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  • 1. Access to the health recordDraft report ISO/TC215/WG1
    • Prepared by the New Zealand Delegation
  • Wednesday 21 June 2000
  • Vancouver
  • Canada
  • something wecouldachieve ...

2. From the TC215 Scope Statement

  • Standardization in the field of information for health, and Health Information and Communications Technology, to achieve compatibility and interoperability between independent systems.

3. From the WG1 scope statement

  • The scope of WG1 is to develop standards for thetrustedmanagement of information concerning health and the healthcare process.
  • WG1 will address health record standards that are independent of setting and technology. The standards willenable the availabilityof the appropriate information at the place and time of decision.

4. From the WG1 scope statement Terms of Reference

  • create a framework of standards that enables health information to be created, used and sharedacross any and all boundariesincluding systems, jurisdictions, disciplines and professions
  • adopt a consistent modelling approach across all health informatics standardization activities,based on an existing modelling notation.
  • include, but not be limited to, the content, structure and documentation of the health record, integration of patient information,interoperabilityand decision support

5. From the resolutions of the WG1 meeting, Tokyo, Nov.99

  • The agreed title of the Work Item is Access to the Health Record
  • The objectives of this Work Item are to define concepts for modelling access, not to determine a set of rules for access
  • A further recommendation was that the work item should lead to a 'technical report', not a 'specification, and that it should be done in collaboration with WG4.

6. Role of WG1 within ISO/TC215

  • WG1 is the pilot committee which should integrate the work of all working groups
  • Interoperability is a key goal of the TC215 process, and of the access item in particular. In our view, this will demand solutions which are both simple and flexible
  • Mention of a shared notation indicates we should be developing concepts for modelling access, ieModels
  • UML was identified as an appropriate notation

7. Overview

  • The ISO/TC215 process has a strictly defined time span
  • there is an urgent need for an accepted access model, and for its implementation
  • We discuss policy issues and propose a model of/forEHR access
  • An agreed access model would be of relevance to all WGs in the TC215 process

8. WG4defined the task

      • 'To define the essential elements of a health care public key infrastructure to support the secure transmission of health care information across national boundaries.
      • The specification must be Internet based if it is to work across national boundaries.from the Technical Specification Draft for Secure Exchange of Health Information, February 2000
  • It seems likely that the public keyinfrastructure proposed by WG4 will provide the basis for implementation of a global system.
  • The concept of attribute certificates would seem to be crucial to the implementation of access control by role, and
  • our task is to develop a model of the access process which will enable that synthesis.

9. Beyond reviewing current concepts and practices, the access control task for WG1 can thus be re-stated:

      • To propose a global policy to both accommodate jurisdictional and national differences in access control and facilitate cross border access
      • To marry these concepts with the evolving work from WG4 (including the Technical Specification Draft for Secure Exchange of Health Information, February 2000)

10. (a brief anthropological detour) The Definition of Social Man

  • Different cultures have distinct views of social responsibility and distributive justice
  • Western industrialised societies tend to emphasise individual autonomy
  • Many others regard the concept of 'self' as more socially constituted
  • In order to be truly international, an Access Standard would need to accommodate diverse definitions of self and society

11. The ISO Access Standard -

  • must contain a framework which permits diverse solutions to the age-old questions of self and society
  • should facilitate exchange of health information between systems with different 'set up' configurations in the networks of rights, obligations, access, and privacy considerations that surround health records

12. The Concept of Ownership

  • The concept of ownership, which can be deconstructed into rights and reciprocal obligations, is problematic when viewed cross-culturally
  • A decision was taken by WG1 members at the Tokyo meeting November 1999 to delete the ownership concept from the title of the work item

13. Review of international literature on access to health records

  • We presented a critical overview of national standards and procedures, including assessment of the extent of international consensus on principles relevant to access(please refer to this in the document on the WG1 web site)
  • www.health.nsw.gov.au/iasd/imcs/iso-215/
  • many OECD countries have broadly similar rules and restrictions regarding access, but:
  • details vary considerably, and
  • relatively little information is available about practices and procedures in other countries

14. Types of Access Control

      • Client hostname and IP address restrictions
      • User and password authentication
      • Role based Access Control
  • Strong authentication techniques
    • Digital and Attribute Certificates
    • Public-Private key encryption (eg PGP)

15. Role Based Access Control (RBAC)

  • The decision to allow access to objects is based on the role of the user, rather than on permission based on another user.
  • The determination of the role membership and the allocation of each role's capabilities are determined by the organisation's security policies.

16. Developing operational concepts and their interrelationships

      • Roles and Rules
      • Selfdefining systems of roles
      • The Role concept in Messaging
      • The Role concept in Security processes

17. Rules and Roles

  • Cultural concepts regulating access can be considered as sets of roles, and rules relating those roles.
  • Operationalizing is challenging and will show up redundancies, inconsistencies (eg David Jones UK scenarios, see Form 4 attachment)
  • Systems of roles and rules are mutually defining. Our task is not to try to evolve some sort of definitive set but rather to develop a model that can accommodate different sets of rules and roles yet remain globally interoperable

18. Selfdefining systems

  • The concept of self defining system comes from linguistics, cybernetics etc.
  • The game of chess is an example.
  • The concept of roles has its own extensive literature in sociology
  • a truly international standard must accommodate and express cultural variation in such systems of roles

19. Maori concepts in Aotearoa/New Zealand

  • the notion of an extended family group ( whanau ) helps to explain the Maoris greater collective interest/input bearing on access to personal information
  • infirm or incompetent individuals often have a 'minder' ( Kai Awhina ) consensually assigned by thewhanau , who is then responsible for decisions relating to, the individual's health care
  • whanauin practice may overrule the decision of an individual to undergo a medical procedure (e.g., abortion) based on cultural values and extensive social supports.

20. The Role concept in Messaging

  • the concept of role is defined (Hinchley CEN "A role of a healthcare agent is undertaken in the context of their relationship with another agent".
  • the messaging standardroleappears to comprise anagent , acontextand anaction .
  • Thus a role can be considered a simple syntactic structure

21. The Role concept in WG4

  • The WG4 paper uses the concept of role in relation to attribute certificates.
  • control decisions about request and disclosure can be rule-based, role-based and rank based .
  • attribute certificate supply role information
  • bound to a health professionals public key.
  • a health professional may have many of these, which reflect multiple roles.
  • attribute certificates are typi