Emergency Health Protocols Supporting Health Data Exchange,

Cloud Storage, and Indexing

Konstantinos Koutsoukos

1,2

, Chrysostomos Symvoulidis

1,2

, Athanasios Kiourtis

Argyro Mavrogiorgou

, Stella Dimopoulou

1,2

and Dimosthenis Kyriazis

Department of Digital Systems, University of Piraeus, Piraeus, Greece

BYTE S.A., Athens, Greece

Keywords: Emergency, Electronic Health Records, EHR Cloud, Remote-to-Device.

Abstract: The health industry has evolved significantly through the last years by adapting to the new technologies and

exploiting them in order to upgrade the services that provides to the people. In this context, a lot of effort has

been focused on converting medical documents to electronic health records and storing them online. However,

taking into consideration the current innovations, it is doubtless that there are many limitations when these

proposals are applied in a real-life scenario. For this reason, this paper proposes a system that combines

electronic data storage and health record exchange between individuals and authenticated medical staff in a

secure way. The specific recommendation is being evaluated through the corresponding applications and

protocols that are developed and finally, the results exhibit the solutions over existing gaps.

1 INTRODUCTION

The Healthcare industry is increasingly adopting new

technologies to enhance and facilitate citizens’ care.

Over the years, paper-based medical records have

been replaced with Electronic Health Records (EHR).

EHRs offer real-time updates of data and access from

any authorized user all around the world. Healthcare

organizations are taking advantage of modern

technology and devices such as mobiles, wearables,

sensors, etc., to gather more precise information

about the citizens and eventually offer appropriate

treatment (Zewe, 2021). The long-range scope of this

initiative is to improve the quality of life by predicting

deadly diseases, monitoring citizens’ habits, and

intervening when it is needed.

Even though almost every Health Organization

uses EHR technologies, in most cases, it is

implemented locally or in association with limited

health centers. Therefore, when a citizen needs to get

treatment and has to interact with multiple Healthcare

Practitioners (HCP), the health information is not

exchanged among them and needs to be done

traditionally, since they are not connected to a central

health network.

Consequently, a common mechanism that is used

by every healthcare organization can enhance the

HCPs’ services and offer a better treatment service to

the citizens. By exploiting two communication

protocols that will be analyzed later in Section 3 of

the paper, the EHR can be uploaded to any available

cloud service and be safely stored. Additionally,

whenever an HCP needs access to the citizen’s health

record, an intermediate mechanism will redirect her

to the health record location where the information

will be up to date. For example, in the case a citizen

has multiple appointments to attend, the data will be

immediately updated after treatment for the next HCP

to use.

The vital importance of such a mechanism is

becoming better understood by applying it to an

emergency scenario. In the case a citizen needs

immediate treatment, multiple stakeholders should be

able to gain access without any delays and the

information must be accurate and up to date. By

assuming that the citizen has made some changes or

has visited a doctor a short time before the accident,

there is a high risk that the newly generated data will

not be available to the HCPs. And in such cases, there

is no room for unnecessary risks. In this context, this

paper proposes the protocols that are responsible for

the proper communication and data exchange

between citizens, healthcare practitioners, and cloud

providers. Moreover, it suggests a background

service which facilitates the handling of urgent

Koutsoukos, K., Symvoulidis, C., Kiourtis, A., Mavrogiorgou, A., Dimopoulou, S. and Kyriazis, D.

Emergency Health Protocols Supporting Health Data Exchange, Cloud Storage, and Indexing.

DOI: 10.5220/0010878900003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 5: HEALTHINF, pages 597-604

ISBN: 978-989-758-552-4; ISSN: 2184-4305

597

situations, when the citizen is not able to grant access

to the uploaded data.

The rest of the paper is organized in the following

sections. Section 2 introduces the related work and

research that has been conducted regarding the

communication between the involved entities, the

techniques used to redirect users to the proper

services, and the security aspect of the data exchange.

It also highlights the deficiencies of these systems and

recites the features that the proposed mechanism

should cover. Afterwards, the overall methodology is

presented in section 3 by analyzing the involved

applications and by explaining the real-life scenario

step by step. Section 4 includes a demonstration of the

system’s functionality and makes a thorough

evaluation. Finally, section 5 introduces the research

conclusions and results as well as future plans.

2 RELATED WORK

2.1 Remote-to-Device (R2D) Backup

Protocol

The communication between user applications and

cloud providers is rapidly becoming a common

occurrence since it facilitates the storage of vital

personal data and its fast and constant retrieval. To

begin with, Dropbox (Dropbox for HTTP

Developers, 2021) offers the possibility to connect an

application with the cloud and interact with each

other by exchanging data. This is achieved by a group

of APIs that support the communication through a set

of HTTP endpoints that are used to establish the

communication between the two entities. In the same

direction, DataVaults (DataVaults Empowering

Secure Data Storage, Sharing and Monetisation,

2021) aims to give users the ability to fully

manipulate their data and share it with other

organizations or individuals by adopting adjustable

sharing schemes. Meanwhile, it offers an innovative

framework whose main scope is to gather information

derived from several sources and finally provide them

in a secure and interoperable manner to the users. As

the overall purpose of the paper suggests, these

technologies offer limited functionalities when it

comes to time efficiency. Therefore, it makes sense

that this kind of services should not be trusted with

vital data such as EHR.

2.2 Remote-to-Device (R2D)

Emergency Protocol

Many cloud providers offer the opportunity to handle

emergencies and other situations where data access

from third parties has a vital significance. Concerning

this, some services provide APIs that are responsible

for sharing the data with one or more stakeholders

when needed. At the same time, several studies have

proposed ways to cope with health-related incidents.

In (Oliveira et al., 2020) the authors suggest a Red

Alert Protocol (RAP) to address situations when the

citizen is not conscious. In the emergency session, a

central authority links the responsible treatment

teams to the citizen’s EHR which is stored in the

cloud. Using an access token to download the data

and an emergency key to decrypt it, the medical staff

acquires access to the medical records. After the

procedure, the access tokens are either removed or

expired and the HCPs can no longer use the citizen’s

information. Although this approach offers an

innovative way to deal with emergencies, it cannot be

used in other occasions such as medical visits. In that

way, a health organization should integrate more

systems for different situations and create a complex

procedure. In a similar manner, (Banerjee et al., 2013)

talks about a centralized cloud database that will store

every user’s medical history in a single standard-

formatted and interoperable document. By exploiting

the multi-document summarization technique, the

system creates a single summarised document that

contains the complete medical history of that person.

Using a graph-based ranking algorithm the system

creates a summary for every single document and

then a meta-document is produced to generate the

result. The main concept is to authenticate the citizen

with the use of biometric data and finally retrieve the

appropriate data to use for the operation. Even though

biometric authentication is an efficient way to access

personal records, it should not be the only option

since, in emergency cases the citizens’ condition may

not support this procedure.

2.3 Health Record Index

Health record indexing is a very crucial procedure

since the quick response and retrieval of the requested

data can be lifesaving. Especially when there are

more than one sources that EHR can be stored to, this

challenge is a lot more demanding. Several types of

research and studies take into consideration that the

needed information may be distributed in different

sources and need to be gathered. Primarily, the

authors of (Ehler et al., 2007) proposed an

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Information Retrieval (IR) tool to index and retrieve

citizens’ EHR. The system creates a table for each

document which contains a table with every word in

the document along with its frequency rate. Taking

into consideration the query, the system locates and

retrieves the documents that contain the query

keywords at a high-frequency rate. The authors in

(Wan et al., 2019) dealt with geographic data

collected from the real world through sensors. Real-

time data creates a challenge since it can be

unpredictable. Hence, they proposed a

multidimensional data indexing scheme to handle

large queries. The proposed methods are utilizing

hierarchical indexing structures by running binary

space partitioning (BSP) algorithms like kd-tree,

quad-tree, k-means clustering, and Voronoi-based

methods striving for better efficiency with less

latency. After a set of detailed simulations, it resulted

that the Voronoi diagram data index model is the most

suitable since it minimizes the average query

response time and energy consumption. These are the

parameters that have stimulated the interest of the

researchers. Finally, a recent study (Yao et al., 2018)

demonstrates an indexing mechanism over EHRs.

The overall concept is referring to citizens as data

owners and they are responsible of their own data.

Doctors, health sensors or any source that can

generate data is referred as data provider. Given the

owner’s consent, they can upload EHR to the cloud

along with an index which will be used for the

retrieval. Coming from any source, the data is always

encrypted before being uploaded to the cloud. The

request for the health records is performed in the form

of a query from an authorized health provider. The

cloud service indexes the stored data according to the

corresponding indexes and returns the proper medical

data without decrypting it. Eventually, the provider

can access the records with the use of a decryption

key. The idea of uploading EHR to a publicly

reachable location with the proper security has

significantly enhanced the communication between

medical personnel and citizens. However, these

techniques have limited efficiency when it comes to

emergencies. In most cases, the proposed way to

identify the citizen is through credentials, which it

will be a major obstacle when the data accessing is

vital. Furthermore, the proposals are trying to deal

with specific problems and circumstances and are not

flexible enough to accommodate different conditions.

2.4 Encryption Mechanisms

When it comes to personal health data it is crucial to

study thoroughly the security aspects of the proposed

system. Therefore, encryption techniques are used to

prevent internal attacks as long as secure data

transfer. Since there is a large number of security

techniques, there are studies that focus on choosing

those that can be used in the health industry.

According to (Madnani et al., 2013) these are

symmetric-key cryptography, public-key

cryptography, and attribute-based encryption. In

(Abbas et al., 2014) the proposed system encrypts the

data using an encryption key known by the cloud

provider. However, this approach raises the concern

of internal attacks considering that acquiring that key

gives access to all the stored data connected to it. The

proposal in (Yang et al., 2019) presents a system that

combines attribute-based encryption and password-

based break-glass (Scafuro et al., 2019) key to create

a self-adaptive access control scheme. More recently,

(Oliveira et al., 2020) suggests the involvement of

ciphertext-policy ABE (CP-ABE) associated with

emergency situations’ policies.

2.5 Advancements beyond the Related

Work

Resulting from the previous studies and works it has

been obvious that the storage of medical records in

cloud repositories has been rapidly evolved regarding

the plurality of services, techniques, and consistency.

Nevertheless, the ability to handle emergency

situations is what challenges the researchers since it

is very demanding to combine punctual reaction and

security. Additionally, most of the proposals are

restricted to a certain country’s infrastructure or

adjusted to a specific scenario with known and tested

circumstances. As a result, this paper proposes a

system that tries to eliminate these gaps. This is

achieved by making the service centralized so that

authenticated personnel can gain access regardless of

the country where the citizen comes from. Moreover,

it attempts to create a paradigm that HCPs can use to

download the EHR even when the citizen is

unconscious. It is important to propose a way to

secure the data in every stage of the process. Finally,

the recommended service should be applicable to any

possible scenario while it complies with all the

parameters.

3 METHODOLOGY

3.1 Involved Applications

To better understand the overall methodology, the

involved terminologies should be presented and

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599

analyzed. All the following applications are

developed in the context of the Interopehrate research

project for this research.

3.1.1 S-EHR Application

The Smart-EHR application is a mobile application

developed to be used by citizens. This application

stores locally the user’s EHR and data generated by

sensors or after a medical visit. Additionally, the user

can use the application in order to upload the EHR to

a S-EHR Cloud of their choice. Finally, as will be

thoroughly described in the following section,

citizens may give their consent for the EHR to be

accessed by authorized HCPs in emergency

situations. When a citizen registers to the service, a

Quick Response (QR) code is generated. This QR

code contains crucial information such as the

citizenId, an emergency token, an encryption key, and

the Health Record Index (HRI) location (Kiourtis et

al., 2021).

3.1.2 S-EHR Cloud

The Smart-EHR Cloud as presented in (Symvoulidis

et al., 2021) is a cloud service that provides storage

for EHRs. Taking into consideration that users have

previously agreed to share this data when needed,

authorized HCPs can access these records and use

them to treat the citizen as will be depicted later.

Furthermore, storing health data in the cloud can be

used as a backup in case the citizen’s device is

damaged or unreachable. Lastly, the S-EHR Cloud

stores audit information that keep track of every

procedure made by clinicians or citizens and can be

accessed through the citizen’s S-EHR app.

3.1.3 HCP Application

HCP application is a software application, operated

by medical staff and provides a way to access cloud

storage and download citizens’ health data assuming

that it is encrypted, and authentication operations

have been completed. More precisely, by exploiting a

set of credentials that identify both the clinician and

the healthcare organization, the system confirms that

the request is originated from an eligible and

authenticated source. Since the overall system needs

to be supported across Europe, every HCP app uses

an integrated translation system that converts the

crucial information into the appropriate language

(Bella et al., 2021).

3.2 Emergency Scenario Overview

This section demonstrates the precise procedure that

every entity is going through by the time an

emergency occurs. Moreover, the actions that need to

be done prior to this incident are also analysed by

examining the protocols.

3.2.1 R2D Backup Protocol

This protocol focuses on the preliminary actions that

need to be done when a citizen starts using the S-EHR

application. Its purpose is to allow users to safely

backup their health records in a remote repository and

correspondingly download them at any time

(Symvoulidis et al., in press). Likewise, in this stage,

the citizen may sign a consent that allows HCPs to

have access to the stored data if it is necessary.

Figure 1: R2D Backup Protocol.

In Figure 1 the general idea of the protocol’s

functionality is depicted by presenting the main

operations taking place between the entities. As

detailed below, the complete procedure consists of

the following stages. Formerly, the user registers to

the preferred cloud service through the Smart-EHR

application. Later, several consents need to be signed

by the user to allow the S- EHR Cloud to store the

data and agree with the sharing of the medical record

with authorized medical staff. It is important to note

that the latter is an optional consent. In the case the

user accepts the first term, it results in generating an

access token which is sent to the mobile device. As a

result, the S-EHR application generates an encryption

key which will encrypt the data before uploading it to

the cloud. By the time the citizen agrees with the

second term, there is a sequence of actions that are

taking place. Firstly, an emergency token is generated

and stored in the app. Secondly, Smart-EHR sends

information to the HR Index, containing the cloud

provider, the citizen’s username, and the emergency

token. Then a QR code is created, containing the

encryption key, the emergency token and information

regarding the user’s HRI entry such as a citizen ID.

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However, if the latter consent is not signed, the cloud

will not be able to share the data with any third parties

and the selected service will be only used as a backup.

Taking into consideration that the first consent has

been signed, the user is able to upload the EHR to the

cloud. Using the encryption key, which is stored in

the app, the health data is being encrypted and

uploaded to the S-EHR Cloud. From now on, the

uploaded records will be automatically updated if any

changes are made to the local files. Finally, in case

the citizen uses a different device, it is always

possible to login to the S-EHR application using the

credentials and download the health records from the

cloud which will then be decrypted and accessible

through the application. It is worth mentioning that

the user can any time withdraw the consent and

change the permissions to the data.

3.2.2 R2D Emergency Protocol

The R2D Emergency protocol is an internet-based

protocol which defines the actions that are taking

place between the S-EHR Cloud and the HCP

application when an emergency occurs in order to

allow the HCP to access the citizen’s health data from

the S-EHR Cloud (Symvoulidis et al., in press). Both

protocols support Fast Healthcare Interoperability

Resources (FHIR) for the exchange of EHRs

(Kiourtis et al., 2018). Moreover, compliance

checking is performed to the exchangeable files to

assure advanced interoperability.

Figure 2: R2D Emergency Protocol.

Figure 2 shows the sequence of the performed

operations when a citizen is admitted to the hospital

due to an emergency. At the initial phase of the

emergency, the HCP who is responsible for the

patient’s treatment needs to collect the QR code and

scan it to acquire the necessary information for the

operation. As described in section 3.2.1 the QR

scanning provides the emergency token which will be

used to make the request to the S-EHR Cloud, the

encryption key that will decrypt the data as long as it

is downloaded, and finally, information about the HR

Index entry to retrieve the cloud location. Following

the successful scanning, an automatic request is sent

to the HRI, and the cloud provider used by the citizen

is returned as a response. Hence, the HCP has

everything that is needed to request the citizen’s EHR

from the cloud. With the use of the emergency token

along with the HCP and healthcare center attributes,

the S-EHR Cloud approves or declines the request. In

the first case, the data is downloaded in an encrypted

format and can then be decrypted locally using the

encryption key. Otherwise, the connection is

terminated and no interaction with the data is

possible. It is worth mentioning that after the

completed verification, the connection remains open

so that the medical records on the cloud will be

updated with the new encrypted data after the

treatment is completed and the patient is discharged.

All this time, the S-EHR application creates a

notification to the citizen’s mobile regarding the

actions made by the HCP over their medical records.

3.2.3 Health Record Index

The role of the HR Index has been stated previously

with the description of the protocols. To better

understand its utility, the scenario needs to be tested

on a situation with special parameters. As it was

explained previously, the citizen chooses a cloud

provider to upload the medical information and then

acquires a QR code which will be printed also on a

card for easier access. Without the HRI, the QR code

would contain a direct link to the cloud service. On

the assumption that the user decides to use a different

cloud service, the records will be removed from the

first cloud and be encrypted and uploaded to the new

one. Supposing that an emergency occurs, and the

citizen needs to be treated immediately, the HCP will

scan the QR code as depicted earlier and will be

redirected to the wrong cloud location which does not

store the user’s records. Health Record Index

overcomes this issue since it is automatically updated

when the cloud is changed and functions as a

mediator between the HCP and the cloud. As a result,

the scanning will always return real-time information

to the health center and will prevent vital

implications. It is worth mentioning that the HR Index

is a background service and neither the S-EHR

application user nor the HCP has direct interaction

with it.

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3.2.4 Encryption Mechanisms

Every stage of the overall process should be

characterized by indisputable security. When it comes

to personal health data, any risks should be eliminated

on data storage and on data transit. Therefore, both

protocols are using a set of encryption technologies to

safely transfer the data and also to allow only certified

entities to have access. R2D Backup protocol uses the

Advanced Encryption Standard 256 (AES-256)

which is a symmetric-key algorithm to encrypt the

data locally in the S-EHR app. This means that a

single key is used for both encryption and decryption.

This key is exchanged between citizens and medical

staff through the QR code after scanning.

Additionally, when citizens use their credentials to

log into the S-EHR Cloud, a JSON Web Token is

returned to the mobile application. Then with the

proper JWT authorization, the encrypted data can be

uploaded to the cloud.

4 EXPERIMENTATION

4.1 Working Environment & Scenario

In this research, a set of services and libraries were

developed to demonstrate and test the functionality.

Specifically, the HCP application and the HR index

have been developed in Java v.8.0 while the S-EHR

application runs on Android v4.3.1 and above.

Regarding the two protocols, a set of Java libraries

were built to implement the communication of the

components according to the protocols’

specifications. Figure 3 demonstrates all the involved

entities and the interactions between them, in the

context of the evaluation scenario that has been

implemented.

Figure 3: Overall scenario and interactions.

4.2 Preliminary Evaluation

To practically test the operational qualification of the

system, the developed services were used to

demonstrate the citizen’s user experience. At the

beginning, the citizen registers to one of the available

S-EHR Cloud providers through the S-EHR

application as shown in Figure 4. Later, two consents

need to be signed regarding the health record storage

on the cloud for backup purposes and then to allow

authorized HCPs access the health data. The

corresponding functionality is depicted in Figure 5,

Given that the consents are signed, the citizen uploads

the EHR to the S-EHR Cloud provider via the R2D

Backup protocol.

Figure 4: S-EHR Cloud registration.

Figure 5: Consent approval option.

After the successful registration, the encrypted

data is uploaded to the cloud and the QR code is

created and presented to the users along with options

to change their preferences and optionally revoke

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their signed consents. From this time, the local files

are periodically synchronized with the cloud to keep

them up-to-date. This step summarizes the user

interface regarding the Smart EHR application.

At a later time, an emergency occurs and the

citizen is transferred to the Healthcare organisasation

where HCPs need to address it in order to offer direct

treatment. To do so, they must provide their attributed

credentials to log into the HCP app. Since the citizen

is unable to assist the clinicians with vital personal

information, the unique QR code is scanned through

the HCP app. Following the scanning, the involved

information is presented encrypted in the application

interface. At this point, the HCP can request access to

the EHR. Providing the information is right and the

credentials are validated by the S-EHR Cloud, a

success message will inform the medical staff that the

connection has been established and they can access

all the citizen’s data in a structured way, via the R2D

Emergency protocol, as depicted in Figure 6.

Figure 6: EHR through the HCP app.

After the treatment, the HCP compiles a

Discharge Report with the procedure details along

with therapy and future recommendations and

uploads it with the updated data to the S-EHR Cloud.

5 CONCLUSIONS

The healthcare field has recently presented many

advancments regarding the exchange of data between

HCPs and citizens. However the limitations of the

existing systems have created the need of a proposal

that offers a functionality beyond these restrictions.

This paper, proposed a system that can take these

studies a step further. For this reason, two protocols

were defined to facilitate the secure backup of

medical data to EHR-based cloud providers and

enhance the exchange of crucial data between

Healthcare Professionals and citizens during

emergency situations. Additionally, HRI is offered to

deal with the case there are multiple cloud services

and redirect the medical staff to the proper one.

During the evaluation process, some restrictions

came up that did not comply with the initial scenario

design. For example, there is no assurance that the

citizen’s QR code will always be reachable. Morever,

the effort has been focused on handling emergency

occasions. This approach could also be applied in

other situations such as everyday medical visits but

without the proper functionalities since this paper

does not cover that view.

Therefore, concerning the following steps, the

goal is to extend the area where the protocols function

in order to be applicable in more scenarios with the

same performance. Besides, the QR code accessing

should be evaluated and saved in a way to be always

available. For the time being, QR code is the main

tool for data accessing in emergency scenarios, but

the fact that its complexity is increased as more

information is stored, it may create the need to

examine other possibilities like Near-Field

Communication (NFC) tags (Vidakis et al., 2020).

Finally, it is important to constantly improve the

performance of the protocols as far as efficiency and

security is conserned, since the needs and the figures

are always changing.

ACKNOWLEDGEMENTS

The research leading to this result has received

funding from the European Union’s Horizon 2020

research and innovation programme under grant

agreement No 826106 (InteropEHRate project).

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