Sharing a Clinical Abstract: Privacy Considerations in Minnesota

1
Sharing a Clinical Abstract Privacy
Considerations in Minnesota
Findings from AHRQs State Privacy Security
Projects

• Donald P. Connelly, MD, PhD
• Daniel T. Routhe, BBA
• University of Minnesota
• AHRQ 2007 Annual Meeting
• September 27, 2007

2
Overview

• What does our project aim to do?
• HIE and Minnesotas patient privacy context
• Minnesotas HISPC work - MPSP
• Changes in MN privacy laws that facilitate our
  work
• Adopting MPSPs privacy security principles
• Lessons learned

3
Our Response to AHRQs invitation

• Focus fill information gaps that occur at care
  transitions
• Patients presenting to ED
• Patients moving from one provider organization to
  another
• Partners Allina, HealthPartners, Fairview Health
  Services
• How deliver a clinical record abstract near the
  point of care
• Leverage partners use of a common EHR vendor
• Use a federated model of contributing clinical
  databases not a centralized one
• Use evolving national standards

4
Information Gaps in the ED

• Gaps are frequent - 32 of visits
• Gaps are consequential
• Very important or essential 48
• Somewhat important 32
• Prolong the ED stay
• Increase costs
• Redundant testing repeated MD assessments

Stiell A et al. CMAJ 2003 1691023-8.
5
Rationale for sharing an abstract instead of the
entire record

• Contents are bounded defined
• A better first step for a public wary of
  confidentiality breaches
• Patients get it. They understand the value of a
  concise clinical abstract for themselves and
  their providers
• Avoiding sensitive content means easier
  consenting wider use
• While not the entire record, clinicians endorse
  the abstract as having high clinical value
• The abstracts succinctness is preferred by some
  emergency room physicians
• Interoperability across vendor platforms should
  be easier

6
My Emergency Data Abstract

• Patient Information
• Contact Information
• Primary Care MD Clinic
• Advance Directives
• Current Problem List
• Current Medications
• Allergies
• Immunizations
• Surgical History
• Family Medical History
• Alcohol and Tobacco use

7
Level 1 MyChart Access
Buffalo Hospital ER (Allina)
(Enrolled in a HealthPartners Clinic)
MyChart Fairview
My Em. Data
8
What weve learned so far Level 1

• MyChart enrollment rate is too low to yield
  enough heart failure patients for our analysis
• An opt-in strategy greatly limits impact
• An opt-in strategy tends to exclude the elderly
  with multiple chronic illnesses the very group
  which may benefit the most
• MyChart hasnt integrated well into ED workflow
• Too few hits in ED to ensure good workflow
  integration or reliable use
• Login names and passwords are not uppermost in
  patients minds in urgent situations
• ED not equipped to provide keyboard access to
  patients

9
Level 2 Direct Health Information Exchange
Buffalo Hospital ER Allina
Epic EHR HealthPartners
Pt Identifier
(Enrolled in a HealthPartners Clinic)
Epic EHR Allina Hosp Clinics
Standards compliant Clinical message
Pt Identifier
Epic EHR Fairview
Review Incorporate
Standards compliant Clinical message
10
Minnesota Privacy and Security Project (MPSP)

• Minnesotas component of the Health Information
  Security and Privacy Collaboration (HISPC)
• We participated
• in the oversight committee
• in the Privacy 4A work groups
• MPSP ? Minnesota law changes effective July 1
• Were adopting key principles put forth in the
  MPSP report

11
MPSP Privacy Workgroup activities

• A systematic review of the states privacy laws
  practices to determine their impact on the
  electronic exchange of health data
• Electronic exchange barriers identified
• Undefined and ambiguous terms in our law
• Current laws are set up for paper exchange
• Need to update Minnesota consent requirements to
  facilitate electronic exchange while retaining
  patient empowerment

12
2007 Revisions to Minnesota Health Records Act

• Major revisions in the Health and Human Services
  Omnibus bill
• Improve readability
• Refine or add definitions for
• Health record
• Medical emergency
• Related health care entity
• Identifying health data
• Record locator service
• Representation of consent
• Liability and responsibility around disclosure
  clarified
• Information requirements for auditing exchanges

13
Record Locator Service (RLS)

• An electronic index of patient identifying
  information that directs providers in a health
  information exchange to the location of patient
  health records held by providers and group
  purchasers.
• Providers may construct an RLS without patient
  consent
• Providers must obtain patient consent to access a
  patients health record

14
RLS Privacy Protections

• Allows multiple groups of providers to create a
  RLS
• Only providers may access information in a RLS
• The Minnesota Department of Health cannot
  access/receive information from a RLS
• Providers must enable patients to completely
  opt-out of the RLS during the consent process
• An exchange that uses a RLS must maintain audit
  logs tracking access to patient health records

15
Minnesotas patient consent requirements

• Patient consent is required for nearly all
  disclosures, including treatment
• Limited exception to consent requirement
• Medical emergency
• Record movement within related health care
  entities
• Written consent (signed dated) is required
• Consent generally expires in one year
• Or

• a representation from a provider that holds a
  signed and dated consent from the patient
  authorizing the release

16
Representation of consent protections

• Only a provider may request a patients health
  record using a representation of consent.
• The requesting provider must have, in possession,
  a signed and dated consent from the patient.
• The releasing entity must document
• identity of the requesting provider
• identity of the patient
• records requested/provided
• date of the request

17
Liability and responsibilities for disclosure now
addressed

• Prior MN law placed all liability for
  inappropriate disclosure on disclosing provider
• Responsibilities are now defined for the patient,
  the requestor, and the discloser
• Each party warrants no information known to the
  person to be false
• Requestor accurately states the patient's desire
  to have health records disclosed or that there is
  specific authorization in law
• Requestor discloser do not exceed any limits
  imposed by the patient in the consent
• Discloser has complied with the legal
  requirements regarding disclosure of health
  records

18
Applying MPSPs security privacy principles is
ongoing

• Concentrating on 4As principles
• Data to be captured in audit logs
• Limit access requests to patients being treated
  and information relevant to that treatment
• Develop accept
• written policies and procedures for participating
  in the exchange
• security credentialing guidelines for authorizing
  individuals to access health information through
  the exchange
• minimum standards for routine auditing of
  individuals access through the exchange

19
Lessons learned

• Attention to privacy concerns pays off
• Law evolves too get involved
• Continuing opportunities
• Conforming our exchanges rules of the road to
  Minnesota law
• Contributing to Minnesotas universal consent
  form due in January 2008
• Avoiding burden to providers in neighboring
  states while conforming to our states laws

20
Acknowledgements

• The many dedicated and committed participants
  from
• Allina Hospitals and Clinics
• Fairview Health Services
• HealthPartners
• University of Minnesota
• Our projects Board members
• Jim Golden, MDH
• AHRQ

This project was funded in part under Grant
Number UC1 HS016155 from the Agency of Healthcare
Research and quality, US Department of Health and
Human Services.