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16. Most U.S. health care providers continue to maintain patient records on paper, but current trends in clinical care, consumer health, public health, and health finance all indicate a shift to electronic records. Without such a shift, the health community's ability to take full advantage of improved networking capabilities would be severely limited. With such a shift, the need for convenient, effective, and flexible means of ensuring security will be paramount.

17. Tools such as Back Orifice can enable a hacker using the Internet to remotely control computers using Windows 95, Windows 98, or Windows NT. Using Back Orifice, hackers can open and close programs, reboot computers, and so on. The Back Orifice server has to be willingly accepted and run by its host before it can be used, but it is usually distributed claiming to be something else. Other such clandestine packages also exist, most notably Loki.

18. For a discussion of key distribution centers, see CSTB (1999), pp. 127-128.

19. For a discussion of some of the limitations of PKI systems, see Ellison and Schneier (2000).

20. It should be noted that when using SSL, data are decrypted the moment they reach their destination and are likely to be stored on a server in unencrypted form, making them vulnerable to subsequent compromise. A number of approaches can be taken to protect this information, including reencryption, which presents its own challenges, not the least of which is ensuring that the key to an encrypted database is not lost or compromised.

21. Whereas one organization may issue a certificate to anyone who requests one and fills out an application, another may require stronger proof of identity, such as a birth certificate and passport. These differences affect the degree of trust that communicating parties may place in the certificates when they are presented for online transactions.

22. Additional information on the Intel initiative is available online at <>.

23. Participating organizations in the HealthKey initiative are the Massachusetts Health Data Consortium, the Minnesota Health Data Institute, the North Carolina Healthcare Information and Communications Alliance, the Utah Health Information Network, and the Community Health Information Technology Alliance, based in the Pacific Northwest. Additional information on the program is available online at <>.

24. Users can do this, for example, by registering their public keys with a public facility, such as the PGP key server at the Massachusetts Institute of Technology.

25. Computer scientists generally consider system (or network) availability to be an element of security, along with confidentiality and integrity. As such, availability is discussed within the security section of this chapter. Other chapters of this report discuss availability as a separate consideration to highlight the different requirements that health applications have for confidentiality, integrity, and availability.

26. Cable modems and DSL services are typically not attractive to businesses, either because the number of connected hosts (IP addresses) is limited or the guaranteed minimum delivered bandwidth is low. In the San Francisco Bay Area, asymmetric DSL delivers anywhere from 384 kbps to 1.5 Mbps, depending on many factors. In other areas, DSL with 256 kbps/64 kbps down/up link speed costs approximately $50 per month, but the costs skyrocket quickly to roughly $700 per month for 1.5 Mbps/768 kbps down/up link speeds.

27. Quality of service mechanisms, such as integrated services, might help ameliorate contention for cable bandwidth, but only if the technology is widely deployed.

28. There is at least one way to hide the identity of the sender: All e-mail applications can be spoofed.

29. Intel Corporation introduced an identifying number into its Pentium microprocessors to help servers identify client machines in the hopes of facilitating electronic commerce. Public concern over the privacy implications of this capability caused the company to take the additional step of providing a means to prevent the number from being revealed.

30. This is essentially what a filtering firewall does: hides the identities (IP addresses) of those behind it.break

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