“ jericho / ut austin pilot” privacy with dynamic patient review june 25, 2013 presented by:...

“Jericho / UT Austin Pilot”

Privacy with Dynamic Patient Review

June 25, 2013

Presented by:David Staggs, JD, CISSP

Jericho Systems Corporation

206/25/2013

Agenda• Administrative issues • Pilot scope• Data flow diagram• Information leakage• Relevant filtering• Data segmentation• Available attributes for various eHealth exchange calls • How to pass the attributes in the PCD request• UT student involvement• Questions• POA&M

306/25/2013

Pilot Administrivia• This pilot is a community led pilot

– Limited support provided by the ONC• Apurva Dharia (ESAC)• Jeanne Burton (Security Risk Solutions)• Melissa Springer (HHS)

• In conjunction with DS4P bi-weekly return of an All Hands meeting• Access to DS4P Wiki, teleconference, and calendar • Meeting times: Tuesdays 11AM (ET)

– Dial In: +1-650-479-3208Access code: 662 197 169URL:https://siframework1.webex.com/siframework1/onstage/g.php?t=a&d=662197169

https://siframework1.webex.com/siframework1/onstage/g.php?t=a&d=662197169




406/25/2013

Scope of the Pilot• 1. Define the exchange of HL7 CDA-compliant PCD between a

data custodian and a PCD repository that includes a report on the outcome of the request back to the healthcare consumer.

• 2. Additional goal: use of identifiers that can uniquely identify the healthcare consumer and PCD repository used to report the outcome of the request back to the healthcare consumer by healthcare consumer’s provider and subsequent EHR custodians.

• 3. Stretch goal: use of the PCD repository as a proxy allowing direct authentication by the healthcare consumer to the provider, subsequently reducing correlation errors.

506/25/2013

Expected Data Flow (updated)

Custodian of Data being Provided at

Patient

PCD Repository2nd Requestor

1st Requestor

B

, = Clinical data

A,B =PCD data

= audit record

And Subsequent Custodian of Data being Provided at

Information Leakage• PCD repository reference implementation options:

– Give the data custodian the entire PCD once and allow use for multiple requests

– Give the data custodian a subset of the PCD relevant to the data custodian and allow use for multiple requests

– Give the data custodian a subset of the PCD relevant to each request for a clinical document

• Information leakage is reduced by providing only what is required to decide patient’s intent for the clinical document being requested

06/25/2013 6

What’s Relevant?• Filtering the PCD to reduce data leakage:

– What information is available and necessary to filter the PCD (SAML attributes)

• organization and organization-id (remote node)• subject-id and subject:npi (remote requester)• role (role of remote requester)• purposeofuse (stated reason for the request)• resource-id (unique patient identifier)

• Provide recommendation meeting clinical workflow

06/25/2013 7

What’s Relevant?• Filtering the PCD to reduce data leakage:

– What information is available and necessary to filter the PCD (SAML attributes)

• organization and organization-id (remote node)• subject-id and subject:npi (remote requester)• role (role of remote requester)• purposeofuse (stated reason for the request)• resource-id (unique patient identifier) use patient-id

• Provide recommendation meeting clinical workflow• Clerks submit requests for clinicians

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X

XX

Data Segmentation• Patient’s consent over release of certain clinical data:

– What information is available and necessary to filter the PCD (attributes from the clinical document)

– Requires segmentation (data tagging) of the clinical document being requested

• HL7 CDA r2 Confidentiality codes (e.g., ETH) in header• HL7 HCS Sensitivity codes (in data segments)

• If data tags are passed in the request for a PCD, only the patient’s restrictions on those data tags need be sent– Custodian already knows the existence of the data

segment because it sees it in the clinical document

06/25/2013 9

Repository Requests VaryWhich responses should require a PCD?

• In response to Cross Gateway Patient Discovery (XCPD)– NHIN Patient Discovery IHE ITI-55– NHIN Patient Location Query IHE ITI-56

• In response to NHIN Query for Documents Transaction– IHE Cross Community Access (XCA) ITI-38

• In response to NHIN Retrieve Document Transaction– IHE ITI XCA Supplement Section 3.39

XCPD maps identifiers, other request have different attributes

06/25/2013 10

Cross Gateway Patient Discovery

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Attribute ID Source Description Optionality PCD Query

urn:oasis:names:tc:xspa:1.0:subject:purposeofuse XUA assertion HL7 value Required Requiredurn:oasis:names:tc:xpsa:1.0:subject:organization-id XUA Assertion unique organizational

identifier of the requestor

Required Required

urn:oasis:names:tc:xpsa:1.0:subject:organization XUA Assertion Name of the organization of the requestor

Required Required

urn:nhin:names:saml:homeCommunityId XUA Assertion Home community id of the requestor

Required If Available

Optional

urn:oasis:names:tc:xpsa:1.0:subject:organization XUA Assertion home community ID of the requestor

Required Optional

urn:oasis:names:tc:xacml:1.0:resource:patient-id

XDS.b metadata patient id Required Required

urn:oasis:names:tc:xacml:1.0:action:action-id N/A Defined Value: DocumentQuery

Required

urn:oasis:names:tc:xacml:2.0:subject:role XUA Assertion ASTM role of the requesting user

Optional Optional

urn:oasis:names:tc:xacml:1.0:subject:subject-id XUA Assertion Requestor name, email address or NPI

Required Optional

urn:oasis:names:tc:xspa:1.0:environment:locality Configuration home community ID of servicing organization

Required Optional

Query for Documents Transaction

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Required Required


Required Required



Optional


Required Optional




Required


Optional Optional


Required Optional


Required Optional

urn:oasis:names:tc:xspa:2.0:resource:type XDS.b Query or Document

LOINC code for document requested

Required Required

urn:oasis:names:tc:xspa:1.0:resource:hl7:confidentiality- code

XDS.b Query or Document

Confidentiality code of CDA document

Required Optional?

Retrieve Document Transaction

06/25/2013 13




Required Required


Required Required



Optional


Required Optional




Required


Optional Optional


Required Optional


Required Optional

urn:oasis:names:tc:xspa:2.0:resource:type XDS.b Query or Document

LOINC code for document requested

Required Required

urn:oasis:names:tc:xspa:1.0:resource:hl7:confidentiality- code

XDS.b Query or Document

Confidentiality code of CDA document

Required Optional?

urn:oasis:names:tc:xspa:1.0:resource:hl7:sensitivity-code

XDS.b Document

Sensitivity code of data Required Required if available

Notes on Data SegmentationHow do we pass attributes in the PCD request?

• Include attributes in SAML/XUA Assertion and keep XDS.b Find Documents query unchanged

• Create new XDS.b query and define attributes as slot query parameters

• Extend existing XDS.b Find Documents query, including attributes as additional optional slot query parameters

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IG Query and Response PCD

1506/25/2013

UT Student Contribution• UT Austin HIT Students: John Bender and Adrian Tan

– Project: "Definition of Data Sets Exchanged During Request for Patient Consent Directive (PCD) on e-Health Exchange"

• Goals:– Review common or emerging privacy and security standards for

the transfer of information within eHealth Exchange– Determine optimal standard(s) for data exchange

• Potential usability of HL7 HCS for Jericho Pilot Stage 2– Health Care Privacy & Security Classification System– Define required security labels within the HCS for PCD

transfer– Define specific PCD data to be exchanged, including metadata

• Deadline: July 22nd06/25/2013 16

1706/25/2013

Reminder: Test Methodology

1806/25/2013

Pilot Timeline• General Timeline, conditioned on agreement of stakeholders

Milestone Target Date Responsible Party

Kick off and Logistics April 2013 Jericho Systems

Basic Infrastructure June 2013 Members

AuthN via Repository August 2013 Members

Reporting Capability October 2013 Members

Complete November 2013 Members

1906/25/2013

Questions?

• For example:• Should we demonstrate data segmentation information being

passed in the PCD request?

20

Plan of Action

• Upon agreement of the participants the POA is: • Identify the elements available from previous DS4P pilots• Scope level of effort, decide on extended scenario• Determine first draft of functional requirements• Review standards available for returning information on requests• Determine any gaps or extensions required in standards• Stand up information holders and requestors• Create XDS.b repository holding PCD• Identify remaining pieces • Document and update IG with results of our experience

06/25/2013

DS4P Standards Material• Location of DS4P Standards Inventory:

http://wiki.siframework.org/Data+Segmentation+-+Standards+Inventory• Location of DS4P Standards Mapping Issues:

http://wiki.siframework.org/file/view/Copy%20of%20DataMappingsIssues%2005102012.xlsx/333681710/Copy%20of%20DataMappingsIssues%2005102012.xlsx

• General Standards Source List:http://wiki.siframework.org/file/view/General%20SI%20Framework%20Standards%20Analysis.xlsx/297940330/General%20SI%20Framework%20Standards%20Analysis.xlsx

• Standards Crosswalk Analysis http://wiki.siframework.org/Data+Segmentation+for+Privacy+Standards+and+Harmonization (at bottom of page, exportable)

• Implementation Guidancehttp://wiki.siframework.org/file/view/Data%20Segmentation%20Implementation%20Guidance_consensus_v1_0_4.pdf/416474106/Data%20Segmentation%20Implementation%20Guidance_consensus_v1_0_4.pdf

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http://wiki.siframework.org/Data+Segmentation+-+Standards+Inventory

http://wiki.siframework.org/Data+Segmentation+-+Standards+Inventory




http://wiki.siframework.org/file/view/General%20SI%20Framework%20Standards%20Analysis.xlsx/297940330/General%20SI%20Framework%20Standards%20Analysis.xlsx




http://wiki.siframework.org/Data+Segmentation+for+Privacy+Standards+and+Harmonization



http://wiki.siframework.org/file/view/Data%20Segmentation%20Implementation%20Guidance_consensus_v1_0_4.pdf/416474106/Data%20Segmentation%20Implementation%20Guidance_consensus_v1_0_4.pdf




2206/25/2013

DS4P References

• Use Case: http://wiki.siframework.org/Data+Segmentation+for+Privacy+Use+Cases

• Implementation Guide: http://wiki.siframework.org/Data+Segmentation+for+Privacy+IG+Consensus

• Pilots Wiki Page: http://wiki.siframework.org/Data+Segmentation+for+Privacy+RI+and+Pilots+Sub-Workgroup

http://wiki.siframework.org/Data+Segmentation+for+Privacy+Use+Cases

http://wiki.siframework.org/Data+Segmentation+for+Privacy+Use+Cases

http://wiki.siframework.org/Data+Segmentation+for+Privacy+IG+Consensus

http://wiki.siframework.org/Data+Segmentation+for+Privacy+IG+Consensus

http://wiki.siframework.org/Data+Segmentation+for+Privacy+RI+and+Pilots+Sub-Workgroup

http://wiki.siframework.org/Data+Segmentation+for+Privacy+RI+and+Pilots+Sub-Workgroup

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Backup Slides

2406/25/2013



Patient


1st Requestor

B

, = Clinical data

A,B =PCD data

= audit record


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Patient


1st Requestor

Clinical exchange #

Clinical exchange #

B

, = Clinical data

A,B =PCD data

= audit record

And Subsequent Custodian of Data being Provided at Fetch PCD Fetch

PCD

Send auditSend audit

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Expected Data Flow (1)


Patient


1st Requestor

, = Clinical data

A,B =PCD data

= audit record

2705/25/2013



Patient


1st Requestor

, = Clinical data

A,B =PCD data

= audit record

2805/25/2013



Patient


1st Requestor

B

, = Clinical data

A,B =PCD data

= audit record


2905/25/2013



Patient


1st Requestor

, = Clinical data

A,B =PCD data

= audit record


3005/25/2013



Patient


1st Requestor

, = Clinical data

A,B =PCD data

= audit record


3106/25/2013



Patient


1st Requestor

B

, = Clinical data

A,B =PCD data

= audit record


Informative Note: PCDs

05/14/2013 32

PCD Format PCD Header

PCD Body

• Structure of the PCD

Query and Response for Location

06/25/2013 33

Query and Response PCD

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35

NHIN IHE XCA

06/25/2013

NHIN Query for Documents Web Service Interface Specification XCA Cross Gateway Query transaction [ITI-38] as the protocol for query for documents

NHIN Retrieve Documents Web Service Interface Specification XCA Cross Gateway Retrieve transaction [ITI-39] as the protocol for retrieving documents

3606/25/2013

Issues from Previous Call1. Issues inherent in embedding PCD repository information

• Embedding PCD Repository information in clinical documents• Providing a pointer to location is static (even if PCD dynamic)• Can we meet goal by embedding query information?

2. Subsequent Custodian of Data should multicast query for PCD • Provide broad information, specific to organization • Provide unique PCD identifier in clinical document

3. Cover new use cases • If PCD not found, multiple PCD found, or new repository

4. Build on previous pilots• Most recent PCD, no de-confliction step considered

3706/25/2013

Running Observations1. XCA simplifies back-end implementation

• Although XDS.b is described in IHE documents, not required• Many current examples of eHealth Exchange use XCA

2. On-Demand Documents Supplement• NHIN has adopted the use of On-Demand Documents • Updates XCA to use dynamically created documents• Allows registration of content dynamically assembled

3. Audit record from custodian of release decision• Previous pilots used unique message ID, not externalized

4. Creation of PCD on demand• If PCD has sensitive data, should not give all information