Abstract

At present, the health- care industry is experiencing a dynamic shift mainly characterised by the use of modern technologies in developing patients’ interaction. Nevertheless, the nature of all the accumulated data in healthcare is rather sensitive and the demands of current legislation like HIPAA or GDPR require that the software be adequately secure and fully compliant. DevSecOps, a practice incorporating security throughout the SDLC, offers a solution to the healthcare industry that DevOps could not. The following work focuses on the effects of DevSecOps during patient engagement application development with enhanced security and compliance. In this paper, such basic concepts as security automation, continuous compliance checking and code security are explained in detail to outline a four-step methodology applicable to healthcare. The work includes case studies, risk studies, implementation issues and comparing traditional DevOps and DevSecOps. Hence, there is a focus on SAST tools, DAST tools, container security and IaC scanning. Last, it emerges that security should be imbued as a foundational mindset and that development teams should be constantly trained. As the findings suggest, adopting DevSecOps also reduces risks for the organization. It furthers compliance and proper security while at the same time improving the speed and stability of software delivery, making this approach critical to the healthcare sector.

Keywords: DevSecOps, Healthcare Applications, Security Automation, Compliance, Patient Engagement, HIPAA, GDPR

1. Introduction

1.1. Importance of DevSecOps in healthcare

Several issues make application development challenging in the healthcare industry, security and compliance included. These are significant challenges due to the nature and importance of patient information, which can only be exchanged, shared, stored and analysed in compliance with the more stringent norms like HIPAA and GDPR (Health Insurance Portability and Accountability Act and General Data Protection Regulation, respectively)^1-4. Several challenges are associated with the current approach in software development; DevSecOps, which focuses on software security during the software development SDLC, is an innovative approach to overcoming these challenges. When introduced at the initial stage and integrated throughout the application development process, DevSecOps increases the chances of delivering secure and compliant healthcare applications. Based on these factors, the following are why DevSecOps is relevant in the healthcare sector (Figure 1).

Figure 1: Importance of DevSecOps in Healthcare.

 ·Protection of sensitive patient data: As in any other field, patient information privacy is essential in the healthcare system. Personal records, diagnosis, disease states and organizational financials are some of the heightened information data that healthcare systems contain and thus are vulnerable to psychopathic attacks. Traditional security models of computing, which are achieved through implementing a security layer at the end of system development, are potential security threats. DevSecOps means that security measures, such as encryption, accessing control and vulnerability scanning, must be implemented from the development side. These safeguards addressed in this guide prevent data loss and privacy invasion, ensuring patients’ confidentiality and confidence in healthcare facilities.

·Compliance with regulatory standards: In this emerging sector, to address the needs of patients, technological solutions and strict rules and requirements like HIPAA, GDPR and PCI-DSS have to be followed. These regulations require that healthcare providers keep patient information and ensure that information management is open. They are also punishable by fines, litigation and damage to the company’s image. Through DevSecOps processes, it is easy to incorporate security compliance while designing, coding, testing and even deploying a particular software solution since the latter flows relatively in a structured pipeline. Thus, through compliance automation, DevSecOps optimizes compliance throughout the SDLC, lowering the probability of compliance issues on authorized healthcare applications and improving the compliance assessment processes.

·Improved time to market with better security: The healthcare industry is bearing the roller-coaster of change in applications that can be implemented to enhance patient experience, interaction and organisational effectiveness. Albeit, the deployment time of these applications should not be affected at the expense of a hazard-free environment. DevSecOps involves all teams in development, security and operations and ensures security becomes part of the process incorporated from the word go. This speeds up the development and shortens the time to market while overshadowing some essential security measures within the application. DevSecOps, therefore, enables quick deployment of safe applications, rolling out better security measures and, therefore, continual testing into the CI/CD cycle.

·Continuous monitoring and risk mitigation: The healthcare industry is constantly developing new security threats and methods of threats, which are getting more frequent. One advantage of DevSecOps is that it monitors and alerts constantly rather than acting merely as a final safety net. By implementing security as code early in the development life cycle, DevSecOps helps to identify and mitigate security issues in operational environments. Tools such as SAST and DAST scan codes for vulnerabilities constantly, while runtime protection pinpoints threats in runtime environments. This systematic approach helps identify and act on threats before they become security issues threatening to compromise data or physical assets.

·Strengthening the synergies between the development and the security functions: DevSecOps creates a system where development, operations and security are in sync. In other words, no silos. In most healthcare-related projects, the work is carried out by cross-functional teams and the sense of ownership that everyone has is appropriate to ensure that the security of the applications under development is not considered an add-on or an incremental factor but is encoded in the development lifecycle. It fosters convergence and helps identify security problems and embrace the finest security development processes much earlier in the process. Therefore, security issues are resolved and distributed because individuals usually do not consider certain aspects of their weaknesses; they are overseen, allowing for the implementation of a unified strategy for healthcare application security.

·Enhancing patient trust and satisfaction: Healthcare consumers provide their most personal details to healthcare entities when seeking help. But when they use health care apps, they expect their details to be protected. This often-incurred trust can be betrayed and the implications can be severe, including being sued or heavily penalized and losing reputation and patients. That way, the concept of DevSecOps was developed to implement security and privacy consistently so that users could be trusted. With operational and compliance tests performed automatically, healthcare firms are dedicated to safeguarding patient information and delivering safe digital care. This bolsters the patient’s trust in the given system, which is crucial for using digital health technologies.

·Cost efficiency through early vulnerability detection: Traditional pre/post development security assessments FC laughingstock security when issues are found in the post-development phase must be remediated at a far higher cost with increased time costs than corrections made during the development cycle. Thus, DevSecOps presupposes detecting the threat, including introducing the security testing processes into the SDLC. This reduces the cost of fixing vulnerabilities because problems can be solved at the development stage, not at the deployment stage when many problems must be patched. Moreover, generalising security measures allows avoiding the build-up of technical debt and entailing long-term cost-saving benefits for healthcare constituents.

1.2. Need for DevSecOps in healthcare

Adopting a cultural approach, the conventional DevOps practices dictate a faster rate in the SDLC to deliver a high-quality solution in the shortest possible time^5,6. Although this has been quite efficient where enabling the fast release of features is concerned, the downside is that security is more frequently addressed as an afterthought, often implemented in later development phases testing and audits. This is particularly alarming because of the great concern in fields such as healthcare, where the consequences of poor security are much more severe. Nothing about a patient’s personal information, whether the patient’s detailed health information or financial records, is safe from hackers because of the increasing use of healthcare applications. This can be disastrous since violating the same can trigger legal consequences, harm the company or the hospital’s reputation or even endanger a patient’s life. In the traditional DevOps frameworks, security is an addendum, where automated security scans or vulnerability fixes are implemented in a fixed program version when in production. This reactive approach allows significant threats to enter the application perimeter, which could have been blocked earlier in the software development life cycle. DevSecOps corrects this issue because the usage of security extends throughout the development life cycle, from design and coding to deployment and monitoring processes. This approach integrates cybersecurity as a cross-functional effort throughout the organization’s DevOps teams. Security is effectively integrated into the DevSecOps process through security automation across the entire DevOps pipeline, with testing, compliance and monitoring in parallel to prioritize identifying and addressing security issues. This proactive approach also enhances overall security and completes the mission to safeguard data and other sensitive information that directly impacts a healthcare organization. Whenever a proactive protection measure is found inadequate, fix it as per the regulatory benchmark and build up the patient’s confidence in an organization. In the same way, via DevSecOps practices, healthcare organisations can produce secure, compliant and quality applications within a timely fluency that does not compromise the innovative aspects that accompany such methodologies (Figure 2).

Figure 2: Regulatory Landscape.

1.2. Regulatory landscape

·HIPAA compliance: HIPAA guidelines’ rules address the privacy, security and availability of the electronic Protected Health Information (ePHI) in the healthcare sector. HIPAA states that many administrative, physical and technical measures must be implemented in healthcare facilities to protect patient information from disclosure, unauthorized access or alteration. These measures include but are not limited to the use of passwords, user log in details, periodic checks and staff orientation to the policies and standards of the University. In a DevSecOps context, these safeguards become Imperative in the DevSecOps model. Privacy and security considerations are integrated into the software delivery pipeline and employed consistently from development to production. HIPAA noncompliance can cost organizations substantially through hefty fines and loss of reputation, which is why its enforcement is critical in the application development lifecycle.

·GDPR compliance: The GDPR is a set of EU regulations on data protection, primarily concerning personal data protection. GDPR emphasizes two core principles: A concept of data protection by design and by default - this basically means that privacy requirements must be built into the solutions as a primary design step rather than be afterthoughts. It also has a significant focus on consent meaning that consumers have control over their personal information, be collected, processed and stored. In the case of healthcare, GDPR is in operation regardless of the organisation's location; that treats residents' data of the blocks of the European Union. In healthcare, this implies that user data is protected effectively from unauthorized access stored, used only where it is necessary and only used by authorized staff. GDPR requirements can be applied and maintained throughout the SDLC and DevSecOps practices to satisfy these requirements, integrated into them and implemented in the following manner; for example, Failure to abide by these Data Protection laws attracts hefty fines, thus the need to embrace security and privacy features in the application of healthcare technology.

2. Literature Survey

2.1. Existing DevOps practices in healthcare

In healthcare industries, DevOps was implemented mainly based on deployment speed, system reliability and operational effectiveness^7-11. These often include making speed of development faster, timely integration of development and operations processes and utilization of resources. Still, a significant weakness exists: the lack of automatic security checks and evaluation and the post-implementation assessment of vulnerabilities. This reactionary approach to application development only increases vulnerabilities as problems are identified after live systems are implemented. Moreover, since most applications in the healthcare domain are complex because of data sensitivity and data regulatory concerns, the ability to detect security vulnerabilities also faces delay consequences.

2.2. Evolution to DevSecOps

DevSecOps is an extension of DevOps that integrates security end-to-end in the development and deployment process of the software. This approach embeds security inherently within CI/CD processes and builds security into applications and development life cycle. It asks for proactive threat modelling, where threats and risks are addressed as soon as they are found in the development phase and real-time monitoring to discern new emerging threats and vulnerabilities. Applying the principles of DevSecOps is built on the idea of shifting security left so that development, security and operations teams are involved right from the beginning of the development process rather than being considered an add-on.

2.3. Case studies

·Case study 1: Mayo Clinic: To fully implement DevSecOps at the Mayo Clinic, the utilization of SAST and DAST tools in the CI/CD processes was employed. Such security measures allowed the organization to mitigate risks before deploying in the environment, thereby minimizing the number of security incidents in the production environments. The positive outcome was a 35% decrease in post-deployment vulnerabilities, which led to the conclusion that the best way to integrate security is at the beginning of the development cycle.

·Case study 2: NHS Digital: During development, NHS Digital integrated container scanning and compliance-as-code solutions to keep the working environment safe and consistent. Due to automated scanning of the images and policy checks for conformity across multiple stages, situational security was maintained throughout different applications and services introduced by NHS Digital. This approach increased scalability and ensured the security of an organization’s update process and compliance with healthcare regulations.

2.4. Gap analysis

The differences between DevOps and DevSecOps became apparent mainly in treating security within the development life cycle. Generally, security testing within traditional DevOps is ad hoc and occurs sequentially at the end of the development phase. This approach often conceals vulnerabilities and puts a wrench in the system that prevents developers from being prepared and able to fix it as soon as possible. On the other hand, DevSecOps integrates and applies security testing throughout the SDLC to identify and address threats early and automatically. In DevOps, compliance checks are normally post-deployment; hence, when there is a check, the organization experiences non-compliance and more work. DevSecOps incorporates an immediate validation of compliance, therefore preventing breaches of regulation. However, there is limited engagement from developers in terms of security activities in the classic DevOps approaches. DevSecOps ensures that everyone has a security mentality, making developers responsible for embedding security from the development phase making software more secure.

3. Methodology

3.1. DevSecOps implementation framework

· Planning & Requirements: The first is identifying security requirements and functional and business goals. Data protection requirements^12-15, compliance directives (for example, the Health Insurance Portability and Accountability Act) and threat analysis are addressed from the beginning. Integration of security into the development and operations plan of a software system makes it possible to avoid considering security as a ‘bolt-on’ system.

Figure 3: DevSecOps Implementation Framework.

·Code commit & static analysis: Once coding is done, security is implemented by code reviews and static application security testing (SAST). Before the code is checked into the main repository, these tools scan for problems like hard-coded credentials, insecure methods and data leakage. STS has to be incorporated at the commit stage to allow identification of issues at the early levels, hence attracting lesser costs and efforts than when it is done at a later state.

·Build & dependency scanning: In the build phase, the compiled code, along with its specified software dependencies in libraries and frameworks, is checked for vulnerabilities by software composition analysis (SCA). These scans detect old libraries, the violation of open-source licensing agreements and open-source software which contains common vulnerabilities and suspicions in the license. With most of these checks running through the CI/CD pipeline, the teams can ensure that code flagged for vulnerabilities does not advance to other stages.

·Test & dynamic analysis: In this stage, the application is tested in the runtime environment using dynamic application security testing (DAST) & interactive application security testing (IAST). These work like replicas of real-world conditions to check vulnerabilities such as injection, broken authentication and improper configurations. Incorporation of security testing into functional and regression testing would have a way of exposing the vulnerabilities before deployment.

·With Infrastructure as Code (IaC), at least partially: The deployment practice is used to provision and configure environments through Infrastructure as Code securely and non-equivocally. Secrets management, security of the network configurations and compliance as code policies are incorporated within the IaC templates. Open-source tools like Terraform or Ansible also highlight that all security patterns are versioned and applied consistently across environments.

·Monitor & incident response: The system is continually monitored with security information and event management (SIEM), intrusion detection systems (IDS) and behavior analytics after deployment. Alerts, threat intelligence and response orchestration are ways of dishing out incidents quickly. The monitoring programs generate feedback incorporated into the planning of the subsequent steps taken under the DevSecOps process.

3.2. Security automation tools

·SAST tools: SonarQube, fortify: White box testing method known as Static Application Security Testing (SAST) tools such as SonarQube and Fortify check source codes in the early phase of the Software Development Life Cycle (SDLC without running the code. These tools assist developers in determining coding problems, application security threats and coding poor patterns, including SQL injections, buffer overflows and code smells. SonarQube is readily integrated into the CI/CD and flexible for multiple languages, while Fortify penetrates the corporation level with profound static analysis and immigrant resolution instruction.

·DAST tools: OWASP ZAP, burp suite: DAST tools like OWASP ZAP and Burp Suite interact with applications in a running state and mimic real-world scenarios to exploit aspects of XSS, broken authentication, insecure redirects, etc. OWASP ZAP is an excellent Python framework for automated assessments, being developed collaboratively. At the same time, Burp Suite is considered a robust, licensed tool for extensive manual testing with modularity extension.

 
Figure 4: Security Automation Tools.

·Dependency scanners: Snyk, White Source: Software Composition Analysis or Dependency tools like Snyk and White Source analyse the set project dependencies to find out if any of them contain known open-source vulnerabilities. Snyk naturally fits into developers’ toolchains and offers on-the-spot remediation advice, whereas White Source is more tailored for vulnerability remediation and license management. This article is important as it outlines and explains these tools for minimizing the risk of using insecure third-party components.

·IaC scanners: Checkov, tfsec: Tools like Checkov and tfsec target IaC templates, including Terraform and CloudFormation, to identify misconfiguration and security vulnerabilities that can be deployed. Checkov uses an extensively customizable policy engine running the policy as source code. At the same time, tfsec works as a detailed check of the Terraform code to identify risks such as open ports, weak encryption and relaxed permissions. These tools contribute to constructing a security perimeter and enforcing compliance from day one in any cloud environment.

3.3. Continuous compliance

The modern IT world requires continuous compliance to maintain regulated scenarios and secure standards which smoothly integrates into the DevSecOps frameworks to utilize in the application and infrastructure. In contrast to the compliance initiative as a check-the-box exercise during or after delivery, compliance is done with CI/CD processes. Incorporating this proactive approach into development and operations^16-19, it is possible to flag compliance issues early on in the process and avoid extensive refactoring and compliance penalties that might be incurred after the deployment phase. It is also one of the primary approaches to the continuous compliance implementation methodology, where compliance rules are integrated into the purpose-built paths. This means integrating security and compliance rules like encryption, access rights, log monitoring and security standard settings to be tested for compliance when code is checked in/checked out, built or deployable. For instance, pipelines can include checks to verify that all provisioned resources adhere to some specified security guidelines; it may also check if all the data storage uses encryption at rest and in transit. One of the great enablers of this process is using tools that deal with policies as codes, such as Open Policy Agent or OPA. Specifically, through OPA, specific controls, policies and their versions can be defined programme -wide across a multistakeholder environment that includes various systems and technologies. It is possible to integrate OPA and have it generated policies written in its Rego language to check infrastructures, configurations, deployment manifests and patterns of applications in real-time, allowing for the rejection of non-compliant builds. This not only strengthens security and compliance on an ongoing basis but also records who has done what, where and when, which enhances the security decision making transparency and accountability. Moving compliance left and making it continuously reduces overhead caused by compliance checks, shortens development cycles and guarantees compliance with security and regulations. It is especially helpful in heavily regulated fields such as the healthcare sector, the General Data Protection Regulation or the Payment Card Industry Data Security Standard.

3.4. Secure coding practices

Adhering to secure coding standards is the bedrock of an application and assists in striking out upcoming general weaknesses easily exploited by wrongdoers. These practices involve the use of code that is not only effective but also safe since it is coded securely. Implementing proper input validation, the principle of least privilege and data encryption are the three basic paradigms that can help to reduce risks from attackers and protect data. It checks data received from users, APIs or any third-party source for accuracy, format and security before further processing. This technique helps avoid data injection attacks, for example, SQL injection, vulnerable cross-site scripting attacks (XSS) and command injection whereby damaging data is viewed as actual codes. Therefore, a big security threat can be reduced if developers begin to validate data on the client and server sides, thereby discarding any extra or unexpected inputs. Strictly speaking, the principle of least privilege (PoLP) states that users, services and applications should have only the minimum levels of access or permissions needed to do their jobs. This lowers the risk exposure in the event of a break-in or systems failure and or misconfiguration. For instance, an application component only required to access a database should not possess read/write or administrator access. Implementing some level of PoLP in code, APIs, system roles and infrastructures reduces threats and enhances their control. Another component of secure coding is data encryption, in other words, encryption of data kept on the machine and during transfer from one host to another. Encryption ensures that the information cannot be understood even when confidential information is leaked or otherwise obtained by the wrong individuals. Passwords should be protected by the following cryptographic measures: the encryption method must not be less than TLS 1.2 and the AES-256 encryption must be utilized. Password, personal and financial data and other personal information must always be protected and encrypted through the software life cycle. For these and other secure coding best practices to make the intended positive difference, practising them regularly, in equal measure and early enough is prudent for organizations.

3.5. Threat modelling

Threat modelling is simply the way of understanding how an attacker approaches an application or system to master the various opportunities that will help the attacker exploit it. Security by design extends through tackling questions such as how could a hostile party try to subvert a system, which vulnerabilities could be exploited and what the repercussions would be. One formula forms the basis of threat modelling: Risk, as defined by the formula, is calculated as follows.

Risk = Threat × Vulnerability × Impact.

As shown in this formula, the level of security risk is defined as a combination of a threat (for example, a hacker or malware), a vulnerability (such as insecure input handling or poor authentication) and the consequence if a threat exploits a vulnerability, for instance, data loss, system outage or violation of regulation. Part of threat modelling is to define assets or to identify parts of a system, its data and trust perimeters or pathways that change from one security domain to another (e.g., from a user device to a cloud server). In this way, the identified areas allow teams to find authentication, data storage and/or communications vulnerabilities. An easy-to-use tool, one such is Microsoft’s STRIDE model, which includes Spoofing, Tampering, Repudiation, Information disclosure, Denial of service and Elevation of privilege. Another widely used method, PASTA (Process for Attack Simulation and Threat Analysis), connects threat modelling with business goals and appreciated risk levels. As a result, threat modelling is not a waterfall activity but a constant activity in the DevSecOps model and is continuously adjusted during the evolution of the application. This makes it possible to revisit systems developed and check for new features and changes in the system architecture. At the same time, when teams apply the formula and evaluate parts of a system with higher risk scores, it is possible to decide on the allocation of security measures. Threat modelling allows developers to understand how a threat actor would approach a system and address these problems before they become real-world issues.

4. Results and Discussion

4.1. Evaluation metrics

·Time to deployment: Throughput is calculated as the period between when a commit is made and when a change is deployed to the production environment. In context to the DevSecOps paradigm, this metric measures the impact that the incorporation of Auto-Sec and compliance- checks exert on the top-line explicit aspects of the deployment process. Even better, by including security right from the design phases and posing many of these steps to be manually carried out later during deployment in an organizational environment, the time which has previously been required to be spent on post-deployment security review and audit can be significantly lowered. Due to a short period to what seems to be the deployment of the final iteration/ release, the development process is more flexible, which is a valuable aspect for sustaining competitive advantage and for addressing the customers’ needs and wants in today’s ever-evolving and technological epoch.

· Number of vulnerabilities detected pre-deployment: This metric measures the number of program flaws and their characteristics when they were still at the developmental stage before the launch in the production environment. Static Application Security Testing, Dynamic Application Security Testing and various security tools within the CI/CD pipeline minimize the chance of opening up vulnerabilities. Reducing threats and susceptibilities pre-deployment is essential for avoiding exploitation in production surroundings. They also give insight into the extent of implementation of security control measures within the DevSecOps cycle, if any firm has effectively acted on the security breaches before reaching the consumer.

·Compliance violations: Compliance Violations represent the degree of compliance conformity established by the assessed application and infrastructure with the administrative and security policies. To name but a few examples, compliance with HIPAA, GDPR or PCI DSS becomes necessary for industries ranging from healthcare and finance to government. DevSecOps Automation prescribes that before any code composed or deployment to production occurs, policy-as-code reviews the compliance status of the code. This metric measures how compliance is improving due to automation across the various stages of the software development process, revealing an increased ability to control risk and adhere to security standards and regulations.

·Developer productivity: Developer Productivity measures the performance of each development team in terms of code production rates, the time required to fix bugs and the time needed to address security problems. In the latest practices of DevSecOps, the aim is to increase productivity by minimizing interactions with security or compliance incidents to let the core development effort happen instead of having to repeat relentless repairs. This metric is about how automation, improved use of security tools and a DevSecOps approach led to a faster development process. In general, increased developer productivity will result in faster delivery and make the software more comprehensively tested.

4.2. Results from pilot implementation

Table 1: Comparison of Metrics Pre- and Post-DevSecOps.