Sharing a Clinical Abstract: Privacy Considerations in

Minnesota

Donald P. Connelly, MD, PhDDaniel T. Routhe, BBA

University of MinnesotaAHRQ 2007 Annual Meeting

September 27, 2007

Findings from AHRQ’s State Privacy & Security Projects

Overview

What does our project aim to do? HIE and Minnesota’s patient privacy

context Minnesota’s HISPC work - MPSP Changes in MN privacy laws that facilitate our

work Adopting MPSP’s privacy & security principles

Lessons learned

Our Response to AHRQ’s 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

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; 169:1023-8.

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 abstract’s succinctness is preferred by some emergency room physicians

Interoperability across vendor platforms should be easier

“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

Level 1 – MyChart Access

(Enrolled in aHealthPartners

Clinic)

Buffalo Hospital ER (Allina)

Username 1Password 1

MyChart

HealthPartners

MyChart

FairviewMy Em.

Data………………………………………………

What we’ve 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 hasn’t 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

Level 2 – Direct Health Information Exchange

Buffalo Hospital ER Allina

Pt Identifier

Standards compliantClinical message

Pt Identifier

Standards compliantClinical message

(Enrolled in aHealthPartners

Clinic)

Epic EHR

HealthPartners

Epic EHR

Fairview

Review &

Incorporate

Epic EHR

Allina Hosp & Clinics

Minnesota Privacy and Security Project (MPSP)

Minnesota’s 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

We’re adopting key principles put forth in the MPSP report

MPSP Privacy Workgroup activities

A systematic review of the state’s 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

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

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 patient’s health record

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

Minnesota’s 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

Representation of consent protections Only a provider may request a patient’s

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

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

Applying MPSP’s security & privacy principles is ongoing

Concentrating on 4A’s 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

Lessons learned Attention to privacy concerns pays off Law evolves too – get involved Continuing opportunities

Conforming our exchange’s “rules of the road” to Minnesota law

Contributing to Minnesota’s universal consent form due in January 2008

Avoiding burden to providers in neighboring states while conforming to our state’s laws

Acknowledgements

The many dedicated and committed participants from Allina Hospitals and Clinics Fairview Health Services HealthPartners University of Minnesota

Our project’s Board members Jim Golden, MDH AHRQThis 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.