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6 Findings and Recommendations
Pages 160-196

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From page 160...
... Computer-based decision support tools can help reduce variation in health care quality across providers, improve adherence to standards of care, and reduce costs by eliminating duplicative or nonefficacious tests and therapeutic procedures. To obtain the benefits of electronic medical records, the nation must address and mitigate concerns regarding the privacy and security of electronic health care information.
From page 161...
... FINDINGS AND CONCLUSIONS Finding 1: Information technology is becoming increasingly important in improving the quality and lowering the costs of health care; attempts to protect patient privacy must therefore center on finding ways to protect sensitive electronic health information in a computerized environment rather than on opposing the use of information technology in health care organizations. As the site visits conducted for this study attest, the shift to integrated health care delivery systems and managed care creates a growing demand for electronic health information and for data networks capable of transferring data within and across organizations.
From page 162...
... As a result, EMRs should not be viewed as a way of undermining patient privacy but as a means of enhancing patient privacy by improving the security of health information. Finding 2: Health care organizations need to take a more aggressive approach to improving the security of health information systems in order to better protect electronic health information.
From page 163...
... Lack of security results, in large part, from a lack of strong incentives to improve it. In the absence of a widespread, public catastrophe regarding information security, many health care organizations reported that they believe the risk of a major breach of security is low and that they could survive a major event without significant consequences.
From page 164...
... For patients to feel comfortable providing personal health information to a care provider, they may need greater authority in helping to determine rules regarding the privacy of health information. Finding 5: The greatest concerns regarding the privacy of health information derive from widespread sharing of patient information throughout the health care industry and the inadequate federal and state regulatory framework for systematic protection of health information.
From page 165...
... Health care organizations have been working for many years to develop mechanisms for protecting health information (in both paper and electronic form) from abuse by authorized users, but they must continue to strengthen their protections by, for example, implementing auditing capabilities and strengthening disciplinary sanctions.
From page 166...
... Audit trails can record all transactions that access patient information. Encryption can be used to protect log-in IDs, passwords, databases, or information transmitted over open communications systems.
From page 167...
... The recommendations below outline the roles of health care organizations, the health care industry, and government in improving privacy and security practices within individual health care organizations, creating the industry-wide infrastructure needed to develop and encourage adoption of stronger privacy and security practices, addressing systemic issues related to privacy and security, and ensuring research to meet future technical needs. To the extent possible, the committee has attempted to identify the organization or organizations best qualified to implement each recommendation.
From page 168...
... These policies either could help health care organizations meet the standards promulgated by the Secretary of Health and Human Services as directed by the Health Insurance Portability and Accountability Act of 1996 or could inform the development of such standards. The penalties established by this act for violations of privacy or security standards may provide sufficient motivation for organizations to adopt these policies.
From page 169...
... Of course, the implementation of these policies, practices, and procedures within individual health care organizations will have to be adjusted to accommodate the requirements specific to those institutions and to the various types of departments and settings within them. The demands of an AIDS clinic may be different from those of a large, urban hospital.
From page 170...
... In addition, all organizations should implement procedures for At should be noted that the use of fine-grained access controls can exacerbate the difficulty of keeping the data in medical records organized so that they correspond with the access privileges of the users. A variety of software tools are under development to assist in managing this task See Chapter 4~.
From page 171...
... Health care organizations should ensure that contractors used to transport and store backup tapes have adequate policies in place for safeguarding the information and protecting integrity. Backup tapes stored in off-site locations represent a significant vulnerability that is often overlooked.
From page 172...
... Organizations that do not implement either of these approaches should allow remote access only over dedicated lines. Many health care organizations currently protect their remote access points by using dial-back procedures7 or by embedding the remote access telephone number in the software employed by remote users to establish a connection.
From page 173...
... Organizational Practices for Immediate Implementation Security and Confidentiality Policies. Organizations should develop explicit security and confidentiality policies that express their dedication to protecting health information.
From page 174...
... Improved Authorization Forms. Health care organizations should develop authorization forms designed to improve patients' understanding of health data flows and to limit the time period for which patients authorize the release of health information.
From page 175...
... This practice not only will enable patients to ensure that their privacy has not been violated but will also help educate patients as to health data flows and perhaps create a more trusting relationship between patients and providers. Security Practices for Future Implementation The practices listed above are intended for immediate implementation in order to provide health care organizations with a minimally sufficient level of security in the current environment.
From page 176...
... Expanded Audit Trails. Health care organizations should implement expanded audit trails.
From page 177...
... 9A regulation to promote these audit trails could be structured to allow adequate time for the development of such systems and to avoid costly retrofitting by requiring only that information systems deployed by health care organizations after 1999 have the functionality necessary to support audit trails.
From page 178...
... While health care organizations have strong incentives to develop health care applications of national information infrastructure, they do not necessarily have strong incentives to improve privacy and security. The committee makes three subrecommendations described below to support this goal.
From page 179...
... Little is known about the extent of violations of privacy and security in the health care industry, in part because the health care industry lacks a formal mechanism for sharing information about the types of attacks and breaches of privacy that organizations have experienced, and mechanisms for improving privacy and security. Establishment of an organization to facilitate information exchanges would provide a means for improving the security of health care organizations as they move into a more networked environment and would provide a sounder basis for making policy.
From page 180...
... are geared toward promoting better policies, procedures, and practices within health care organizations for protecting patient health information. As noted in Chapter 3, the greatest concerns regarding patient privacy stem from the widespread dissemination of information throughout the health care industry and related industries, often without the knowledge or consent of patients.
From page 181...
... Moreover, public awareness and concern may be an essential prerequisite to the passage of necessary legislation of any strength. Recommendation 3.2: The Department of Health and Human Services should work with state and local governments, health care researchers, and the health care industry to establish a program to promote consumer awareness of health privacy issues and the value of health information for patient care, administration, and research.
From page 183...
... These claims originated at a time in which public concerns for privacy were far less intense than they are today and in which technologies to protect anonymity were far less developed. A fresh look to determine the minimum set of patient-identifiable data needed for these stated goals could result in a significant reduction of collected data that 1lThese include, but are not limited to, the American Hospital Association, American Medical Informatics Association, American Health Information Management Association, College of Health Information Management Executives, Healthcare Information and Management Systems Society, Computer-based Patient Record Institute, and American Medical Association.
From page 184...
... In other cases, such as some long-term medical research, identifiable data may be the only alternative. Understanding these different uses and the differing needs for patient-identifiable data will allow a more reasoned debate of patient privacy issues.
From page 185...
... , employer, health plan, and health care provider for use in the health care system. The decision to implement a universal health identifier and the particular design of the identifier have significant implications for patient privacy to the extent that they facilitate or impede the linking of records between and among institutions.~3 The ability to link patient records among health care organizations has many advantages in the provision of care, epidemiological research, and the analysis of care and utilization patterns.
From page 186...
... Recommendation 4: Any effort to develop a universal patient identifier should weigh the presumed advantages of such an identifier against potential privacy concerns. Any method used to identify patients and to link patient records in a health care environment should be evaluated against the privacy criteria listed below.
From page 187...
... 3. It should be unidirectional to the degree that is technically feasible: it should facilitate the appropriate linking of health records given information about the patient or provided by the patient (such as the patient's identifier)
From page 188...
... , become more commonplace and as additional research investigates new types of identification and records-linking schemes (see Recommendation 5~. In the meantime, many health care organizations have found that they can effectively link patient records within their expanding health care systems through the creation of master patient indexes.
From page 189...
... The question the nation must therefore address is whether there are ways of attaining the presumed benefits of a universal patient identifier better-informed health care, improved detection of fraud in connection with paying for health care services, and simplification of the administration of health care benefits without jeopardizing patient privacy 16 Meeting Future Technological Needs Recommendation 5: The federal government should take steps to improve information security technologies for health care applications. 14Szolovits, Peter, and Isaac Kohane.
From page 191...
... Many of the technologies that could be used to better protect health information will be developed by the computer security community regardless of the needs or demands of the health care industry. Technologies for authentication, authorization, encryption, and system reliability, for instance, apply to many areas in which information security is relevant and will continue to receive attention from researchers and technologists.
From page 192...
... Research is needed to find ways of indexing and linking patient records in a manner that protects patient privacy. The ideal scheme would meet the three criteria for privacy outlined in Recommendation 4.
From page 193...
... Today, the trade-offs between the benefits and cost of greater access to electronic health information are not well understood, with the result that decision makers in health care organizations lack a sound analytical basis from which to determine the appropriate level of attention to protecting information. Research is needed that better explicates the costs and benefits of various levels and types of information protection so that decision makers need not function in a vacuum.
From page 194...
... Although the National Library of Medicine has funded the development of numerous testbeds to explore health care applications of the national information infrastructure, these efforts do not have as their primary focus attempts to explore privacy and security practices. A number of targeted security testbeds would provide useful information to the health care industry.


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