Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine...

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Telemedicine, E-Health, Ubiquitous Health 성균관의대 사회의학교실 E-mail: gwheel@med. skku. ac. kr

Transcript of Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine...

Page 1: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Telemedicine, E-Health, Ubiquitous Health

성균관의대 사회의학교실

김 윤

E-mail: [email protected]

Page 2: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Telemedicine

Telemedicine The exchange health information at a distance to facilitate clinical care using telecommunication technology

Applications of TelemedicineTelepathologyTeledermatology TeleradiologyTelesurgeryTeleHomecare

Use of information, communications, measurement and monitoring technologies to evaluate health status and deliver healthcare from a distance to patient care at home

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Telemedicine vs. TeleHomecare

Telemedicine Associated with sophisticated, expensive, and high-tech tools of institutionalized medicineRemote care delivered by physicians

TeleHomecareAssociated with the usual routine care provided in home health visit by nursesFocused on the care of chronically ill patients

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Telemedicine vs. TeleHomecare

TeleHealth = Telemedicine + TeleHomecare

TELEMEDICINE

*Telecare = TeleHomecare

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E-health

Definition"the combined use of electronic communication and information technology in the health sector for clinical, educational and administrative purposes, both at the local site and at a distance“ (Mitchell, 1999).

E-health Considered an equivalent of E-commerce in the healthcare industry Embraces a broader context and seems more appropriate Seems more useful in attracting investorsTelemedicine has become an obsolete term

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TeleHomecare System

Provider Station Patient Station

Communication Link

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System Architecture

Home #1

Visiting nurse

HospitalGP

Specialist

Distributed Distributed Medical Medical

Information Information SystemSystem Control

Centre

Home #2

Home #4

Home #3

Wide area network

Local area network

Physiological Sensors 11 22 33 44 55 66

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Technologies InvolvedSensors and Assistive devices

To monitor health related parameters To provide appropriate therapy and support

Home communications network To enable communications between the physically distributed components within the home Local processor unit which link between the home and the appropriate care providers

System intelligenceMixture of both human experience and computerized artificial analysis and decision makingFiltering information to sort out the relevant information from the ‘noise’

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Sensors for TeleHomecarePhysiological

ECG: Pulse rate and variabilitySpirometer: Respiration rate, peak flow, inhale/exhale ratioSphygmomanometer: Blood pressureThermometer: Basal temperatureGalvanic skin response: SweatingColorimeter: Pallor, throat inflammationStethoscope: Heart and breathing sounds

LifestylePassive infra-red: Client mobility / securityAccelerometer: Fall and tremorInductive badge: Room occupancy I.R. smart badge: Person identification & location

EnvironmentalThermometer: Room temperatureMicrophone: Noise-pollutionCoil clamp: Power consumption / appliance usageI.R. smoke alarm: Fire detector

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Home Monitoring DeviceFlexible Sensor Connectivity

Blood sugarBlood sugar

Blood pressureBlood pressure

ThermometerThermometer

StethoscopeStethoscope

ECGECG

Pulse O2Pulse O2

CameraCamera

Digital ScaleDigital Scale

309

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Home Monitoring Devices

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The Hospital Without WallsAA telehomecaretelehomecaresystem system incorporating incorporating vital signs vital signs monitoringmonitoring

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Monitoring Device

Controlled by PC in homeControlled by PC in home4 sensors (8,000 bits/sec) 4 sensors (8,000 bits/sec)

3-axis accelerometers: fall detectionHeart rate monitor“Panic button”2-lead ECG

TwoTwo--way transmission way transmission 2.4 GHz ISM band2.4 GHz ISM band

UltraUltra--low power low power -- up to 2 weeks battery lifeup to 2 weeks battery life100m range100m range

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Radio System

100100mm

Diversity Diversity antennaantenna

Radio base Radio base stationstation

ModemModem

Fixed sensorsFixed sensors

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Blood pressureBlood pressure

Pulse oximetryPulse oximetry

Heart monitorHeart monitor

Body area network

Body Area Network

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Real time vital signs display

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TeleHomecare Integrated with EMR

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Vital sign data from the TeleHomecare unit

TeleHomecare Integrated with EMR

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Driving Forces

Cost EffectiveCost EffectiveTechnologyTechnology Healthcare Cost Healthcare Cost

IncreaseIncrease

Increased Increased AcuityAcuity

Aging Aging PopulationPopulation

Patients Move Patients Move Toward SelfToward Self--CareCare

Managed CareManaged CareCapitated PaymentsCapitated Payments

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TeleHomecare Services

First-generation systems Anxiety reduction among elderly and high-risk patientsPersonal alarm systems and emergency response telephones

Second-generation systemsContinuously monitor variables sensitive to changes in functional health status and generate alarms without the intervention of the patientIntegrated with evolving "smart home" technology for home automation, security and environmental control

Third-generation systems Attempt to deal with issues of loneliness and quality of life ofpatients by creating a virtual community of clients, carers, healthcare providers and other community services

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Suitability of TeleHomecareUK report (1998)

15% of home visits could be replaced with telecare

Gann D, Tang P, Curry R. Feasibility study: technologies for telecare in the home. SPRU, December 1998.

US report (1999)46% of all activities carried out by on-site nursing could be replaced by telenursing

Allen A, Doolittle GC, Boysen CD, et al. An analysis of the suitability of home health visits for telemedicine. J Telemed Telecare 1999; 5: 90-96

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Uses and Outcomes

UsesCongestive Heart FailureCOPDDiabetesCancerAsthmaHigh risk pregnancyHospiceMental HealthPost surgical

OutcomesImprove access to careIncreases quality of lifeEarly detection/interventionCost effective

• Decreases ED visits• Decreases hospital

readmissionsPatient empowermentPatient satisfaction

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Outcomes of the Kaiser Permanente TeleHomecare Project

OBJECTIVETo evaluate the quality, use, patient satisfaction, and cost savings from the use of remote video technology

PARTICIPANTSCongestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, anxiety, or need for wound care

INTERVENTIONControl groups: home visits and telephone contactIntervention group: + consultation using remote video system

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Reimbursement system

Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000

Became effective Oct. 1, 2001 Eliminate important limitations to TeleHealth reimbursement, mandated under the Balanced Budget Act of 1997

Fee-sharing requirementsExpands eligible geographic areas, services, and types of presenters

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Reimbursement system

Fee sharing: EliminationBBA: A distant specialist split his/her fee with the referring siteNew Law: Originating site($20), specialist (full payment)

Eligible Presenters : At the originating siteEliminates the requirement that a physician or eligible practitioner must present a patient

Eligible Geographic areas: Expansion From the designated health professional shortage areas To a county not included in a Metropolitan Statistical Area

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Reimbursement system

Eligible Services: ExpansionThe listed specific CPT codes that are to be eligible Included codes are professional consultations, office visits, and office psychiatry

Store-and-Forward Interactive Consult (BBA)Demonstration projects in Hawaii and Alaska will be eligible for reimbursement

Telehomecare Health ServicesHome health agencies may adopt TeleHealth technologies but these technologies will neither be recognized nor reimbursed Home health agencies can spend prospective payment dollars on TeleHealth

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Other Third Party Payer PoliciesMedicaid

20 states’ programs cover telemedicine servicesArkansas, California, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Montana, Nebraska, North Carolina, North Dakota, Oklahoma, South Dakota, Texas, Utah, Virginia, and West Virginia

Coverage: idiosyncraticsome states only covering teleradiology, while others cover the full range of services.

Private Health insuranceThree States prohibit insurers from discriminating between regular medical and telemedicine servicesBlue Cross/Blue Shield provided at least some telemedicine coverage in 11 of the states

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Issues: Reimbursement system

TelemedicineGeographic Location: Urban underserved areas are not eligible for Medicare telemedicine payments Services: Exclude speech, physical, and occupational therapy and nutritional counseling from coverageSettings: Nursing homes are not eligible for payment

TeleHomecareLack of incentive: Savings from reduced hospitalizations accrue to the payers, not the home health agencyProductivity gains for home health agencies outweigh the investment required for agencies such as process changes and staff training

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Characteristics of Ideal TeleHomecare System

ATA Technology SIG White Paper (2000)Modularity: “Plug-and-Play”Intuitive interface Based on standardIntegrated w/ EMR: Distributed: geographically independent access to patient information Bandwidth independent: store-and-forwardSecure: security, safety

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Key Technologies for Smart TeleHomecare

Distributed Computing:Frameworks for interoperability and plug-and-play devices,Standards for terminology and device interaction, andHome-based networks that allow distributed medical devices to function as virtual systems.

Intelligent Processing:Knowledge assimilation algorithms that collate data from separate devices into care decision matrices,Artificial intelligence, neural network, and fuzzy logic algorithms for making care decisions,Information reduction technology for avoiding physician and patient information overload, and

Information Surety:Authentication and access control: biometric algorithmsOwner-aware sensors,Surety mechanisms for protecting data integrity and reliability

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Key Technologies for Smart TeleHomecare

Devices and Sensors:Wearable devices: non-invasive, self-calibrating, and low-power sensors,Body LANs that use low-power telemetry to unite data from autonomous sensors worn on the body, and Processing algorithms that filter data prior to storage and transmission.

EPR and Data Repositories:Distributed EPR repositories and knowledge databases that can besecurely accessed, andTemporary EPR and knowledge databases that reside in the home.

Standards:information architectures, security, plug-and-play hardware, communication, messaging, storage, nomenclature, diagnostic protocols and procedures, and device descriptions.

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Telemedicine Reference Architecture (TRA)

Telemedicine Reference Architecture (TRA) Object-oriented device architecture for secure, plug-and-play telemedicineused to build prototypical hardware and software

Key idea The interfaces between components are standardized The mechanisms needed to support plug-and-play and distributed operation are built into system elementsPossible to create a range of telemedicine devices from a common set of building blocks.

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Seven Service Areas of TRAUser Interface Medical Devices Patient Records

application-level interfaces for storing and retrieving patient-encounter data

Communications Service Area communication with other devices and the services

Protocols Service Area The programs or scripts accomplish specific medical objectives E.g.> measure BP, store the reading, and tell the user interface to display the reading

Backplane mechanisms that tie the other six areas togetherincludes the "middleware" (e.g. CORBA, DCOM, RMI)

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Seven Service Areas of TRA

Patients Record Server

Personal Status Monitor

Patients Station

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Smart Home

“Wires” houses and automates certain routine functions of daily livingAll appliances can be redesigned

To improve the quality of life To Reduce the healthcare threats

Falls and accidentsExposure to pathogens and allergens

Not yet embraced the provision of health services

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Smart Home for TeleHomecare

Current Features Thermostat, humidifierFloor sensor/alarms to prevent fallsAudio/video reminders for medicationsBlankets that alerts patients/caregiver about wound care needsRefrigerators for food ordering and expiration date reminders

Future Examples“Wearable research”: bio-monitors in clothing and jewelry that gather personal details on the wearers' body chemistry

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Future Home Layout

Home LAN

Fully Distributed Network of Healthcare Information Resources

*T/R

*T/R: Transmitter/Receiver

LivingRoom

Patient vital signs monitor with wrist display

Air-born agent sensor

Flexible Communications

Electronic medical

records and knowledge database

Health education, diagnosis and treatment

Set-top box

Television

Electronic Patient Record

Repositories

Data ProcessingAlgorithms

High-Performance Computers

KnowledgeDatabases

RF Link

T/R

Hospitals T/R

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Web Resources

TIE (Telemedicine Information Exchange)http://tie.telemed.org/

ATA (American Telemedicine Association)maybe useful for the members

OAT (Office of Advanced Technology)http://www.telehealth.hrsa.gov

Sandia http://www.sandia.gov/CIS/6200/Telemedicine/

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E-disease management

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Significance & NeedsPatients with chronic diseases

account for a great portion of mortality, healthcare utilization, and costs in the United States (Bringewatt, 1998).

70% of healthcare costs 80% of mortality.

Needs Most consumers lack the information needed to effectively managetheir chronic conditions. During the physician office visit, over two-thirds of patients did not receive information about medications or their conditions (Cyberatlas, 1999). Lack of information would

adversely affects ability and motivation of patients on self-managementresult in poor compliance

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DefinitionsDisease management

“A set of coordinated healthcare interventions and communicationsfor populations with conditions in which patient self-care efforts are significant (Disease Management Association of America, 2003)." target groups of disease management

Diabetes, congestive heart failure, asthma, HIV, and cancer patients.

E-disease management system Internet based disease management systemCentral component: Improving the self-management

through connecting patients with caregivers, information, and decision-support systems using the internet technology (Demeris and Eysenbach, 2001).

PurposeNot to replace traditional disease management, but to enhance it using internet technology

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E-healthRelationship between Telemedicine, E-disease management, E-health

E-disease Management

Telemedicine

E-Health

Traditional Healthcare Services

Web-based Healthcare Service

Page 43: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

E-disease management vs. Telemedicine

E-disease Management Telemedicine

Medical Profession-focusedTechnology-orientedStandalone Service

Consumer-focusedService-orientedIntegrated with Traditional Healthcare Services

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Potentials

Improve chronic disease management through the provision of essential functionalities:

providing ease and accuracy of data entryenhancing communication between patients and their caregiversensuring access to relevant informationdelivering decision support for both patients and caregivers

Page 45: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Potential Benefits of E-disease Management

Potential Benefits Components of Disease Management

Ease and accuracy of data entry to aid patient monitoring

Patient risk screeningPopulation screening

Improved patient communication with care givers

Team-base careAlternate encounter

Improved patients’ access to disease-specific information

Patient empowermentOutreach/case management

Improved access to patient tracking and decision-support tools at the point-of-care

Support of guideline/protocolDecision support at the point of care,

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Empirical EvidencePacifiCare Health Systems and Health Hero Network, Inc: CHF

A small and inexpensive device called the Health BuddyCollect information regarding their weight, medication compliance, clinical symptoms, and functional indictors each morningReduced half of admissions and 73 percent of emergency room visits, and resulted in an average savings per patient of $5,271 and a 200 percent return on investment for PacifiCare.

Highmark Blue Cross Blue Shield and CorSolutions, Inc.CHF patients using the application so called Cardiac SolutionsA nurse was assigned to each enrolled patient in order to facilitate a strong interpersonal relationship. After a six-month pilot program

1) hospital admissions declined by 60 percent2) 58 percent of patients were taking their medications at an optimal level3) satisfaction rates with the program were very high among physicians (75%) and members (90%).

CIGNA HealthCare and American Healthways, Inc. (1997)disease management program for its 87,000 members with diabetesintegrate CIGNA’s systems with American Healthways’ diabetes management applicationIn 1998, hospital admissions were reduced by 6 percent.

Tufts Managed Care Review, 2001

Page 47: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

ModelsExtended model:

integrated with pre-existing disease management servicesenhance current disease-management systems through the addition of new functionalities

Standalone model subscription-based program establish self-containing service systems

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Models & ViabilityViability:

to successfully enroll patients, their physicians must first be motivatedphysician referral is the most significant factor for patient participation

Revenue-generation model independent from the healthcare reimbursement contract between the E-disease management system and a healthcare organization Patients with chronic disease are less likely to pay the subscription fee additional benefit: not great

overlapped with traditional healthcare services or disease-management servicesHealthcare organizations are not likely to buy financial impact of E-disease management services is hard to measure, especially in short-term scale.

Page 49: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Clinical Appropriateness Recommendations of E-disease Mx

Information on self-management and patient education and management recommendations for physiciansKnowledgebase of the recommendations should be valid and maintained to have consistency with up to date medical knowledge(LeGrow, 2001).

Local adaptation of the knowledgebaseavailability of services

e.g. a system recommends a CT scan, but CT scan is not available to the hospital

preference in disease management policiesdesignated clinical review committee responsible for

examination of the clinical validity local adaptability of knowledgebase and recommendations

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Evidence on Cost-effectiveness

Only few empirical studies Performance of E-disease management

Few small scale studiesCost-effectiveness

To persuade policy makers, payers, and healthcare organizations and professionals to adopt E-disease management

Key factors of success and failure

Reimbursement

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UsabilityUsability

The most important factor affecting the success of projectsFrequently ignored by designers and evaluators

Important usability considerations ease of use

Chronic patients: usually old and unfamiliar with ITSimple to use, minimum training required

considerations on functional limitations of usersReduced sensory, cognitive or motor capability (Telecommunications Industry Association, 2003).

Example Well@Home and Health Buddy: allow users to input data without using a keyboard.

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Privacy and ConfidentialityUbiquitous issue in the health care sector

Health Insurance Portability and Accountability Act (HIPAA)

Security measures to meet the requirements of HIPAA (LeGrow, 2001)

Communication between patients and their caregivers (occurring) behind the firewall of the applicationAdoption of username and password systemTracking (system) for all edits, look-ups, and usage of patients’informationPoint-to-point security, such as a network encryption method

E-health care systems can attract patients only when they ensure patient privacy and confidentiality.

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Patient and Provider Acceptance

Diffusion of an innovation depends on Attitudes of users

Potential impacts should be carefully examined to facilitate the acceptance of users: patients, caregivers, family members, providersto avoid potential resistance and conflicts among usersregarding their financial, socio-cultural, and legal aspectsExample

need to guarantee 24-hour accessibility to the system's help desk and a reasonable response time.

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How to facilitate widespread adoption of E-disease management

1) the system should be integrated with traditional disease management services for better performance and viability

2) clinical appropriateness of knowledgebase should be ensured

3) financial incentives for E-disease management services should be built into the healthcare reimbursement systems

4) Technology employed in E-disease management should be user-friendly for their potential users with functional disadvantages

5) Appropriate security measures should be in place to protect privacy and confidentiality of patients

6) Potential impacts of the E-disease management system should be carefully examined, and the system designed to minimize users’ resistance and enhance acceptability.

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Information Security &Public Key InfrastructureDr. Paul J. Hu

Accounting and Information Systems University of Utah

January 16, 2003

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Sample Online Transactions

Confidentiality/Privacy: Information sent is not

intercepted and read by an unauthorized third party

Authentication and data integrity: Kate is in fact the sender of the order; and the

message has not been altered during transmission

Message & Credit Card Information

Kate Air FluffSend one pound of pop corn

Page 57: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Information Security: Example

Bob’s messageTo Alice: “Will

You marry me?”Hash

Message Digest ofBob’s Message

EncryptMessage

Text

EncryptMessageDigest

Send Both to Alice

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Information Security: Example

New MessageDigest Derived

from Bob’s Message

HashBob’s

Message

Receive Bob’sMessage and

Message digest

DecryptBob’s

MessageDigest

DecryptBob’s

Message

MessageDigest asReceivedfrom Bob

Compare

“Will you murderMe?”

Not From Bob?

Message DigestsNot the Same!!+

Page 59: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

IS: Fundamental Requirements

Confidentiality: Information is revealed only to the intended receiver, not to unauthorized partiesIntegrity or data integrity: The intended receiver can verify whether a message has been modified (altered) during transmissionAuthentication: The intended receiver can verify the origin of a message (i.e., identity of the sender)Non-repudiation: The intended receiver can prevent a message sender from falsely denying sending the message at a later timeAvailability and legitimate use: Specified users and their legitimate access to or use of information must be provided and preserved

Page 60: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Non-Electronic Security Mechanism

Notarized signatureCertified or registered mail

Non-repudiation

Indelible inkHologram on credit card

Integrity

Sealed letterOpaque envelopeInvisible ink

Confidentiality

Locks and keysMaster key systemCheckpoint guard

Access Control

Photo identification card Knowledge of mother’s maiden name

Authentication

Non-Electronic Mechanism ExamplesSecurity Service

Page 61: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Internet Security Issues

User name and password or other kind of access control mechanisms

Digital certificatesand other technologies used to authenticate identity

Digital signature

SolutionDoes a user have permission to access a specific computer or collection of information?

Is the user truly who he or she purports to be?

Did the person sending a message actually send it? Can receiver be sure that the message has not been changed?

Authorization

Authentication

Integrity

Business ConcernProblem

Page 62: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Internet Security Issues

Public-private key encryption algorithms

Log, audit, systems management policies and procedures

Firewalls

Solution

Is my conversation (or business transaction) private? Is anyone eavesdropping or spying?

Is anyone stealing from me?

Can someone enter my internal information systems and/or networks and access private information or destroy/alter information?

Business Concern

Privacy

Fraud/theft

Sabotage

Problem

Page 63: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

A General Process

Plaintext Ciphertext Plaintext

Encryption Decryption

Page 64: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Classification of Cryptography

Symmetric or Secret-key technologySubstitutionTranspositionSubstitution + Transposition (e.g., DES)Character stuffingOthers

Asymmetric, public-key or dual-key technology (e.g., RSA, DSA, PGP, etc.)Symmetric + asymmetric (e.g., digital envelop)

Page 65: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Symmetric Technology

Key

Plaintext PlaintextEncrypt Decrypt

System A System B

Page 66: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Common Symmetric Algorithms

Algorithm Key Size (bits) Block Size (bits) Example Applications

DES 56 64 Kerberos, PEM, SNMPv2Triple DES 112 64 PEMIDEA 128 64 PGP

SKIJACK 80 64 Clipper

DES = Data Encryption StandardIDEA = International Data Encryption AlgorithmPEM = Privacy Enhanced MailSNMPv2 = Simple Network Management Protocol, version 2PGP = Pretty Good Privacy

Page 67: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Symmetric Technology: Substitution

Simple mono-alphabetical substitution: Each character in P is replaced by a corresponding character in C (e.g., Caesar Cipher and ROT 13)Simple mono-code substitution: Each character in P is replaced by a group of characters (code) in C Homophonic substitution: Each character in P is replaced by one of several pre-determined characters in CPolygram substitution: Each group of characters in P is replaced by a corresponding group in C Poly-alphabetical substitution: P is encrypted with several simple mono-alphabetical substitution

Page 68: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Symmetric Cryptography

Symmetric cryptography has been widely used since early 1970sSymmetric techniques involves one and only one key; that is, the same key is used for encryption and decryptionThe key is kept secret from everybody except the sender and intended receiver(s)A symmetric algorithm may operate as a block cipher (e.g., 64-bit) or stream cipher

Page 69: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Analysis of Symmetric Technology

Strengths: Relatively low processing costs, as measured

by processing time and computing resource requirements Straight-forward key management

WeaknessesDifficulty in key distributionDoes not support spontaneous transactionsPotential use of multiple keys and needs for

frequent key changes

Page 70: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Key size (bits) Number ofAlternative Keys

Time Required at 1Encryption/µs

Time Required at 106

Encryptions/µs

232 = 4.3 ´ 109 231

Exhaustive Key Search:Average Time Requirements

32 µs = 35.8 minutes 2.15 milliseconds

56 256 = 7.2 ´ 1016

2128 = 3.4 ´ 1038

255

2127 µs = 5.4 ´ 1024 years

µs = 1,142 years 10.01 hours

128 5.4 ´ 1018 years

Page 71: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Asymmetric Cryptography

Use a key pair (i.e., public key and private key): one for encryption and the other for decryptionOne key is kept secret (i.e., private key) and the other key (i.e., public key) can be placed in the public domain One key offsets the other keyGiven one key, cannot derive the other keyFundamental assumption: The key owner is the ONLY person has access to the private key

Page 72: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Public-key Cryptography:Essential Foundations

Two fundamental theorems: 1. Given one key, we cannot derive the other key2. One key cancels the other key; thus, we can

use one key for encryption and use the other for decryption that is, Public (Private (P)) = P, and

Private (Public (P)) = P

Page 73: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

PGP Encryption: Plaintext

Page 74: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

PGP Encryption: Ciphertext

Page 75: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Digital Signature

A digital signature is a data entity derived from a message and often is transmitted together the message, plain or encryptedA digital signature can be used to

Ascertain message (data) integrity, data origin (sender’s) authentication, or bothProvide non-repudiation services

Require a “sign” operation at the sending end and a “verify” operation on the receiving end

Page 76: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Digital Signature: Sign and Verify

Plaintext

Sign

Sender’s Private Key

Signature

Verify

Sender’s Public Key

Plaintext

Originator Transmitted Message Recipient

Page 77: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Digital Signatures

Message

Digitally sign the message

using sender’sprivate key

+

Recipient UsesSender’s Public

Key to Decrypt or Verify the Digital

Signature

Sender’sPublic Key

Digital Signature

Message+ RecipientSender’s

Private Key

Message

Sent by John

Page 78: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Digital Signature with Hash FunctionsOriginator

Message

Encrypt

Signature

Sender’sPrivate

Key

Digest

Hash Function Message

Signature

Message

Decrypt

Expected Digest

Sender’s Public

KeyActual Digest

Hash Function

TransmittedMessage

Recipient

If these are the same, the signature is then verified

Page 79: Telemedicine, E-Health, Ubiquitous Health 2004 Spring Lect(10... · 2004. 6. 11. · Telemedicine vs. TeleHomecare Telemedicine Associated with sophisticated, expensive, and high-tech

Public Key Infrastructure (PKI)A method of encryption and authentication that uses keys to convert encrypted information into a readable format plus identify the author

Uses a string of numbers (keys) to encrypt documents to protect against unauthorized access and decrypts for authorized users

A 3rd party (a certificate authority) manages the creation and use of key pairs and digital certificates for each user.Digital certificate : public key and a private key

Public key is used to code document.Private key is used to decrypt and must be kept secure.