerged as the most significant factor influencing staff beliefs and behaviors. This variable represented 24% of all the variances measured in the EFA and was also the most common category identified across all coded interviews (281/692, 40.6%). The word frequency analysis showed that systems, patients, and people represented the top 3 recurring themes reported by the interviewees.

CONCLUSIONS

To improve cyber security governance in large health care environments, efforts should be focused on demonstrating how confidentiality, integrity, availability, policies, and cloud or vendor-based controls (the main contributors of usefulness measured by the EFA) can directly improve outcomes for systems, staff, and patients. Further consideration also needs to be given to how clinicians should share data and collaborate on patient care, with tools and processes provided to support and manage data sharing securely and to achieve a consistent baseline of secure and normalized behaviors.

Cybersecurity in Internet of Medical Vehicles: State-of-the-Art Analysis, Research Challenges and Future Perspectives

The "Internet-of-Medical-Vehicles (IOMV)" is one of the special applications of the Internet of Things resulting from combining connected healthcare and connected vehicles. As the IOMV communicates with a variety of networks along its travel path, it incurs various security risks due to sophisticated cyber-attacks. This can endanger the onboard patient's life. So, it is critical to understand subjects related to "cybersecurity" in the IOMV to develop robust cybersecurity measures. In this paper, the goal is to evaluate recent trends and state-of-the-art publications, gaps, and future outlooks related to this research area. With this aim, a variety of publications between 2016 and 2023 from "Web-of-Science" and "Scopus" databases were analysed. Our analysis revealed that the IOMV is a niche and unexplored research area with few defined standards and frameworks, and there is a great need to implement robust cybersecurity measures. This paper will help researchers to gain a comprehensive idea of this niche research topic, as it presents an analysis of top journals and highly cited papers, their challenges and limitations, the system model and architecture of the IOMV, related applicable standards, potential cyber-attacks, factors causing cybersecurity risks, various artificial intelligence techniques for developing potential countermeasures, the assessment and parameterisation of cybersecurity risks, constraints and challenges, and future outlooks for implementing cybersecurity measures in the IOMV.

CYBER-AIDD: A novel approach to implementing improved cyber security resilience for large Australian healthcare providers using a Unified Modelling Language ontology

Purpose

This paper proposes a novel cyber security risk governance framework and ontology for large Australian healthcare providers, using the structure and simplicity of the Unified Modelling Language (UML). This framework is intended to mitigate impacts from the risk areas of: (1) cyber-attacks, (2) incidents, (3) data breaches, and (4) data disclosures.

Methods

Using a mixed-methods approach comprised of empirical evidence discovery and phenomenological review, existing literature is sourced to confirm baseline ontological definitions. These are supplemented with Australian government reports, professional standards publications and legislation covering cyber security, data breach reporting and healthcare governance. Historical examples of healthcare cyber security incidents are reviewed, and a cyber risk governance UML presented to manage the defined problem areas via a single, simplified ontological diagram.

Results

A clear definition of 'cyber security' is generated, along with the 'CYBER-AIDD' risk model. Specific examples of cyber security incidents impacting Australian healthcare are confirmed as N = 929 over 5 years, with human factors the largest contributor. The CYBER-AIDD UML model presents a workflow across four defined classes, providing a clear approach to implementing the controls required to mitigate risks against verified threats.

Conclusions

The governance of cyber security in healthcare is complex, in part due to a lack of clarity around key terms and risks, and this is contributing to consistently poor operational outcomes. A focus on the most essential avenues of risk, using a simple UML model, is beneficial in describing these risks and designing governance controls around them.

Health Information System and Health Care Applications Performance in the Healthcare Arena: A Bibliometric Analysis

There have been several studies centred on health information systems with many insights provided to enhance health care applications globally. These studies have provided theoretical schemes for fortifying the enactment and utilisation of the Health Information System (HIS). In addition, these research studies contribute greatly to the development of HIS in alignment with major stakeholders such as health practitioners and recipients of health care. Conversely, there has been trepidation about HIS' sustainability and resilience for healthcare applications in the era of digitalization and globalization. Hence, this paper investigates research on HIS with a primary focus on health care applications to ascertain its sustainability and resilience amidst the transformation of the global healthcare space. Therefore, using a bibliometric approach, this paper measures the performance of health information systems and healthcare for health care applications using bibliometric data from the web of science database. The findings reveal solid evidence of the constructive transformation of health information systems and health care applications in the healthcare arena, providing ample evidence of the adaptation of HIS and health care applications within the healthcare arena to the fourth industrial revolution and, additionally, revealing the resilient alignment of health care applications and health information systems.

Scientific Publication Patterns of Systematic Reviews on Psychosocial Interventions Improving Well-being: Bibliometric Analysis

Background

Despite numerous empirical studies and systematic reviews conducted on the effectiveness of interventions improving psychological well-being, there is no holistic overview of published systematic reviews in this field.

Objective

This bibliometric study explored the scientific patterns of the effectiveness of different psychosocial interventions improving well-being among various categories of individuals with mental and physical diseases, to synthesize well-being intervention studies, and to suggest gaps and further studies in this emerging field.

Methods

The bibliometric analysis included identifying the most productive authors, institutions, and countries; most explored fields and subjects of study; most active journals and publishers; and performing citation analysis and analyzing publication trends between 2014 and 2022. We focused on data retrieved from known databases, and the study was conducted with a proven bibliometric approach.

Results

In total, 156 studies were found concerning the research domains and retrieved using LENS software from high-ranking databases (Crossref, Microsoft Academic, PubMed, and Core). These papers were written in English by 100 authors from 24 countries, among which, the leading country was the United Kingdom. Descriptive characteristics of the publications involved an increased number of publications in 2017 (n=35) and 2019 (n=34) and a decreased number in 2021 (n=4). The top 2 leading authors by citation score are James Thomas (3 papers and 260 citations) and Chris Dickens (3 papers and 182 citations). However, the most cited study had 592 citations. BMJ Open (n=6 articles) is the leading journal in the field of medicine; Clinical Psychology Review (n=5), in psychology; and Frontiers in Psychology, in psychological intervention (n=5) and psychology (n=5). The top 2 publishers were Wiley (n=28) and Elsevier (n=25).

Conclusions

This study indicates an overall interest in the declared domains within the last decade. Our findings primarily indicate that psychosocial interventions (PIs) were evaluated as being effective in managing mental and physical problems and enhancing well-being. Cognitive behavioral therapy was assessed as being effective in treating anxiety, psychoeducation in relapse prevention, and gratitude interventions in improving overall health, and the mindfulness approach had a positive impact on decreasing distress and depression. Moreover, all these intervention types resulted in an overall increase in an individuals’ well-being and resilience. Integrating social and cultural factors while considering individual differences increases the efficiency of PIs. Furthermore, PIs were evaluated as being effective in managing symptoms of eating disorders, dementia, and cancer. Our findings could help provide researchers an overview of the publication trends on research domains of focus for further studies, since it shows current findings and potential research needs in these fields, and would also benefit practitioners working on increasing their own and their patients' well-being.

Hospital cybersecurity risks and gaps: Review (for the non-cyber professional)

Background

Healthcare is facing a growing threat of cyberattacks. Myriad data sources illustrate the same trends that healthcare is one of the industries with the highest risk of cyber infiltration and is seeing a surge in security incidents within just a few years. The circumstances thus begged the question: are US hospitals prepared for the risks that accompany clinical medicine in cyberspace?

Objective

The study aimed to identify the major topics and concerns present in today's hospital cybersecurity field, intended for non-cyber professionals working in hospital settings.

Methods

Via structured literature searches of the National Institutes of Health's PubMed and Tel Aviv University's DaTa databases, 35 journal articles were identified to form the core of the study. Databases were chosen for accessibility and academic rigor. Eighty-seven additional sources were examined to supplement the findings.

Results

The review revealed a basic landscape of hospital cybersecurity, including primary reasons hospitals are frequent targets, top attack methods, and consequences hospitals face following attacks. Cyber technologies common in healthcare and their risks were examined, including medical devices, telemedicine software, and electronic data. By infiltrating any of these components of clinical care, attackers can access mounds of information and manipulate, steal, ransom, or otherwise compromise the records, or can use the access to catapult themselves to deeper parts of a hospital's network. Issues that can increase healthcare cyber risks, like interoperability and constant accessibility, were also identified. Finally, strategies that hospitals tend to employ to combat these risks, including technical, financial, and regulatory, were explored and found to be weak. There exist serious vulnerabilities within hospitals' technologies that many hospitals presently fail to address. The COVID-19 pandemic was used to further illustrate this issue.

Conclusions

Comparison of the risks, strategies, and gaps revealed that many US hospitals are unprepared for cyberattacks. Efforts are largely misdirected, with external-often governmental-efforts negligible. Policy changes, e.g., training employees in cyber protocols, adding advanced technical protections, and collaborating with several experts, are necessary. Overall, hospitals must recognize that, in cyber incidents, the real victims are the patients. They are at risk physically and digitally when medical devices or treatments are compromised.

AI-based Ethical Hacking for Health Information Systems (HIS): a simulation study (Preprint)

BACKGROUND

Health information systems (HISs) are continuously targeted by hackers, who aim to bring down critical health infrastructure. This study was motivated by recent attacks on health care organizations that have resulted in the compromise of sensitive data held in HISs. Existing research on cybersecurity in the health care domain places an imbalanced focus on protecting medical devices and data. There is a lack of a systematic way to investigate how attackers may breach an HIS and access health care records.

OBJECTIVE

This study aimed to provide new insights into HIS cybersecurity protection. We propose a systematic, novel, and optimized (artificial intelligence-based) ethical hacking method tailored specifically for HISs, and we compared it with the traditional unoptimized ethical hacking method. This allows researchers and practitioners to identify the points and attack pathways of possible penetration attacks on the HIS more efficiently.

METHODS

In this study, we propose a novel methodological approach to ethical hacking in HISs. We implemented ethical hacking using both optimized and unoptimized methods in an experimental setting. Specifically, we set up an HIS simulation environment by implementing the open-source electronic medical record (OpenEMR) system and followed the National Institute of Standards and Technology's ethical hacking framework to launch the attacks. In the experiment, we launched 50 rounds of attacks using both unoptimized and optimized ethical hacking methods.

RESULTS

Ethical hacking was successfully conducted using both optimized and unoptimized methods. The results show that the optimized ethical hacking method outperforms the unoptimized method in terms of average time used, the average success rate of exploit, the number of exploits launched, and the number of successful exploits. We were able to identify the successful attack paths and exploits that are related to remote code execution, cross-site request forgery, improper authentication, vulnerability in the Oracle Business Intelligence Publisher, an elevation of privilege vulnerability (in MediaTek), and remote access backdoor (in the web graphical user interface for the Linux Virtual Server).

CONCLUSIONS

This research demonstrates systematic ethical hacking against an HIS using optimized and unoptimized methods, together with a set of penetration testing tools to identify exploits and combining them to perform ethical hacking. The findings contribute to the HIS literature, ethical hacking methodology, and mainstream artificial intelligence-based ethical hacking methods because they address some key weaknesses of these research fields. These findings also have great significance for the health care sector, as OpenEMR is widely adopted by health care organizations. Our findings offer novel insights for the protection of HISs and allow researchers to conduct further research in the HIS cybersecurity domain.

A bibliometric analysis of global publications on graft-versus-host disease research

BACKGROUND

Graft-versus-host disease (GVHD) is a fatal complication of hematopoietic stem cell transplantation and is an enormous burden on the patient economy and related health systems. Nevertheless, only a few bibliometric studies have examined the direction of research and the major findings within the field.

METHODS

Statistical and visualization bibliometric analysis was performed in April 2021. Our research data were retrieved from the Web of Science using an advanced search strategy. We then used bibliometric analysis to determine the current general research direction and trend of publications and established the most prolific and distinguished authors, institutions, countries, funding agencies, and keywords in GVHD research. We employed VOSviewer (Leiden University, Leiden, Netherlands), Microsoft Excel (Microsoft, Redmond, State of Washington), and GunnMap (https://lert.co.nz/map/) to retrieve, integrate, and visualize the results.

RESULTS

Overall, 15,378 publications from 500 journals were extracted from the Institute for Scientific Information (ISI) Web of Science Core Collection database based on our analysis, of which the United States and the Fred Hutchinson Cancer Research Center were the most prolific countries and institutions, respectively. Moreover, we identified future research trends and the current status of GVHD research based on the top 10 most cited articles. Finally, influential authors' analysis demonstrated that Blazar, BR were both the most productive and most cited among all authors.

CONCLUSION

Our study provides an exhaustive and objective overview of the current status of GVHD research. This information would be highly beneficial to anyone seeking information on GVHD and would serve as a reference guide for researchers aiming to conduct further GVHD research.

Global research productivity in cybersecurity: a scientometric study

Purpose

The purpose of the study is to conduct a scientometric analysis of cybersecurity literature indexed in the core collection of the Web of Science for a period of ten years (2011–2020).

Design/methodology/approach

Cybersecurity is a focused topic of research across the globe. To identify the global research productivity in the field, the terms “cybersecurity, cyber-security, web security, information security, computer security, etc.” were used for retrieving the publications in the advanced search mode of the database “Web of Science”, limiting the time frame for 2011– 2020. The results retrieved were downloaded in the Excel file for further analysis and interpretation. The harvested data was analysed by using scientometric techniques to measure the progress such as growth rate, doubling time and author collaborations. Besides, the Biblioshiny and VOSviewer software were used for mapping networks.

Findings

The research output in the field of cybersecurity has shown an increasing trend during 2011–2020, and the maximum number of scholarly publications was published in 2020 (1,581), i.e. more than 715% of 2011 (221). A good number of countries (93) have contributed globally in cybersecurity research, and the highest share in research publications was reported by the USA (23.55%), followed by China (23.24%), South Korea (5.31%), UK (5.28%) and India (4.25%). The authorship patterns in cybersecurity publications show a collaborative trend, as most articles have been published by multiple authors. Total 5,532 (90.14%) articles have been published in co-authorship, whereas only 605 (9.86%) articles have been published by single authors. Keyword analysis shows that the most common keyword research by the authors is cybersecurity and its variants such as “cyber security” and “cyber-security” (1,698) followed by security (782), computer security (680) and information security (329).

Research limitations/implications

The database studied for the work does not represent the total literary output available on the theme. There are plenty of other databases, such as Scopus, Compendex, INSPEC, IEEE Xplore, arXiv, contributing to the same theme as well.

Practical implications

The findings of the study may help researchers, information technologists, library professionals and information specialists to identify the research progress, authorship patterns, collaborative networks and hot topics of research in the field of cybersecurity. Besides, it will assess the global response to the cybersecurity issue.

Originality/value

The study is the scientometric analysis of the cybersecurity based on current literature and will highlight the progress and development of global research in the said field.

Preparing for hybrid warfare and cyber-attacks on health services' digital infrastructure: what nurse managers need to know

AIM

This article aims to outline the key concepts in hybrid warfare and cyber-attack to better inform nurses managers in their strategic contribution to the defence of critical digital infrastructure.

BACKGROUND

Hybrid warfare often targets a nation's critical digital infrastructure including health services. Hybrid warfare against national health services, primarily through cyber-attack, is likely to increase in a more destabilised and conflictual international environment.

EVALUATION

Key literature, reports and assessments on hybrid warfare, advanced persistent threats and cyber-attack referenced to health services were analysed.

KEY ISSUE

Health services are a key element of a nation's critical infrastructure and as such are a key target in hybrid war strategies. Cyber-attack through exploiting clinicians', such as nurses', online susceptibilities, is a key route of attack. Nurse managers, to be effective planners, need to be fully informed on both the context for and specific nature of cyber-attack.

CONCLUSION(S)

Articles that deal with the relationship of hybrid warfare and cyber-attack on health services are rarely aimed at nurses and nurse managers.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers need to be fully informed about the the geo-political nature of cyber-attacks if they are to be fully consulted and listened to in response planning.

Machine and cognitive intelligence for human health: systematic review

Brain informatics is a novel interdisciplinary area that focuses on scientifically studying the mechanisms of human brain information processing by integrating experimental cognitive neuroscience with advanced Web intelligence-centered information technologies. Web intelligence, which aims to understand the computational, cognitive, physical, and social foundations of the future Web, has attracted increasing attention to facilitate the study of brain informatics to promote human health. A large number of articles created in the recent few years are proof of the investment in Web intelligence-assisted human health. This study systematically reviews academic studies regarding article trends, top journals, subjects, countries/regions, and institutions, study design, artificial intelligence technologies, clinical tasks, and performance evaluation. Results indicate that literature is especially welcomed in subjects such as medical informatics and health care sciences and service. There are several promising topics, for example, random forests, support vector machines, and conventional neural networks for disease detection and diagnosis, semantic Web, ontology mining, and topic modeling for clinical or biomedical text mining, artificial neural networks and logistic regression for prediction, and convolutional neural networks and support vector machines for monitoring and classification. Additionally, future research should focus on algorithm innovations, additional information use, functionality improvement, model and system generalization, scalability, evaluation, and automation, data acquirement and quality improvement, and allowing interaction. The findings of this study help better understand what and how Web intelligence can be applied to promote healthcare procedures and clinical outcomes. This provides important insights into the effective use of Web intelligence to support informatics-enabled brain studies.

The Evaluation of Software Security through Quantum Computing Techniques: A Durability Perspective

The primary goal of this research study, in the field of information technology (IT), is to improve the security and durability of software. A quantum computing-based security algorithm springs quite a lot of symmetrical approaches and procedures to ensure optimum software retreat. The accurate assessment of software’s durability and security is a dynamic aspect in assessing, administrating, and controlling security for strengthening the features of security. This paper essentially emphasises the demarcation and depiction of quantum computing from a software security perspective. At present, different symmetrical-based cryptography approaches or algorithms are being used to protect different government and non-government sectors, such as banks, healthcare sectors, defense, transport, automobiles, navigators, weather forecasting, etc., to ensure software durability and security. However, many crypto schemes are likely to collapse when a large qubit-based quantum computer is developed. In such a scenario, it is necessary to pay attention to the security alternatives based on quantum computing. Presently, the different factors of software durability are usability, dependability, trustworthiness, and human trust. In this study, we have also classified the durability level in the second stage. The intention of the evaluation of the impact on security over quantum duration is to estimate and assess the security durability of software. In this research investigation, we have followed the symmetrical hybrid technique of fuzzy analytic hierarchy process (FAHP) and fuzzy technique for order of preference by similarity to ideal solution (FTOPSIS). The obtained results, and the method used in this estimation, would make a significant contribution to future research for organising software security and durability (SSD) in the presence of a quantum computer.

Fuzzy Cognitive Scenario Mapping for Causes of Cybersecurity in Telehealth Services

Hospital organizations have adopted telehealth systems to expand their services to a portion of the Brazilian population with limited access to healthcare, mainly due to the geographical distance between their communities and hospitals. The importance and usage of those services have recently increased due to the COVID-19 state-level mobility interventions. These services work with sensitive and confidential data that contain medical records, medication prescriptions, and results of diagnostic processes. Understanding how cybersecurity impacts the development of telehealth strategies is crucial for creating secure systems for daily operations. In the application reported in this article, the Fuzzy Cognitive Maps (FCMs) translated the complexity of cybersecurity in telehealth services into intelligible and objective results in an expert-based cognitive map. The tool also allowed the construction of scenarios simulating the possible implications caused by common factors that affect telehealth systems. FCMs provide a better understanding of cybersecurity strategies using expert knowledge and scenario analysis, enabling the maturation of cybersecurity in telehealth services.

Information Security Awareness and Behaviors of Health Care Professionals at Public Health Care Facilities

OBJECTIVES

This study investigated information security behaviors of professionals working in the public health sector to guide policymakers toward focusing their investments in infrastructure and training on the most vulnerable segments. We sought to answer the following questions: (1) Are certain professional demographics more vulnerable to cybersecurity threats? (2) Do professionals in different institution types (i.e., hospitals vs. primary care clinics) exhibit different cybersecurity behaviors? (3) Can Internet usage behaviors by professionals be indicative of their cybersecurity awareness and the risk they introduce?

METHODS

A cross-sectional, anonymous, paper-based survey was distributed among professionals working in public health care organizations in Kuwait. Data were collected about each professional's role, experience, work environment, cybersecurity practices, and understanding to calculate a cybersecurity score which indicates their level of compliance to good cybersecurity practices. We also asked about respondents' internet usage and used K-means cluster analysis to segment respondents into three groups based on their internet activities at work. Ordinary least squares regression assessed the association between the collected independent variables in question on the overall cybersecurity behavior.

RESULTS

A total of 453/700 (64%) were responded to the survey. The results indicated that professionals with more work experience demonstrated higher compliance with good cybersecurity practices. Interestingly, nurses demonstrate higher cybersecurity aptitude relative to physicians. Professionals that were less inclined to use the internet for personal use during their work demonstrated higher cybersecurity aptitude.

CONCLUSION

Our findings provide some guidance regarding how to target health care professional training to mitigate cybersecurity risks. There is a need for ensuring that physicians receive adequate cybersecurity training, despite the opportunity costs and other issues competing for their attention. Additionally, classifying professionals based on their internet browsing patterns may identify individuals vulnerable to cybersecurity incidents better than more discrete indicators such as age or gender.

Blockchain in supply chain management: a review, bibliometric, and network analysis

Blockchain is a distributed ledger technology that has attracted both practitioners and academics attention in recent years. Several conceptual and few empirical studies have been published focusing on addressing current issues and recommending the future research directions of supply chain management. To identify how blockchain can contribute to supply chain management, this paper conducts a systematic review through bibliometric and network analysis. We determined the key authors, significant studies, and the collaboration patterns that were not considered by the previous publications on this angel of supply chain management. Using citation and co-citation analysis, key supply chain areas that blockchain could contribute are pinpointed as supply chain management, finance, logistics, and security. Furthermore, it revealed that Internet of Things (IoT) and smart contracts are the leading emerging technologies in this field. The results of highly cited and co-cited articles demonstrate that blockchain could enhance transparency, traceability, efficiency, and information security in supply chain management. The analysis also revealed that empirical research is scarce in this field. Therefore, implementing blockchain in the real-world supply chain is a considerable future research opportunity.

The Computer Will See You Now: Overcoming Barriers to Adoption of Computer-Assisted History Taking (CAHT) in Primary Care

Patient health information is increasingly collected through multiple modalities, including electronic health records, wearables, and connected devices. Computer-assisted history taking could provide an additional channel to collect highly relevant, comprehensive, and accurate patient information while reducing the burden on clinicians and face-to-face consultation time. Considering restrictions to consultation time and the associated negative health outcomes, patient-provided health data outside of consultation can prove invaluable in health care delivery. Over the years, research has highlighted the numerous benefits of computer-assisted history taking; however, the limitations have proved an obstacle to adoption. In this viewpoint, we review these limitations under 4 main categories (accessibility, affordability, accuracy, and acceptability) and discuss how advances in technology, computing power, and ubiquity of personal devices offer solutions to overcoming these.

Determining the Intellectual Structure and Academic Trends of Smart Home Health Care Research: Coword and Topic Analyses

Background

With the rapid development of information and communication technologies, smart homes are being investigated as effective solutions for home health care. The increasing academic attention on smart home health care has primarily been on the development and application of smart home technologies. However, comprehensive studies examining the general landscape of diverse research areas for smart home health care are still lacking.

Objective

This study aims to determine the intellectual structure of smart home health care in a time series by conducting a coword analysis and topic analysis. Specifically, it investigates (1) the intellectual basis of smart home health care through overall academic status, (2) the intellectual foci through influential keywords and their evolutions, and (3) intellectual trends through primary topics and their evolutions.

Methods

Analyses were conducted in 5 steps: (1) data retrieval from article databases (Web of Science, Scopus, and PubMed) and the initial dataset preparation of 6080 abstracts from the year 2000 to the first half of 2019; (2) data preprocessing and refinement extraction of 25,563 words; (3) a descriptive analysis of the overall academic status and period division (ie, 4 stages of 3-year blocks); (4) coword analysis based on word co-occurrence networks for the intellectual foci; and (5) topic analysis for the intellectual trends based on latent Dirichlet allocation (LDA) topic modeling, word-topic networks, and researcher workshops.

Results

First, regarding the intellectual basis of smart home health care, recent academic interest and predominant journals and research domains were verified. Second, to determine the intellectual foci, primary keywords were identified and classified according to the degree of their centrality values. Third, 5 themes pertaining to the topic evolution emerged: (1) the diversification of smart home health care research topics; (2) the shift from technology-oriented research to technological convergence research; (3) the expansion of application areas and system functionality of smart home health care; (4) the increased focus on system usability, such as service design and experiences; and (5) the recent adaptation of the latest technologies in health care. Based on these findings, the pattern of technology diffusion in smart home health care research was determined as the adaptation of technologies, the proliferation of application areas, and an extension into system design and service experiences.

Conclusions

The research findings provide academic and practical value in 3 aspects. First, they promote a comprehensive understanding of the smart home health care domain by identifying its multifaceted intellectual structure in a time series. Second, they can help clinicians discern the development and dispersion level of their respective disciplines. Third, the pattern of technology diffusion in smart home health care could help scholars comprehend current and future research trends and identify research opportunities based on upcoming research waves of newly adapted technologies in smart home health care.

Scientific Publication Patterns of Mobile Technologies and Apps for Posttraumatic Stress Disorder Treatment: Bibliometric Co-Word Analysis

Background

Mobile apps are viewed as a promising opportunity to provide support for patients who have posttraumatic stress disorder (PTSD). The development of mobile technologies and apps shows similar trends in PTSD treatment. Therefore, this emerging research field has received substantial attention. Consequently, various research settings are planned for current and further studies.

Objective

The aim of this study was to explore the scientific patterns of research domains related to mobile apps and other technologies for PTSD treatment in scholarly publications, and to suggest further studies for this emerging research field.

Methods

We conducted a bibliometric analysis to identify publication patterns, most important keywords, trends for topicality, and text analysis, along with construction of a word cloud for papers published in the last decade (2010 to 2019). Research questions were formulated based on the relevant literature. In particular, we concentrated on highly ranked sources. Based on the proven bibliometric approach, the data were ultimately retrieved from the Web of Science Core Collection (Clarivate Analytics).

Results

A total of 64 studies were found concerning the research domains. The vast majority of the papers were written in the English language (63/64, 98%) with the remaining article (1/64, 2%) written in French. The articles were written by 323 authors/coauthors from 11 different countries, with the United States predominating, followed by England, Canada, Italy, the Netherlands, Australia, France, Germany, Mexico, Sweden, and Vietnam. The most common publication type was peer-reviewed journal articles (48/64, 75%), followed by reviews (8/64, 13%), meeting abstracts (5/64, 8%), news items (2/64, 3%), and a proceeding (1/64, 2%). There was a mean of 6.4 papers published per year over the study period. There was a 100% increase in the number of publications published from 2016 to 2019 with a mean of 13.33 papers published per year during this latter period.

Conclusions

Although the number of papers on mobile technologies for PTSD was quite low in the early period, there has been an overall increase in this research domain in recent years (2016-2019). Overall, these findings indicate that mobile health tools in combination with traditional treatment for mental disorders among veterans increase the efficiency of health interventions, including reducing PTSD symptoms, improving quality of life, conducting intervention evaluation, and monitoring of improvements. Mobile apps and technologies can be used as supportive tools in managing pain, anger, stress, and sleep disturbance. These findings therefore provide a useful overview of the publication trends on research domains that can inform further studies and highlight potential gaps in this field.

Cybersecurity in PACS and Medical Imaging: an Overview

This article provides an overview on the literature published on the topic of cybersecurity for PACS (Picture Archiving and Communications Systems) and medical imaging. From a practical perspective, PACS specific security measures must be implemented together with the measures applicable to the IT infrastructure as a whole, in order to prevent incidents such as PACS systems exposed to access from the Internet. Therefore, the article first offers an overview of the physical, technical and organizational mitigation measures that are proposed in literature on cybersecurity in healthcare information technology in general, followed by an overview on publications discussing specific cybersecurity topics that apply to PACS and medical imaging and present the "building blocks" for a secure PACS environment available in the literature. These include image de-identification, transport security, the selective encryption of the DICOM (Digital Imaging and Communications in Medicine) header, encrypted DICOM files, digital signatures and watermarking techniques. The article concludes with a discussion of gaps in the body of published literature and a summary.

Theory-Based Model and Prediction Analysis of Information Security Compliance Behavior in the Saudi Healthcare Sector

The adoption of health information systems provides many potential healthcare benefits. The government of the Kingdom of Saudi Arabia has subsidized this field. However, like those of other less developed countries, organizations in the Kingdom of Saudi Arabia struggle to secure their health information systems. This issue may stem from a lack of awareness regarding information security. To date, most related studies have not considered all of the factors affecting information security compliance behavior (ISCB), which include psychological traits, cultural and religious beliefs, and legal concerns. This paper aims to investigate the usefulness of a theory-based model and determine the predictors of ISCB among healthcare workers at government hospitals in the Kingdom of Saudi Arabia. The study investigated 433 health workers in Arar, the capital of the Northern Borders Province in the Kingdom of Saudi Arabia. Two phases involved in this study were the hypothetical model formulation and identification of ISCB predictors. The results suggest that moderating and non-common factors (e.g., religion and morality) impact ISCB, while demographic characteristics (e.g., age, marital status, and work experience) do not. All published instruments and theories were embedded to determine the most acceptable theories for Saudi culture. The theory-based model of ISCB establishes the main domains of theory for this study, which were religion/morality, self-efficacy, legal/punishment, personality traits, cost of compliance/noncompliance, subjective norms, information security policy, general information security, and technology awareness. Predictors of ISCB indicate that general information security, followed by self-efficacy and religion/morality, is the most influential factor on ISCB among healthcare workers in the Kingdom of Saudi Arabia. This study is considered as the first to present the symmetry between theory and actual descriptive results, which were not investigated before.

Patients' Perceptions of Barriers and Facilitators to the Adoption of E-Hospitals: Cross-Sectional Study in Western China

BACKGROUND

As an innovative approach to providing web-based health care services from physical hospitals to patients at a distance, e-hospitals (ie, extended care hospitals through the internet) have been extensively developed in China. This closed health care delivery chain was developed by combining e-hospitals with physical hospitals; treatment begins with web-based consultation and registration, and then, patients are diagnosed and treated in a physical hospital. This approach is promising in its ability to improve accessibility, efficiency, and quality of health care. However, there is limited research on end users' acceptance of e-hospitals and the effectiveness of strategies aimed to prompt the adoption of e-hospitals in China.

OBJECTIVE

This study aimed to provide insights regarding the adoption of e-hospitals by investigating patients' willingness to use e-hospitals and analyzing the barriers and facilitators to the adoption of this technology.

METHODS

We used a pretested self-administered questionnaire and performed a cross-sectional analysis in 1032 patients across three hierarchical hospitals in West China from June to August 2019. Patients' sociodemographic characteristics, medical history, current disease status, proficiency with electronic devices, previous experience with web-based health services, willingness to use e-hospitals, and perceived facilitators and barriers were surveyed. Multiple significance tests were employed to examine disparities across four age groups, as well as those between patients who were willing to use e-hospitals and those who were not. Multivariate logistic regression was also performed to identify the potential predictors of willingness to use e-hospitals.

RESULTS

Overall, it was found that 65.6% (677/1032) of participants were willing to use e-hospitals. The significant predictors of willingness to use e-hospitals were employment status (P=.02), living with children (P<.001), education level (P=.046), information technology skills (P<.001), and prior experience with web-based health care services (P<.001), whereas age, income, medical insurance, and familiarity with e-hospitals were not predictors. Additionally, the prominent facilitators of e-hospitals were convenience (641/677, 94.7%) and accessibility to skilled medical experts (489/677, 72.2%). The most frequently perceived barrier varied among age groups; seniors most often reported their inability to operate technological devices as a barrier (144/166, 86.7%), whereas young participants most often reported that they avoided e-hospital services because they were accustomed to face-to-face consultation (39/52, 75%).

CONCLUSIONS

We identified the variables, facilitators, and barriers that play essential roles in the adoption of e-hospitals. Based on our findings, we suggest that efforts to increase the adoption of e-hospitals should focus on making target populations accustomed to web-based health care services while maximizing ease of use and providing assistance for technological inquiries.

Smart Glasses for Caring Situations in Complex Care Environments: Scoping Review

Background

Anesthesia departments and intensive care units represent two advanced, high-tech, and complex care environments. Health care in those environments involves different types of technology to provide safe, high-quality care. Smart glasses have previously been used in different health care settings and have been suggested to assist health care professionals in numerous areas. However, smart glasses in the complex contexts of anesthesia care and intensive care are new and innovative. An overview of existing research related to these contexts is needed before implementing smart glasses into complex care environments.

Objective

The aim of this study was to highlight potential benefits and limitations with health care professionals' use of smart glasses in situations occurring in complex care environments.

Methods

A scoping review with six steps was conducted to fulfill the objective. Database searches were conducted in PubMed and Scopus; original articles about health care professionals’ use of smart glasses in complex care environments and/or situations occurring in those environments were included. The searches yielded a total of 20 articles that were included in the review.

Results

Three categories were created during the qualitative content analysis: (1) smart glasses as a versatile tool that offers opportunities and challenges, (2) smart glasses entail positive and negative impacts on health care professionals, and (3) smart glasses' quality of use provides facilities and leaves room for improvement. Smart glasses were found to be both a helpful tool and a hindrance in caring situations that might occur in complex care environments. This review provides an increased understanding about different situations where smart glasses might be used by health care professionals in clinical practice in anesthesia care and intensive care; however, research about smart glasses in clinical complex care environments is limited.

Conclusions

Thoughtful implementation and improved hardware are needed to meet health care professionals’ needs. New technology brings challenges; more research is required to elucidate how smart glasses affect patient safety, health care professionals, and quality of care in complex care environments.

Transforming Healthcare Cybersecurity from Reactive to Proactive: Current Status and Future Recommendations

The recent rise in cybersecurity breaches in healthcare organizations has put patients' privacy at a higher risk of being exposed. Despite this threat and the additional danger posed by such incidents to patients' safety, as well as operational and financial threats to healthcare organizations, very few studies have systematically examined the cybersecurity threats in healthcare. To lay a firm foundation for healthcare organizations and policymakers in better understanding the complexity of the issue of cybersecurity, this study explores the major type of cybersecurity threats for healthcare organizations and explains the roles of the four major players (cyber attackers, cyber defenders, developers, and end-users) in cybersecurity. Finally, the paper discusses a set of recommendations for the policymakers and healthcare organizations to strengthen cybersecurity in their organization.

Why Employees (Still) Click on Phishing Links: Investigation in Hospitals

Background

Hospitals have been one of the major targets for phishing attacks. Despite efforts to improve information security compliance, hospitals still significantly suffer from such attacks, impacting the quality of care and the safety of patients.

Objective

This study aimed to investigate why hospital employees decide to click on phishing emails by analyzing actual clicking data.

Methods

We first gauged the factors that influence clicking behavior using the theory of planned behavior (TPB) and integrating trust theories. We then conducted a survey in hospitals and used structural equation modeling to investigate the components of compliance intention. We matched employees’ survey results with their actual clicking data from phishing campaigns.

Results

Our analysis (N=397) reveals that TPB factors (attitude, subjective norms, and perceived behavioral control), as well as collective felt trust and trust in information security technology, are positively related to compliance intention. However, compliance intention is not significantly related to compliance behavior. Only the level of employees’ workload is positively associated with the likelihood of employees clicking on a phishing link.

Conclusions

This is one of the few studies in information security and decision making that observed compliance behavior by analyzing clicking data rather than using self-reported data. We show that, in the context of phishing emails, intention and compliance might not be as strongly linked as previously assumed; hence, hospitals must remain vigilant with vulnerabilities that cannot be easily managed. Importantly, given the significant association between workload and noncompliance behavior (ie, clicking on phishing links), hospitals should better manage employees’ workload to increase information security. Our findings can help health care organizations augment employees’ compliance with their cybersecurity policies and reduce the likelihood of clicking on phishing links.

Information Technology and Medical Technology Personnel's Perception Regarding Segmentation of Medical Devices: A Focus Group Study

Objective: Segmentation is one way of improving data protection. The aim of this study was to investigate Information Technology (IT) and Medical Technology (MT) personnel’s perception in relation to ongoing segmentation of medical devices and IT infrastructure in the healthcare sector. Methods: Focus group interviews with 9 IT and 9 MT personnel in a county council in southern Sweden were conducted. The interviews focused on two areas: Positive expectations and misgivings. Digital recordings were transcribed verbatim and analyzed using qualitative content analysis. Results: Responses related to 2 main areas: Information security and implementation of segmentation. Informants stated that network segmentation would increase the overall level of cybersecurity for medical devices, addressing both insider and outsider threats. However, it would also increase the need for administration and the need for knowledge of the communication patterns of medical devices from the manufacturer’s perspective. Conclusion: IT and MT personnel in a county council in southern Sweden believed that segmentation would increase cybersecurity but also increase administration and resource needs, which are important opinions to take into consideration. The present study can be used as a model for others to increase awareness of opinions of healthcare organizations.

Cybersecurity in cardiac implantable electronic devices

INTRODUCTION

Cardiac implantable electronic devices (CIEDs) integrate numerous automatic and monitor functions. Nowadays, most CIEDs are connected to the Internet (via Wi-Fi, Bluetooth or smartphone) to ensure remote monitoring of technical and clinical data: despite the importance of such a monitoring, especially from a clinical point of view, concerns have been raised about information (IT) security in terms of both privacy and security for CIEDs' carriers.

AREAS COVERED

This review will provide an outline of remote monitoring of CIEDs, main IT security issues that have affected them so far, main cybervulnerabilities and possible solutions.

EXPERT OPINION

Although there is no evidence that cyber-attacks have been carried out against any CIED so far, they may occur in the future. Cyber-attacks are usually aimed at stealing sensitive information or granting access to the IT systems to which CIEDs are connected; the possibility of an active reprogramming of CIEDs by cyber-attacks is extremely low. Political, regulatory, scientific, and clinical integration is essential to provide not only effective IT solutions for CIEDs and their carriers, but also for the development of educational programs; it should also promote cooperation between stakeholders in order to reduce the risk of CIEDs' cybervulnerability and increase patient safety.