As the app industry grows—current estimates are that downloads will reach nearly 270 billion by 2017—the opportunity for the medical device industry to create healthcare apps is vast.1 Yet, while these apps offer the potential to improve the complex world of healthcare, they can present many challenges related to safety, security and privacy issues. These themes are prevalent for all software and apps, but they are critical in the field of healthcare.
Safety and Security of Information
Whether or not they are related to healthcare, nearly all apps contain data such as names, location tracking and historical data that most people would consider personal. Mobile health apps typically collect data that is much more sensitive, as it contains health readings, monitoring information, diagnoses, medications and vital statistics. Adding to the inherently sensitive nature of the information an mHealth app is data gathering. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 contains specific security rules to assure confidentiality and information protection. One of the largest issues with mHealth apps is keeping personal health data safe and secure.
Devices that have a public interface or use a web server are especially susceptible, as they attract more potential security risks. Often, devices that reside solely within a hospital network are not adequately secured. For example, they may use default or common passwords given the expectation that internal hospital devices will only be used on the internal hospital networks. However, if an attacker is able to exploit employee credentials, he or she may gain unfettered access to all internal systems, which compounds the inherent risk any app has to be compromised.
Planning ahead is a critical step to protecting patient information. First and foremost, consider how your app will collect data, understand what data is needed for your app to function, and limit the data you collect to essential information. Then, determine which data, if any, will be shared with external servers and which will stay on the device. Also, consider what will happen as your app is updated in the future. Be prepared to wipe data that is no longer needed from both the device and external servers. Limiting data as you collect and store it will limit exposure and reduce the threat of breaches.
Whenever possible, plan to store all data without user-identifiable information. Instead, assign users unique identifiers that do not directly link to personal information. This safeguard helps to ensure that if someone gains access to a unique identifier, this person cannot access information in the app. Using defensive programming strategies is also an important process that all medical software should employ as a key mitigation technique for cyber security.
Be prepared to test apps to ensure that they are keeping data secure. Determining vulnerability in data transmission is crucial and will help ensure the security of user data while being HIPAA compliant. HIPAA is very concerned with user data, and testing for security and encryption of data at motion as well as at rest are crucial to the development process. It is important to test how the data is being sent from origin to destination and utilize encryption algorithms to handle data.
As seen recently, no amount of testing can keep software immune to attacks. However the right kind of security testing and protection can make an app less susceptible, in turn keeping user information and brand reputation safe. Having security built into the app itself is one of the most effective ways to keep an app HIPAA compliant and safe from attacks.
In addition to considering what information an app will gather, developers must also consider how to handle the data that is collected. This is where in-app security comes into play. Whether through PINs, passwords, or timeout features, it is imperative that methods are employed to the need for user control, security and interaction.
There is a fine balance between security and usability. It is important to develop an app with the user in mind, while also ensuring security isn’t being sacrificed. Understand how users will interact with software. Doing so will make securing function easier. For example, while an app may allow for a four-digit PIN to access data, having a lockout for entering the wrong PIN more than five times should deny further access. Allowing an infinite number of tries could allow an attacker to exploit the intended safety feature of a PIN to try numerous combinations. The balance here is a minimal inconvenience to the user with five attempts, while limiting unauthorized access.
Allowing users to manage their data however they choose is a key benefit in mHealth apps. For any sensitive information, give users the opportunity to agree to its use at all. For example, many general apps inform a user when they want to use current locations, and users can elect not to share that information. Users should be able to categorize and delete data without concerns that the data will reappear elsewhere or be stored. Likewise, users should have to the option to opt out of data collection or sharing altogether. In general, companies should take the default stance that users do not want to share data with anyone but a healthcare provider. Taking this approach will ensure that any information shared is explicitly approved by the user.
It is important to consider how to handle data that is collected. User data should not be sent off a device, unless absolutely necessary, and secure channels such as SSL/TLS should be used. Defensive coding also helps limit the damage a user can inflict by using mechanisms that account for negative inputs and providing a predictable response. Encrypting data is also good practice in securing information, as is the use of hash values, instead of Mobile Equipment Identifiers (MEID) or International Mobile Equipment Identifiers (IMEI) numbers. Two-factor authentication is especially useful for sensitive information like medical data. Finally, testing to ensure an app isn’t logging data inappropriately without the user’s or developer’s knowledge can address any final security concerns.
Because the apps in question are destined to handle sensitive data and are subject to additional layers of legal requirements such as HIPAA, it is important for developers and manufacturers to employ best practices for continuing to protect patient privacy. In addition to the steps outlined above, some general practices throughout the app development process can also assist in developing a successful app versus a failed one:
- Familiarity with the industry. Get to know the healthcare industry to better understand what apps might be useful. Consider involving a subject matter expert to help ensure the app is helpful, relevant and necessary to the industry. Additionally, educate yourself on the rules and regulatory requirements that may apply to your app. For example, in addition to HIPAA, if the app is diagnostic in nature, there may be additional FDA regulations that apply.
- Prepare for general usability issues. Human factors can offer surprises to developers and users alike. Planning for usability issues—both those you can anticipate and those unforeseen—is essential. While you can’t predict all the usability issues that might arise, you can have a plan in place for addressing such issues, should they emerge. Knowing how you will address both types of issues can save everyone a lot of headaches down the road.
- Test Products. Be prepared to test apps for security. Conducting tests to make sure an app isn’t sharing information, sending information unknowingly, or is easily compromised can save developers and manufacturers from many headaches down the road. Additionally, testing is required if your application is diagnostic in nature; specifically it requires proof that the product can diagnose with a certain amount confidence to whatever product or functionality the app is replacing. For diagnosis apps, you are considered a medical application from the start, which means you have to meet all the normal medical equipment/equivalency rules. To that end, consider third-party testing, as a fresh perspective towards your app, coupled with knowledge of the industry, to help identify weaknesses, potential issues and determine the strengths of your product.
As the number of mobile health apps continues to grow, concerns about privacy, safety and security are at the forefront of many minds, including patients, healthcare providers, regulators, developers and manufacturers. Taking the extra steps from the start to ensure an app’s overall security and privacy standards are in place can help alleviate those concerns and pave the way for successful app development, creation and success in the market place.
- Mobile App usage – Statistics and Facts. Statista. Accessed June 10, 2015. Retrieved from: http://www.statista.com/topics/1002/mobile-app-usage/.