Printable = Version

The Brooklyn HIE's Security = Strategy

How the Network's Privacy Protections Will = Evolve

Howard Anderson, Managing Editor,=20 HealthcareInfoSecurity.com
July 8, 2010

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The=20 nation's healthcare information exchanges must focus on privacy = and=20 security as they develop new functions and features, says Irene = Koch,=20 executive director of the Brooklyn Health Information Exchange, = also known=20 as BHIX.=20

In an exclusive interview, Koch describes the exchange's:=20

=E2=80=A2 Use of encryption, which will evolve as BHIX enables = physicians to=20 access the exchange directly from their electronic health records = systems;=20

=E2=80=A2 Approach to verifying the identities of those sending = and receiving=20 information;=20

=E2=80=A2 Policies for gaining patient permission for sharing = information;=20

=E2=80=A2 Plans for working with providers to give patients an = accounting of=20 who has viewed their information; and=20

=E2=80=A2 Collaboration with other HIEs in the state on the = broader security=20 issues that will emerge when the exchanges are linked.=20

Koch has led BHIX since its formation in 2007. She is a member = of the=20 Policy and Operations Council of the New York eHealth = Collaborative. She=20 formerly served as associate general counsel at Maimonides Medical = Center=20 in Brooklyn. And she was assistant counsel with the New York State = Department of Health in the Bureau of Professional Medical = Conduct.=20

HOWARD ANDERSON: This is Howard Anderson, managing = editor at=20 Information Security Media Group. Today we're talking with Irene = Koch,=20 executive director of the Brooklyn Health Information Exchange. = Thanks for=20 joining us today, Irene.=20

IRENE KOCH: Thanks for having me.=20

ANDERSON: Please give us an update on status of the = Brooklyn=20 HIE.=20

KOCH: We are live with our health information exchange = at BHIX.=20 We have a bunch of hospitals and homecare agencies, nursing home = and=20 payers now contributing data and starting to also access the data = from the=20 health information exchange. We went live initially in the fall of = 2008=20 and now have an upgraded system that is operational.=20

ANDERSON: What kinds of information are the participants = sharing=20 now, and what kinds of transactions are on the horizon?=20

KOCH: At the current time we have an assortment of = clinical data=20 that comes in from all these various different organizations. And = it=20 ranges from admission/discharge/transfer data from the = registration=20 systems to different kinds of clinical data like procedures, = diagnosis,=20 healthcare advance directive information, labs and so forth. And = so the=20 actual focus of the data exchange currently has been on = transferring this=20 clinical information for viewing and historical purposes. But = immediately=20 on the horizon for us is turning to the world of transactions to=20 facilitate the kinds of referrals and exchanges of data that = happen on a=20 one-to-one basis when patients go from one place to the other. And = those=20 are the kinds of things, like referrals...that are on our = immediate=20 horizon.=20

ANDERSON: Can you give us a few examples of how = participants are=20 using the exchange now?=20

KOCH: Sure. Like I said, right now we're live with = clinicians=20 pulling data from a clinical portal sponsored by BHIX. So we have=20 physicians who might be treating the patient in an emergency room, = for=20 example, who need to get information on that patient because the = patient=20 may be comatose or unable to participate in their care. Physicians = can do=20 what's called a "break the glass" inquiry on the BHIX clinical = portal for=20 one-time access to this patient's clinical information to treat = them in=20 the emergency. And we've gotten feedback from those clinicians = that=20 they've actually been able to get very valuable information on = those=20 patients through BHIX that they would never have known about = otherwise to=20 help care for that patient.=20

And so although the workflow of getting data from a clinical = portal=20 outside of one's own information system isn't ideal, we still are = getting=20 feedback that the data is very, very valuable. So when I refer to = the=20 workflow issue, what we're working on and testing right now is = having a=20 physician from within his own electronic medical record be able to = push a=20 button to get the same exact data that I talked about sent right = into=20 their system as a summary document....=20

ANDERSON: So are you using encryption now to protect = information=20 being exchanged or will that be added as you move to the = transactional=20 model in the months to come?=20

KOCH: There is currently encryption. It's just a = different sort=20 of encryption that happens when you're using the portal versus = when you're=20 exchanging data into an electronic medical record using these = newer=20 profiles. So right now we are doing encryption of the data through = VPN=20 tunnels and so forth, and the data being retrieved from the system = is=20 accessed through an encrypted process as well....=20

ANDERSON: How do you go about verifying the identities = of those=20 sending and receiving information?=20

KOCH: When data is being retrieved from the system = through the=20 BHIX portal, the user's identity is determined through...their = user name=20 and their password. And once the login is complete, their role and = consent=20 is evaluated to determine what activities that user can perform. = But=20 again, we're very much moving toward the world where that is not = the only=20 way to access data through BHIX. We're moving toward being able to = serve=20 up the data to a user who identifies himself from within his or = her own=20 EHR system.=20

And so when you're using those interoperable electronic health = records,=20 the mechanism is a little bit different and uses...client = certificates and=20 other technology that the technical team has spent a lot of time = in our=20 project and through statewide work defining.=20

ANDERSON: What is your policy for enabling patients to = opt in or=20 out of having their information exchanged?=20

KOCH: The policy that we have implemented here at BHIX = is=20 entirely consistent with the parallel universe of the policy = that's gone=20 on through the entire New York state collaboration process (among = various=20 HIEs.)....We don't actually even refer to it as opt in or opt out = because=20 it's a little bit misleading. What it really amounts to is that = when a=20 clinical provider wants to access a communitywide batch of data = through a=20 health information exchange governed by that exchange, since it's = not just=20 one providers organization at a time, there needs to be an = affirmative=20 consent from the patient to be able to authorize that one user to = access=20 that information.=20

So it's really called an affirmative consent model and each = patient is=20 given the option to either grant each different provider = organization=20 consent to see their data, to access their data through BHIX, so = that=20 would be a "grant consent" or they can give them the option to = "deny=20 consent" so that for that particular provider organization they = may not=20 ever access data on that patient through BHIX. Or, there's that = "interim"=20 status, until you know the answer of the patient or if the patient = wants=20 to just leave it that way, which is that only in an emergency = situation=20 may the provider access information through BHIX and we just = referred to=20 that earlier when we talked about "breaking the glass."=20

So it's really an all-or-nothing consent of that patient. We = don't=20 filter based on different types of data for this large amount of=20 communitywide exchange....As we move from a communitywide exchange = of data=20 to a more one-to-one or push type of model, there's going to be a = lot more=20 discretion on picking and choosing bits of data that one provider = opts to=20 send to another, and that's a whole different way of using a = health=20 information exchange to improve care.=20

ANDERSON: How do you plan to enable patients who request = it to=20 get a list of who has accessed their information via an exchange?=20

KOCH: Our privacy policies have a lot provision about = the=20 participants that use BHIX so that they can engage with their = patients to=20 provide them the information that they need to satisfy the = patient's=20 request for information. Enabling patients to get their data = through BHIX=20 is going to be happening through our provider organizations = because=20 they're the ones that really have the relationship with the = patient.=20

So if a patient is at a hospital and requests a record from = that=20 hospital, we will work with that hospital who's a member of BHIX = to help=20 them amass a list of access points through BHIX to that patient's = data....=20

ANDERSON: It sounds like you anticipate that your = exchange will=20 be linking up with others throughout the state. What additional = security=20 issues does that raise?=20

KOCH: Yes, we very much anticipate that our health = information=20 exchange will link up with others throughout the state and, of = course,=20 here in New York City....=20

So of course we're going to need to link up with other health=20 information exchanges throughout the state and even in other = states=20 because patients come to New York City for business and for care. = In order=20 to really improve the care of these patients, you need to get data = from=20 lots of different places. So it's not even just security issues = that you=20 need to address when you think about all of those interactions. = It's the=20 identification of the patients from different hubs and the = identification=20 of the users to make sure that the users here have proper access = to not=20 just the data that was originally from BHIX but from these other=20 information organizations and exchanges as well.=20

So we're very actively participating in statewide work to start = discussing those issues with our colleagues. But that's definitely = a work=20 in progress and something that's requiring a lot of effort for = everyone to=20 work on together.=20

ANDERSON: Finally, what advice on privacy and security = issues=20 would you give to other HIEs that are just in the formative stages = based=20 on your experience so far?=20

KOCH: It's absolutely central to everything that the = health=20 information exchange does to be able to think of the privacy and = security=20 domain as they relate to every new function and technical feature = that is=20 deployed. To think of it as an afterthought is a real mistake.=20

One of the strengths of BHIX actually was that in every bit of=20 technical build we wove in not only the privacy and security kind = of=20 perspective but also the clinical perspective to make sure that = they were=20 all aligned at the same time so that the technical folks don't = build in a=20 bubble. That's going to be essential for anyone going forward.=20

As we think of the National Health Information Network that's = really=20 developing across the country, we really need to make sure that = the=20 privacy and security issues that get resolved in each region, in = each=20 state, harmonize with one another so that we actually can = effectuate the=20 kind of exchange that we need to do across the country. Because = the worst=20 thing that would happen would be that there would be bubbles and = silos of=20 places where you could exchange data but not really take it to the = next=20 level, which will really bring the most value.=20

ANDERSON: Thanks, Irene. We've been talking today with = Irene=20 Koch of the Brooklyn Health Information Exchange. This is Howard = Anderson.=20 Thanks so much for listening.