Healthcare Patient Consent -- Lessons learned from Creative Commons

I have learned lately that Creative Commons is working on some specific applications of Patient Consent. There are not much details on what they intend to target or create. The only details I can find are at “CC Science - Sharing V. Privacy”.

There are two very cool things. They recognize Security-Tags, and have a good process that will help us.

Security-Tags:

The first one is that they refer to “Data-Tagging”, which is general IT discussion toward a solution. This is very similar to the “Healthcare Privacy & Security Classification System” that we have defined and created profiles for – One example is the DS4P. This concept of Security-Tags has been integrated into XDS (XCA, XDM, XDR), and also into HL7 FHIR. This is a useful vector for the purpose of enforcing Access Controls including Privacy aspects.

This is, as Creative Commons indicates, not sufficient.

Consent Language Communications:

The more cool thing is the concept of applying the methodology that Creative Commons have done for Copyright/License to Privacy Consent.  They have created a reasonable set of Licenses that can be used in a very useful and actionable way. For example, my blog is published under the

"Attribution-NonCommercial-ShareAlike 3.0 Unported" License. Which is understandable by many means of reading and processing.

With Patient Consent, we struggle with a similar problem to the Copyright/License problem that Creative Commons initially addressed. The language that organizations want to use is written once, by them, for their purposes; thus the language at each organization must be read and understood. Most of the time the language is in legal terms and thus not very consumable by non-lawyers, and also not consumable by computers. The result of this confusion is that the humans involved are not well informed. Also true is the failure in the computers that should be protecting the data, which includes providing access to those that are authorized.

Creative Commons have come up with a very useful “Design and Rational” that creates three layers that are very useful with Patient Consent.. There is the “Legal Code” that includes the legal specifics. There is the Human Readable, which is specialized for normal humans to read, possibly translated into multiple languages and such. There is a Machine Readable form, that is structured and coded.


I will note that the current Machine Readable form is very much like what we did with IHE-BPPC; that is it is most of the time simply an established URL per policy. Thus all that is necessary for the computer to know which license is applicable is to see which of the Creative Commons URLs are applied. The main difference is that they host and thus create the machine readable URLs. Whereas with IHE-BPPC the creation and publication is a ‘local matter’. Creative Commons "REL" is a similar container as the CDA structure defined by IHE-BPPC, or the potential future HL7 FHIR ConsentDirective could be..

As applied to Healthcare Privacy Consent:

So, the result of Creative Commons effort might be a set of boilerplate Privacy Consent policies. The equivalent of what I have referred to as Opt-IN, Opt-OUT, OPT-OUT-breakGlass, etc.

Using the Creative Commons methodology this would result in a set for each of these: Legal Code, Human Readable, and computable URL.


This is not an easy thing to write. I have been involved in many workgroups that have worked on these. In each case a number of people, mostly lawyers, wanted to have special wording in for their special cases. I presume that Creative Commons has mechanisms to work through these differences.

We might even get some cool icons like they have for the License, where the icons visually represent the essence of the language.

Patient Friendly Interview Process:

Going one step further, Creative Commons have created an interview process for people that want to apply a Creative Commons License to their works.

The interview process walks the person through a set of decision points. This results in a recommended CC Mark.



This today is not all that 'friendly' and the population that are Patients (healthcare consumers) likely need far more 'friendly' interfaces. However the concept is similar in that one tends to narrow the choices over time.

There are a few pilots that have attempted this, including one from HHS/ONC that resulted in some very interesting observations.

Conclusion: 

I have said all the above before, in 2009,  Consumer Preferences and the Consumer.  The difference is that Creative Commons might bring their methodology and thus some maturity to the conversation.

Blog resources: Patient Privacy controls (aka Consent, Authorization, Data Segmentation)

• Enabling Patients to Delegate Healthcare Information Access Authority
•  Define Atom -- Too many definitions in use today 
• Defining Privacy
• Safety vs Privacy
• Privacy Consent State of Mind
• Defining Privacy
• Universal Health ID -- Enable Privacy
• Texas HIE Consent Management System Design
• Simple and Effective HIE Consent
• IHE - Privacy and Security Profiles - Basic Patient Privacy Consents
• Data Segmentation - now I know where the term comes from

Performance vs Privacy

Sadly this week we hear about a HUGE breach of Patient Identities. This did NOT NEED TO HAPPEN!!!

What happened? Community Health Systems (CHS) pulls ALL identities from their partners so as to do patient cross-reference matching. This results in a Centralized Identity Knowledge database, that was not protected well enough. There are better deployment architectures that I will explain.

200 Hospitals Hit Affecting 4.5 Million Patients (August 18, 2014) Tennessee-based

CNN Money 

Community Health Systems (CHS) says that intruders accessed its system over a three-month period earlier this year, compromising patient names, addresses, and Social Security numbers
(SSNs) of 4.5 million people. The company maintains that medical and financial information was not affected. CHS operates more than 200 hospitals in 29 US states. The company claims that the attacks emanated from China. Information in CHS's Securities and Exchange Commission

• http://www.darkreading.com/community-health-systems-breach-atypical-for-chinese-hackers/d/d-id/1298095?
• http://www.bbc.com/news/technology-28838661
• http://bits.blogs.nytimes.com/2014/08/18/hack-of-community-health-systems-affects-4-5-million-patients/
• http://www.computerworld.com/s/article/9250464/About_4.5M_face_risk_of_ID_theft_after_hospital_network_hacked?taxonomyId=17
• http://www.theregister.co.uk/2014/08/18/hospital_chain_claims_chinese_hackers_stole_45_million_user_details/
• http://www.forbes.com/sites/katevinton/2014/08/20/data-breach-bulletin-chinese-hackers-allegedly-steal-4-5-million-patient-records/
• http://mashable.com/2014/08/18/hackers-steal-millions-records-hospital/
• http://www.theledger.com/article/20140818/NEWS/140819308 
• http://www.washingtonpost.com/blogs/wonkblog/wp/2014/08/19/health-care-data-breaches-have-hit-30m-patients-and-counting/
• http://money.cnn.com/2014/08/18/technology/security/hospital-chs-hack/

There are two models of patient record locator service (RLS). That is, how do I learn of all the locations that have patient data for the specific patient I am interested in. This is more important today where patients have had many home cities, patients travel on business and pleasure, and specialty healthcare practices are easy to get specialist care. The two models of location discovery are very different and carry very different Privacy impacts.

Federated Identity Knowledge Discovery:

If Privacy was most important, a Federated Identity Knowledge Discovery model would be used. This is the model that IHE has defined for Cross-Community Access exchanges (XCA). The Cross-Community Access (XCA) is the model defined for federating multiple regional exchanges. The XCA model defines the XCPD Profile, as explained by Karen earlier in my blog.

That is a model where one discovers the locations that have data on a given patient when you need to know. This model does not try to pre-coordinate patient identities as the identities are created and updated. This model, when the patient is seeking care, asks everyone if they know of the specified patient. As such this model does mean the answer might take a long time to come back, and might be missing some locations that didn't respond in time or didn't have enough data to make an exact match.

The failure to match due to not enough information isn't unique to this model, but this model does make these failures more likely as the match does need to be made quickly.

The failures to match can also be detected as the patient can indicate the various locations they know of, and if the results seems to be missing those locations more refined query can be done. In this case the refinement would be based on the patient knowledge of how they were known at the time they were cared for in that location.

The bigger problem with Federated Identity Knowledge Discovery is that the response time is potentially many minutes long, and really is not deterministic as to when one has all the responses from everyone.

Centralized Identity Knowledge

The second model is to centralize all knowledge about the patient. This is the model that IHE has defined for use with in an XDS Health Information Exchange. The solution that IHE defines for a regional exchange. Note that not all regional exchanges should use XDS, one can actually make a federation exchange using XCA within a region. So you could use the above model. However within a region one often has many instances of the Patient visiting multiple sites within that region. So the benefits of Centralized Identity Knowledge might be worth the risk.

The Centralized Identity Knowledge model leverages HL7 “ADT” – Admit, Discharge, Transfer. Which is actually more than just those three verbs. In the Centralized Identity Knowledge model we use the IHE Profiles of PIX and PDQ. In these models whenever a new patient identity is created somewhere, knowledge of that patient identity is forwarded to some central authority. Similar when that patient is registered at a site, discharged, transferred. Similar when mistakes in the identity are corrected, including Merge or Link events. All of these actions on the Patient Identity are forwarded to the central authority. This central authority is receiving identity information from ALL of the sites participating in the Health Information Exchange, and will do a match of identity as it receives the identity knowledge.

This model, can also involve humans when the matching algorithm detects a potential match. The human can do some research and fix the match as needed. So this model is often seen as more accurate. Less prone to False-Positive and False-Negative matches.

One advantage of this is that it is easy for hospitals to simply copy their ADT feed and send it to the Centralized Identity Knowledge store. The hard processing is centralized.

The biggest advantage of the Centralized Identity Knowledge is that the “Cross-Reference” is known well in advance of someone needing to know. So a Patient Record Location Service call is very quick and deterministic. This model is best when Performance is most important. We hear much about how unlikely Doctors are to wait a few seconds.

The Privacy disadvantage is that ALL patients are known in a centralized database. This is regardless of if the information is needed ever. Think about a patient that never has moved, always sees the same doctor, never needs the HIE service. Thus a breach of this database breaches ALL Centralized Identity Knowledge.

On the positive side, the Centralized Identity Knowledge is just identities, no medical information is needed in this database. However that is not to say it doesn't also get centralized.

Patient Centric

There is another model, and that is that the Patient mediates all information flow. This is the model where the patient is the only one that knows who all have interacted with them. This is where the patient provides all the information. This is also the model where the system totally fails if the patient is in an emergency situation. The patient can also better hide information they don’t want to share, which is a privacy benefit, but a potential risk to patient safety and quality of care.

Conclusion

I hear of new exchanges being put together that choose to use the Centralized Identity Knowledge method. Their excuse is that it is faster, which it is. They also point out that it is easier to get quality results, which is somewhat true. 

Privacy Matters. It is important to consider Privacy and Security up front. They are way too often left to an after-thought. It is when they are left to an after-thought that they become burdensome and are seen as nothing but trouble. When one considers Privacy and Security up front, they can be enablers of workflows and most importantly things that make the Patient happy. 

Is waiting a bit longer for a query to happen, followed with a discussion with the patient really that hard for Healthcare Provider -- Professionals?

Nationwide Health Exchange (HealtheWay).

I will note that the Federated Identity Knowledge Discovery is the model that is used by the NwHIN-Exchange, now known as HealtheWay. Thus this breach did NOT come from here, and couldn't.

Patient Identity Resources 

• PDQm - Patient Demographics Query for Mobile API
• Policy needs to get out of the way of good Patient Identity management
• HIE Patient Identity problem
• Identity Proofing and Authentication -- Patient vs Provider
• Patient Identity Matching
• Universal Health ID -- Enable Privacy
• The Basics of Cross-Community Patient Discovery (XCPD)
• NwHIN-Exchange use of XCPD for Patient Discovery
• Direct addresses- Trusted vs Trustable

Updated August 21 -- added an introduction, graphic from CNN Money, and more links to articles.

IHE Digital Signature Profile - updated -- Need COMMENTS

The IHE Digital Signature (DSG) profile has been updated. Well it is out for Public Comment through the IHE Change Proposal system -- Ballot 24 -- as Change Proposal 412.

IF YOU ARE AN IHE MEMBER, PLEASE COMMENT!!!! We need constructive comments on this proposal. It was not intended to be a breaking change, but reality is that there is no unified understanding of what the old DSG supplement was defining. The old DSG supplement must be considered fundamentally broken. So this CP must be considered a breaking change.

The goal of Change Proposal 412 is four very important things, none of them are related to failures of the original.

• The original supplement was written before IHE had a concept of a Content Profile, so it was never written this way. Now that we have a concept, we can write it in a way that is more readable. There was also some loose-ends related to the now deprecated NAV profile.
• The current supplement template has some other formatting requirements. Actually we also needed to do proper section number reservation and management. So many simple 'editorial' needs.
• The original only supported a Detached signature, where the content was managed in an XD* environment and the linkage to the signature was done by the XDS Association type "SIGN". This is still needed but we also need an Encapsulating signature that can be used where no XD* is available to hold the things together, so encapsulating signature is an outer envelop of the Digital Signature that holds the signed document inside.
• The digital signature standard has been updated and now includes everything we needed. So we now specify XAdES-L-T, which brings inside the certificate and a timestamp; and we utilize the CommitmentTypeIndication for Purpose Of Signature. Thus we just bind in a vocabulary specific to Healthcare needs.
• We did not include the new CDA digital signature. This is not because it isn't useful or interesting, but more because that would have been a very different technology. Those that want this profiled by IHE, should bring a New Work Item Proposal to profile it.

I have had this Change Proposal on my plate since I wrote that it was needed back in 2009. It didn't happen because there simply was not enough use of Digital Signatures in healthcare. However now there is more interest, driven by some Anti-Fraud use-cases.

The main problem with Digital Signatures is NOT the standards, it is the Policies and overhead in issuing proper Digital Identity (PKI). Once there are Digital Certificates issued for the purpose of Digital Signatures, then there are many use-cases that can be enabled. However that first justification of the costs is very hard to do, and somehow combining justifications just never seems to happen.

Review the proposed new supplement as Change Proposal 412.

The changes to the IHE DSG profile are significant should be considered a breaking-change from the original DSG supplement published in 2009. The DSG supplement has remained in “Trial Implementation” since 2009. Breaking changes during “Trial Implementation” are proper and should be expected.

The Document Digital Signature (DSG) profile is a Document Content profile that provides general purpose methods of digitally signing of documents for communication and persistence. This method can be used within a Document Sharing infrastructure (e.g., XDS, XCA, XDM, XDR, and MHD). There are three methods of digital signature provided: Encapsulating (An encapsulating signature is a signature approach that encapsulates the signed content within the signature syntax.), and Detached (manifest).

Electronic documents are being increasingly relied upon in healthcare. Signatures have been a part of the electronic documentation process in health care and have traditionally been indicators of accountability.  Reliable exchange of data between disparate systems requires a standard that implements non-repudiation to prevent document creators from denying authorship and rejecting responsibility.

This second revision of the DSG supplement addresses the following:

• Puts the profile into the current supplement template
• Puts the profile into the current Document Content format
• Adds Encapsulating signature, which is especially useful when Document Sharing are not used. For example: RFD based output.
• Update the signature standards: XaDES specifically that now includes profiles for Long-Term signatures

Other Digital Signature Blog Posts

• IHE - Privacy and Security Profiles - Document Digital Signature
• Signing CDA Documents
• Using both Document Encryption and Document Signature
• Non-Repudiation is a very old art