Cyber-Attacks and Countermeasures at the Perception Layer for Electromedical Devices in Community-Based Care: A Systematic Review

This review investigates cyber-attacks and countermeasures of the perception layer in electromedical devices used in decentralized healthcare contexts. Emphasis is placed on sensing and actuation functionalities performed outside hospital environments, where physical exposure and heterogeneous communication protocols increase threat complexity. A systematic search was performed across Scopus, Web of Science, IEEE Xplore, and PubMed using a structured query covering cybersecurity threats and countermeasures in perception-layer medical devices. Only peer-reviewed English articles were included. Screening and eligibility assessment followed PRISMA guidelines and Kitchenham’s methodology, excluding studies unrelated to perception-layer cybersecurity or lacking countermeasure discussion. A structured framework was developed to classify devices, attack types, and defensive strategies. Twenty-one studies were included, revealing a research focus on wearable devices and monitoring functionalities, while portable and implantable systems with actuation capabilities remain underexplored. Most documented attacks involve replay, DoS, eavesdropping, and Man-in-the-Middle attacks, whereas advanced threats like side-channel attacks are rarely addressed. Defensive strategies mainly rely on authentication schemes and transmission-level cryptography, while recovery capabilities are inadequately addressed. Research on perception-layer cybersecurity in electromedical devices is still fragmented, with uneven protection of critical security properties. Future work should expand to implantable and actuation-enabled devices, develop multi-layer defenses addressing all security objectives, and introduce resilience mechanisms to support robust cybersecurity in decentralized healthcare environments.