hi all In france this issue of access to medical records scanned the subject of a great debate. The state decided the opportunity for every citizen to have a medical records housed at a host accredits
The patient received the right to refuse that certain information not be available for doctors It is the patient's medical opposite to the doctor Organizations of doctors consider that this personal medical records (DMP) can be useful in their work. best regard's Dr R LONJON France > > > > > > Hi B > > > > b.cohen wrote: > > This issue raises the thorny problem of Healthcare Security Policy, the nub > of > which is to specify a policy which, verifiably, satisfies ALL of the > following > criteria: > (a) no item of patient data may be disclosed to any party to whom the patient > denies it; > (b) any clinician with responsibility for the healthcare of the patient must > have access to all patient data relevant to that care; > > > Subject to clause (a) > > > (c) all accesses to patient records, and all records granting and > rescinding > such access, must be recorded in audit trails for eventual use in either the > defence or the prosecution of malpractice suits. > > > I think it is worth differentiating between access logs and the sum of > changes to the health record (usually called audit trails). > > > As well as being extremely topical in the UK, given the recent data loss in > the > NHS, it has been a serious problem for much longer. > In 1996, Ross Anderson famously reported that the NHS's enormously expensive > networking plans could not be shown to satisfy a dozen or so requirements of > this nature, a report that led the BMA to advise its members not to transmit > any patient data on that network. > In the same year, I constructed a formal, set-theoretic model of most > of these constraints (see http://www.soi.city.ac.uk/~bernie/hsp.pdf). I > submitted it for publication in a Healthcare Security > Conference, where it was rejected by a panel including Ross Anderson. At that > time, emotions were running high and the very idea of a networked EPR raised > fears of security breaches that could not be addressed rationally. Also, to > the > healthcare community at that time, any attempt to address such issues > mathematically was anathema. Perhaps times have changed. If anyone would like > to explore the continued development and validation of such a formal model, I > would be happy to help. > > > It would be very useful. The issue here is the balance between the red > flag carriers and the perceived and actual benefit from those who > consent to having an EHR. The unit record (one per patient) is still > less than 100 years old and I guess that was the actual beginning of > major threats to privacy. The mobility of patients and specialisation > and sophistication of interventions does increase the likelihood that, > when you are seriously ill or have long term health care you are likely > to benefit from broad access and input into a shared health record. > > > > The challenge from my point of view is to maintain the distribution of > information where it is required and firm up the person's control of > their own health record. I am a believer in the full health record > being held by a trusted third party (an NGO for instance) as a mutual > organisation which uses revenue from thoughtful use of the data to > improve the services to clients. This guarantees lifelong records - > decay with time being the biggest threat that I can see to the > information about us. I am also interested in holding my own health > record, perhaps on my phone, with blue tooth access or something. I > would like to have it partitioned in a very simple way - open stuff > (allergies perhaps), closed stuff (routine access) and private stuff > (only accessable with another process). > > > > It does need thinking about and the openEHR access list is one step in > this direction, allowing people to provide rules regarding specific > compositions. > > > > BUT, we need to keep this working for clinicians and patients - so I > like the iPod example where the musicians (clinicians?), record > companies (health providers) and consumers (patients) had to agree on > the rules before it could proceed. Just so, a health record that does > not meet the needs of all parties will not thrive. An example might be > the ability to hide whole compositions but not part of a composition - > thus the drug list may be private - but not show part of the drug list > (which is clearly dangerous if it is not clear to the physician). > > > > Anyway - lots of ideas and so little time! > > > > Cheers, Sam > > > > Quoting JP Freriks <jpfreriks at gmail.com>: > > > > There are some things I would like to add to my last posting: > > 1. 'Author Access Control' is the concept I believe we're talking > about (instead of Author Mandate). /Although the two concepts are > related./ > This doesn't imply at all that a patient cannot request to see > the 'private' information. It is the author that must hand over > the info, so the author has the access control. Now, the > 'architecture overview' document section 7 only / mostly(?) speaks > about patient access control. > > 2. I think that there's agreement on the desirability on having > author acces control modelled in the open EHR architecture. Arguments: > > 1. It's advisable to put all possible requirements in, even > when some countries have the policy not to accomandate for > private notes. Policies change. (see Dipak's contribution). > And allready it seems to be normal policy in Germany (as > Karsten pointed out). > 2. Plus: private comments are part of the health care proces > (as many of you pointed out). Health care providers want to > make comments, or put in reminders that shouldn't be > disclosed to a patient instantly. These comments need to be > recorded too, connected to (or part of?) the patients record. > > /And I think also in the EHR, because (as Gerard pointed > out) when a patient requests it these comments must be > shown. So they must be sharable. And some comments (like the > ones Shinji mentioned) want to be shared amongst healt > ptoviders. What other place should it be recorded than > within the EHR? [As I understand it, the EHR is the whole > complex of medical information, with the EPR being a subpart > of it. Is this correct?] > > / > 3. There are different types of information that under certain > circumstances must become/remain inaccessible to the patient. What > types, according to which situations can be distinguished? > There's info that is part of the medical record but can become > inaccessible (when requested by the patient, for instance), and > there are working notes of the physician that aren't part of the EPR? > > /I guess (since I don't have a copy of it) that this is all in// > CEN 13606 part 4? > > - /Should stuff like working notes be accomodated for by > openEHR, or is this something extra to it, supplied for by > applications? > > 4. It's good to differentiate between: > 1) clinical management policies and information management policies; > 2) the definition of these policies and their use, and their > implementation; > 3) between a faithfull representation of (inter)national policies, > and the representation of the domain of plausible access policy > decisions (rules) in as generic and interoperable way as possible. > (Dipak) > > 5. The question remains on how author access control should be > covered by openEHR. > > 1. There is an existing standard (EN 13606 Part 4) that is 'a > logical model to represent the domain of plausible access > policy decisions (rules)' (Dipak) and covers '95% of all use > cases' (Gerard). Are there any objections on using this > standard within openEHR? > 2. What is the best way to handle access control? By creating > an Access Control Archetype or templates (as Gerard > suggests), or by modelling it as meta-data in the Reference > Model (as Ian suggests)? Or by security components / > Desktop, Networks, Applications, Service? > > /I think author comments should have a different status than > objective patient information. It seems better to provide > for this by adding an author controlled comment section > separately to the EPR part. This means that it would be > better to create archetyped meta-data in the RM, and not on > ENTRY level. Does this line of thinking make sense? > > / > 6. How to go from here? > > 1. The Architecture Overview chapter 7 treats access control > mainly as patient access control. (That's where ROLE comes > in.) We want a section speaking about author control, too? > 2. Will openEHR pick our 'recommendations' up, or should we > make an official request? > 3. Is there a committe that does the 'official' thinking, or > are we, as the community, doing that? > 4. Would it be advisable to form some sort of working group, > getting other people (specialists) involved too? (like Ian's > contact). > > > Best wishes, > > Josina > > > > > > > > > > -- > > > sam.heard signature > > > > > Dr > Sam Heard > > Chief Executive Officer > Ocean > Informatics > > > > > Director, openEHR Foundation > > Senior Visiting Research Fellow, University College London > > Aus: +61 4 1783 8808 > > UK: +44 77 9871 0980 > > > > --
