use case documents from the health care domain - ROLES

Technical (archive)
1

Bill Walton wrote:

The "Health Care Facility Nominated Trusted Clinician" section on page 5
contains the sentence "This access will be on a 'need to know' basis." Here
in the U.S., HIPAA has specifically rejected "need to know" as a valid basis
for access. A user of the EHR may only access information the patient has
granted them the right to access. This complicates Access Control
considerably since it requires not only control of levels of information but
also specific health care episodes.

Yet a patient may typically grant relatively broad access to their
information (e.g. all physicians of an entire group, all staff of
an entire health care provider organization) under HIPAA. Within that
subgroup, it is still very likely appropriate to stratify access on a
need-to-know basis.

david

2

Bill,

In response to:

The “Health Care Facility Nominated Trusted Clinician” section on page 5 contains the sentence “This access will be on a ‘need to know’ basis.” Here in the U.S., HIPAA has specifically rejected “need to know” as a valid basis for access. A user of the EHR may only access information the patient has granted them the right to access.

My response is typically a French one: partially following the US point of view, but also complementary.

First, following HIPAA’s point of view, French legislation tells that the patient decides who will be allowed to access the EHR data.
So, when authoring patient’s data, we may consider that the Patient’s physician has the delegation to define the ACL.

Second, by default, the HealthCare Agent’s category (i.e. a surgeon, a physician, a nurse, a student…) defines restrictions of accessibility to the EHR.

Third, the patient’s physician may delegate exams or treatments to other HealthCare Agents (HCA). To complete this delegation, the healthcare agents need a view on the EHR: so a restriction of the access rigths to the patient’s EHR. If these HCA themselves delegate acts to other HCA, these delegations also come with appropriate restrictions on the visibility of the EHR.

Forth (and last, so pull the entire stack into action’s parameters), all these rules may not apply.
For example, because the Patient’s Physician is in vacation, and the Patient’s conciousness is also in vacation: holiday time, the Patient is in coma (an example ? diabetes). So a physician comes to see the Patient and tells the program: “I, Physician, in charge of managing the Patient’s Health in a possible case of life or death, do transgress the program’s and EHR data limitations, with full conciousness of what this means. I fully assume the consequences. So now, give me unlimited, full access to the Patient’s information. Signed: XXXX”. And this transgression will be added to the Patient’s record. And this transgression will also be notified to the Patient and to the physicians that the Patient choose: so any abuse may lead to legal consequences. Also, in a case of emergency, the program -and the software company which made it- will not be responsible of the death of a human being.
Conversely, if the use of a program leads or may lead to the patient’s death or illness, you may be sure that (1) the importation and use of the program will be prosecuted in most european countries; (2) the software authors and editors will assume the full consequences, including jail and money.

So, now, the Patient is in the middle of a desert. Around him, the only help is a less competent healthcare agent: for example, a student, or a nurse. Because of the possible consequences, the heathcare agent may type on his/her PDA/GPS/satellite_link_to_eath’s_global_health_service’s TTY: “I, less competent people, require appropriate information to do my best”. And we all will pray.