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I. Introduction
In the last decade, healthcare organizations (i.e., clinics and hospitals) have been increasingly moving toward online data aggregation of patient medical records using cloud computing and other storage methods [1]. In recent years, the use of Internet of Things (IoT) technology in healthcare has increased, and online data and communication have also been used for operating medical devices [2]. The collection and storage of medical data may exceed the boundaries of organizations and be carried out by states, as occurred during the coronavirus disease 2019 (COVID-19) pandemic [3]. The use of computerized data can increase the efficiency of patient care. However, like other personal data, this type of information is sensitive and valuable, and is thus highly vulnerable to attack by cyber-criminals [4].
The COVID-19 pandemic has highlighted the importance of securing patient data that may be insufficiently protected. In 2020, healthcare organizations around the world such as hospitals and clinics suffered from an unprecedented spike in cyber-attacks [5,6]. In 2020, more than 400 organizations and 20 million individuals were affected in the United States healthcare system alone [7]. Well-known attacks have also occurred in the recent past, before the COVID-19 pandemic, including the May 2017 coordinated ransomware attack (WannaCry) that affected more than 200,000 devices in more than 150 countries, including the United Kingdom’s National Health Service, resulting in mass chaos and the suspension of health services in many locations. In addition to their financial threats, cyber-attacks could result in patient mortality if care is disrupted [8]. No country is immune to these threats, and national regulatory bodies must allocate the resources and means to protect against these attacks [6].
Advances in cryptographic data protection [9] have the potential to improve the security of medical records by providing not only a perimeter defense against attacks from outside the organization, but also an ongoing defense against both external and in-house attacks. This is achieved by storing the data in an encrypted or masked form, so that even if an attacker breaks the perimeter defense to infiltrate the system, they will not compromise data security. Using state-of-the-art methods in cryptography, such a defense is feasible not only for data-at-rest but also for data-in-use [10–13].
While there is a clear need to invest in new approaches and to develop policies that will increase the security of medical data, healthcare providers may be reluctant to adopt and utilize the most advanced cybersecurity technologies available. At the organizational level, cybersecurity can be seen as essential but expensive [14], particularly in organizations with limited resources. At the operational level, staff members might consider cybersecurity to be a burden or an interruption to their workflow and to patient care [15]. Healthcare management may also be cognizant of the need to allow continuous access to patient data among their medical and administrative staff, including remote access by physicians [16]. However, few studies have examined factors that may account for the willingness to adopt future innovative cybersecurity techniques within the healthcare sector.
This paper describes a qualitative study of data collected through a series of interviews with key cyber-protection stakeholders in the Israeli healthcare system. The Israeli healthcare infrastructure, which is under threat of cyberattack, consists of 33 major hospitals, four major research institutes, and four health maintenance organization (HMO) networks with about 2,500 community health clinics. In 2017, cyberattacks targeting four Israeli hospitals were successfully deflected [17]. However, in October 2021, a massive ransomware attack on a public hospital did breach the system, paralyzing the majority of the hospital’s computer systems [18]; the hospital refused to pay the ransom and reestablished its information systems in 52 days, when eventually all patients’ medical information was restored and no patient data was leaked [19]. In the years leading up to the cyber-events, Israeli policymakers have worked to promote the digitization of medical records, organizational databases, and a national shared network of medical data [20]. Several entities have been established in these years to address the emerging regulatory cyber-challenges (the National Cyber System, the Privacy Protection Authority and the Digital Health and Computing Division of the Ministry of Health). However, the Israeli health sector may not be adequately prepared for the risk of cyber-threats against national healthcare critical infrastructure, and a comprehensive law for cyberprotection in Israel is currently only in the drafting stage [21].
The aims of this study were (1) to assess current data management and security procedures and perceptions of vulnerability to cyber-attacks, and (2) to identify attitudes (perceived risks and benefits/usefulness), knowledge, perceived norms, and self-efficacy with regard to the adoption of advanced cryptographic techniques. These constructs are drawn from well-established behavioral theories such as the technology acceptance model [22], the theory of planned behavior [23], and protection motivation theory [24]. These theories have been used to explain variation in the adoption of technological practices and products in prior research [15,22]. The aims of this study were addressed through an analysis of data elicited via interviews assessing participants’ perceptions and attitudes. Finally, we offer guidelines that could help policymakers and data security professionals work together to ensure that the patient data is secure but also accessible. The suggested guidelines are described in Section IV, where we provide an interpretive analysis of the study’s findings and offer practical guidelines based on the results.
II. Methods
1. Study Design
We applied a naturalistic approach in this qualitative study to design and conduct 12 in-depth semi-structured interviews with the proposed group of data security managers and individuals in key cybersecurity positions within Israeli healthcare organizations. Based on the framework suggested by Guba and Lincoln [25], four criteria were considered for maintaining the trustworthiness of our study throughout all its stages as detailed below: credibility, transferability, dependability, and confirmability [26].
The interview protocol (Appendix 1) included questions addressing: (1) technological aspects, with an emphasis on cryptographic technologies; (2) organizational aspects, with an emphasis on the Israeli healthcare ecosystem; and (3) psychosocial aspects, with an emphasis on understanding the respondents’ perceived benefits and costs of alternative methods of patient data security, their willingness to adopt innovative cryptographic methods, and (perceived and actual) obstacles to adoption.
2. Participants
In order to create purposive sampling of key cybersecurity positions in the Israeli health system, an online search engine (Google) was systematically queried. The search strategy included a combination of keywords under two predetermined inclusion criteria: (1) healthcare institute or organization name (e.g., Clalit Health Services or Tel Aviv Sourasky Medical Center) and (2) name of the key position or senior job description (e.g., CIO or Head of division + Cybersecurity). The search identified 25 names of potential participants who were invited to take part in the study, of whom 12 participants (10 men and two women) from seven Israeli healthcare organizations accepted the invitation and volunteered to be interviewed. All participants held a senior position in their organization and had over 10 years of employment experience that included several positions in the fields of cybersecurity or information security, focused on the healthcare domain. Most participants were aged between 40 and 55.
Table 1 provides participants’ specialty, position, and the type of organization they represented, which are important data for understanding the possible transferability of this study, which refers to the degree to which qualitative data for a unique case is based on a broad representation [25,26]. As can be seen in Table 1, the sample of participants represented several types of sites (organizations) and several types of positions (interviewees), all of which are part of the healthcare system.
3. Data Collection
Potential participants were invited via email to participate in a 60-minute interview, noting that all collected data would be stripped of identifying details. The invitation included information about the research objectives, funding organization, and the principal investigators. The recruitment phase was carried out between January and March 2019. The research team members conducted face-to-face interviews over a 1-year period (May 2019 to May 2020) at the participants’ place of work. Considering the interdisciplinary nature of this study and in order to strengthen the credibility of the study by researcher triangulation [25,26], the interviews were conducted by two interviewers from different backgrounds of expertise (computer science and health policy). Using the funnel approach [27], interviews began with broad questions about information and cybersecurity management within the organization and then progressed to more specific questions about their familiarity with cryptographic methods and perceptions of the necessity and willingness to adopt them. In order to strengthen the credibility of the data [25], we concluded all interviews with an understanding check. This process helps verify that the qualitative data and its interpretation by investigators are congruent with the reality as grasped by participants [25,26]. Specifically, the interviewers concluded all interviews with a summary of what they understood was said by the study participant during the interview and then asked the interviewees if their summary was correct, and whether there were any further insights that should be included in the interview.
All participants provided informed consent to be interviewed, and ethical approval was granted for this study by the Ethics Committee of the Faculty of Social Sciences at the University of Haifa (IRB No. 19/081).
4. Data Analysis
In order to address the dependability of the study, consent to recording and full documentation of the interview was requested from all interviewees. All but one of the interviewees agreed to the documentation of the interviews, which were transcribed verbatim. The only interview not recorded was documented by the interviewers, who followed standards for taking notes and capturing data during semi-structured interviews [27]. Qualitative analysis of the data was performed using thematic network mapping [28] after each interview. First, three authors separately performed line-byline coding of the data, interpreted the data, and inductively identified concepts. Second, similar concepts were grouped into global themes, organizing themes, and subthemes, and conceptual links among themes were identified. Third, the entire team reviewed and refined the preliminary interpretations, added new themes, and produced a shared codebook. The new meaning units were independently reviewed by all authors, and consensus was formed during team meetings. This multi-stage data analysis enabled us to ground our conclusions on interpretations from several different perspectives, strengthening the confirmability of the study [25,26]. Furthermore, following the qualitative analysis principles presented by Charmaz [29], we conducted interviews over time, and the interviews provided insights and conclusions that shaped the evolving theoretical categories. Through this process, we also reached a point at which no further theoretical insights were revealed and saturation was achieved. The flow of the study is presented step-by-step in Figure 1, which describes the process by which conclusions were drawn.
III. Results
1. Main Findings
The analysis of the interviews allowed us to address our first two study aims (i.e., to assess current perceptions and attitudes). The findings indicated that participants in key data security positions did not believe that highly advanced cybersecurity is, or should be, a high priority for funding or adoption in their organization. Table 2 summarizes the theme mapping of this study. We identified three major barriers to the adoption of advanced cryptographic technologies for information security: (1) barriers associated with regulators; (2) barriers associated with healthcare providers (including organizations such as hospitals and HMOs and individuals such as medical staff); and (3) barriers associated with the vendors that develop and market cybersecurity systems.
2. Themes
1) Barriers associated with regulators
Most participants felt that the data security regulations with which they must comply were not aligned with the reality of data security in healthcare. Participants noted that regulatory standards were imprecise, often impossible to comply with in practice, and did not provide clear guidelines for application. Without clear and explicit regulatory standards, respondents expressed reluctance to petition for additional resources for upgrading security infrastructure.
Vague standards: “Drafts are issued and then stay at the draft level for two or three years, because there are a lot of questions raised that are never resolved. On the other hand, even when it [the draft] eventually comes out as a regulation—enforcement is not even at the minimum level, which results in everyone doing whatever they want.”
Lack of regulation: “The lack of regulation in our field is well known. The difficulties that information security faces in the medical world are endless because there are not enough resources… because there is no one that forces our management or the Ministry of Health to provide these resources… Suppose I now ask my management for a new million-dollar system. They will look at me – ‘What do you want from us? Where is it written that we need this?’”
Unrealistic regulations: “It is not wise to impose regulations without providing resources, just as it’s not smart to tell me to do something that I have no chance of doing. Look, for example, the regulator says all computers have to have Windows 10. Okay, but we have an OCT machine for eye photography with XP. You cannot fulfill the regulation! Replacing all devices according to the regulation would cost millions, and ‘It does not work that way.’”
2) Barriers associated with healthcare providers
Participants perceived the healthcare environment as dynamic, complex, and characterized by constraints that require balancing a commitment to patient data protection alongside organizational demands for efficient patient care and service, particularly the need to ensure continual access to patient data by the professional staff.
(1) Low capacity: Participants acknowledged the difficulties posed by the continually rising costs of cybersecurity when the resources available to them are very limited, in terms of both budget and professional human capital. They cited this tension as an obstacle to upgrading their security systems.
“Lack of resources also causes employee burnout. The existing resources are people… I’m not buying new systems anymore, because I can’t afford it with my existing resources [small number of employees].”
“Today I need to protect more and more vectors…the whole IoT world is coming in so I need to protect that as well…. I mean, it’s no longer just IT and medical devices. We have more vectors to protect but much lower budgets.”
(2) Business priorities: Some participants assessed that information security was not seen as a high priority in their organization. They believed that their organization prioritized resource allocation toward core healthcare activities rather than toward investing in data security infrastructure.
“I remind you that the hospital’s business is to provide care. One more PET-CT machine is more important than any of the organization’s cybersecurity. That is a risk assessment, at the economic level for sure.”
“One should always look at two aspects: information systems usually deal with the technological side, and the business management always looks at the business interest. Somehow information security was created to link business to technology, it is about balances, because there are limited resources.”
(3) The importance of an uninterrupted workflow: Several participants perceived there to be a tradeoff between data security and access, when excessive security might hinder the optimal workflow of the professional staff. Several participants (computer and information security professionals) felt that ensuring employees’ ability to access patient data was vital, even at the cost of less stringent security protocols.
“We are enablers, not preventers. We manage permissions for users who need them for various applications and systems... give access and not deny access. Doctors are not here 24/7... If we need their advice, it is necessary that they access the patient’s record remotely. The access is managed according to the guidelines set by the Ministry of Health and those we set ourselves.”
“I’ll tell you where it becomes a problem. Suddenly some of our users cannot work properly and then you have to start chasing an information security team that does not understand where the problem is. You have to call 30 people trying to understand who made the change that now affects you...”
(4) A responsive approach: Another recurring theme in our analysis was the participants’ approach to decision-making. Most participants in our study adopted a responsive approach to decision-making with regard to cyber-threats, rather than a preventative approach by investing resources in cyber-defense to mitigate future risks.
“Unfortunately, in the world of cybersecurity, as long as everything is fine then the management does not really see any need beyond a reasonable level. In May 2017, there was an attack on the world of healthcare. The management said: ‘We were not hurt? Ok. Next!’ Not every attack that hits someone else shocks them.”
“If someone were to ask for an extra budget for pandemic diseases in 2019, then they probably would not get a penny. The same also goes for cybersecurity. If there is a major event here, maybe even if people get hurt, then there is no doubt that everyone will wake up.”
3) Barriers associated with vendors
Participants discussed the cyber-defense systems they use on a daily basis as products that are expected to provide added value. When vendors fail to prove added value, there is a reduced likelihood that organizations will invest in the advanced cryptographic security systems that they offer.
(1) Unclear return on investment (ROI)/necessity: Some participants were skeptical about claims that cryptographic methods of cybersecurity would provide them with significant added value relative to the infrastructure they currently use.
“I think we would use existing tools and would not mess with it for now (cryptographic technology)… First, we look for added value.”
“It is difficult to prove the direct and immediate link between information security and ROI because it does not exist. The ROI that comes from information security is very long-term. This is risk minimization and not something that can be quantified in real money.”
IV. Discussion
This qualitative study examined the attitudes of individuals occupying key positions in cybersecurity and information security towards adopting advanced cryptographic methods for enhanced data protection in healthcare. Our results indicate that the Israeli healthcare system is not yet ready to adopt this technology, and we identified several barriers in the healthcare ecosystem that can account for this. The third aim of the study was to offer guidelines that could assist policy-makers and data security professionals in working together via an interpretive analysis of the findings. Indeed, we found that the results can offer new insights into the relationships between actors involved in patient data protection—healthcare providers, regulatory bodies, and the technological sector. It is noteworthy that most of the interviews were conducted before the COVID-19 pandemic, while others were conducted during the early stages of the pandemic. However, we did not identify differences in the themes raised by different interviewees according to the timing of the interviews.
The results of this study point to several implications and recommendations for enhancing patient data security within the Israeli healthcare system and reducing the risk of future data breaches.
1. COVID-19: A Call for Integration against Growing Threats
The COVID-19 pandemic has raised critical questions regarding how healthcare organizations and countries can and should protect patient data at a time when healthcare infrastructure is a particularly significant target for attackers. These questions involve stakeholders across multiple sectors— policy-makers, healthcare professionals, data security experts, the technological sector, and the public. The study findings reflect a responsive rather than a proactive approach towards cyber-threats in the healthcare field. However, at present, a breach of patient data of the type that has already occurred [18,19] may exact an even more devastating price than ever before. For example, patient data will now include patients’ history of COVID-19 infection and vaccinations. These data are highly sensitive. The process by which these data are collected, stored and shared will have widespread social, political, and economic implications. There is an urgent need for integration between stakeholders in order to develop data security policies that are clear and enforceable, but also well matched to the needs of the healthcare sector and aligned with products and technologies currently being developed in the market.
2. GDPR as a Model for Regulation
The results of this study underscore the central role of regulation as the key driving force for the adoption of enhanced security. Specifically, participants described a work environment in which regulations regarding the security of medical information are not applicable due to being unclear or unrealistic. Regulation provides a policy framework for evaluating and updating cybersecurity strategies and defining objectives at the national level. Yet, a comprehensive law for cyber-protection in Israel is currently only in the drafting stage. This fact hinders government bodies from enforcing consistent cybersecurity standards and guidelines in the healthcare sector [21].
Regulation also can serve as a driving force, provided that the specific regulations are realistic and supported by adequate funding and enforcement. However, effective regulation must avoid the potential pitfalls indicated by the participants of this study of erring toward being overly vague or overly specific. In either case, the outcome is identical, as a regulation can be ineffective either by failing to define clear mandatory requirements or by being so specific that its requirements are impossible, leading, de facto, to the regulation being ignored. To avoid such pitfalls, we recommend that regulators avoid specifying particular technological solutions, which are likely to soon become obsolete, and instead follow the example of the European General Data Protection Regulation (GDPR) in setting ethical standards, as has been customary in the European Union since 2016 [30], together with legal repercussions and enforcement mechanisms.
3. Collaboration between Vendors and Health Professionals in Market Research and Product Development
Study participants indicated that they were not convinced that innovative cryptography-based data security systems would provide them with a significant ROI. It is unlikely that advanced technological approaches to securing patient data will be adopted unless key stakeholders in the health system understand the benefits and value of these techniques. Furthermore, these stakeholders need to be persuaded that these techniques offer significant benefits compared with current data management procedures. The study results showed that advanced security is not a high priority among individuals in key cybersecurity positions, who prefer systems that can also guarantee the business interests of the organization. In this regard, technology developers should consider collaboration with health professionals in market research and product development to ensure that new cyber-technologies offer high protection from cyber-attacks, together with accounting for the demand for efficiency and access to data within the healthcare sector.
In conclusion, health organizations face a growing threat of cyber-attacks on healthcare providers and their systems. Thus, it is essential to map the various stakeholders that manage and protect patient data in order to understand their different perspectives. The study findings point to several major barriers to the adoption of advanced cryptographic techniques within these organizations. These barriers are related to organizational priorities, work processes, and the limited resources available within healthcare organizations. We highlight ways in which cross-sectoral collaboration may help address these barriers to enhance patient data security and how these would benefit the healthcare sector and the public.
The findings of this study also suggest that one of the key factors that may account for reluctance to adopt cybersecurity technology is a lack of coordination between relevant stakeholders. For example, regulators craft policies and technical guidelines related to cybersecurity that health organizations may be unable to implement in practice. From another perspective, vendors that develop cybersecurity solutions for the healthcare setting sometimes fail to convince healthcare organizations that their products can offer added value over existing solutions and will be a worthwhile investment of limited organizational resources. These circumstances create obstacles to the coordination and standardization of cybersecurity technology and its implementation in healthcare at the national level. The study results support the call for stakeholders in the healthcare sector to work collaboratively to facilitate discourse related to constraints, opportunities, and stakeholder needs for the protection of patient data.
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