Thursday, November 19, 2009

Who should Own a Patient’s Health Data, Where should they be Stored, and How should they be Exchanged (Part 1 of 2)

A thought-provoking conversation on LinkedIn (see this link) examines whether the patient data stored in the national health information network (NHIN) will, within the next five years, likely be "owned" by major firms such as Oracle, Google, and Microsoft.

While most (though not all) commenters replied NO, the discussion covered some very interesting topics about data ownership, storage, privacy, and exchange. Following are excerpts.
I replied to the original question this way:
I contend that ONLY group of people who should be allowed to OWN a patient's (consumer's) identifiable health data is the patient him/herself. The patient may allow other people (i.e., "Trusted Partners") to have access to certain data and to store it securely in centralized databases behind a firewall and/or in distributed encrypted data files stored locally. And when it comes to de-identified data for research purposes, I suggest that those data be available to anyone (e.g., under government control).
The best model for data exchange between the Trusted Partners (TPs) and between the patient and the TPs, imo, is a P2P pub/sub mesh node network resembling telephone networks.
Several others concurred with me about patient ownership and added comments such as:
…interoperability and access to longitudinal patient health data across physicians and time is a burden on bandwidth and very costly…the ownership of data will ultimately be the patient but the help of the government in providing a non-for-profit repository where the data sits and is maintained is a must. France is a good example of how this is possible…The best architecture for a national Health Information Exchange will be technology agnostic infrastructure, where EHRs are easily aggregated from multiple data sources simultaneously upon request by an authorized healthcare organization…All seem to agree that "networks of networks" model is a bit cumbersome and that patients should own the data…While I agree that the patient is the ultimate owner of the data, I do not agree that they should be the data aggregator - which means that patients should not be held accountable or responsible for the collection, entry and management of all their health information.
Another commenter I suggest this scenario:
Patient data "lives" in an encrypted "cloud", identified using a Universal Healthcare Identifier as is being developed by Global Patient Identifier, Inc. In order to render the data useless to hackers & thieves; financial & social security data is NOT stored with it.
EHR standards similar to ASC X12 HIPAA transactions, such that an entity (i.e. Provider) can request the Patient data vie a standard internet web-part that is populated based on selected parameters such as: all data, data for a specified time period, specified type of data (Radiology only, Lab results only) - or a combination of these parameters. In this way - data is available anywhere on the globe it may be needed.
We'll still need to devise a way for the Patient to grant access. Also, we'll have to think about controlling the data which was requested and locally populated. Can it then be stored locally / should it be erased? Perhaps this is managed via the TYPE of access the Patient grants to the requesting entity.
To which I replied:
…I suggest that any database in a public cloud should only contain de-identified data from multiple sources for research (aggregate analyses); the cloud could also store back-ups of encrypted data files for each patient with the originals residing on each end user's (clinician's, patient's, organization's) computer hard drive (or network server). These data files would contain patient records made up of data fed from locally stored sources (e.g., EHRs, PHRs, CPOEs), manual inputs, medical device data streams, and so on. A P2P, pub/sub, node network cyber-infrastructure would enable authorized nodes/users to conveniently exchange of data sets from patients' data files; to minimize cost and complexity, the files can be exchanged via encrypted e-mail attachments. I'll be offering more details on this novel health data exchange model over the next couple of weeks. See this link.
Note that patient control is enabled by decompositing a locally stored data file based on rules reflecting a patient's privacy wishes, so that only the portions authorized by the patient are exchanged. See this link.
Another commenter then wrote:
Consider the information related to a patient to be an "object" in a massive data warehouse. Different data attributes associated with this object are (at least today) "owned" by different people/organizations. For example, some of the provider data is and should be "owned" by the provider and not available to other providers, payers, or patients. I see this as one of today's key perceived barriers to physician/practitioner acceptance of the NHIN model.
Conceptually this design is possible, but a challenge remains with the "physical owner" of the data warehouse, its database and application design characteristics, and its security administration. Ultimately, in any Information System, someone needs to be the "master administrator". Furthermore, the patient does have ownership over who may be authorized to "tag onto" their patient-object (i.e., who have they authorized to provide them care).
One suggestion may be to encrypt the content-data so that the "master administrator" can set the security for various attributes (between provider, patient, payer, government, or other users) without having the ability to access the content. This service can be designed so that the patient may designate these roles, but only for their own patient-object.
I propose that the HIO [health information organization] provide for physical ownership at a "relatively" local level (by metropolitan area or rural region), using cloud computing principles that are updated to incorporate HITECH and related concerns. There needs to be a common interface between these HIO's in order to achieve the NHIN.
To which I replied:
While a patient ought to "own" all their health data, it doesn't mean that such ownership is the same as having actual physical possession of them all. After all, each healthcare provider (from an individual clinician to hospitals to large health system such as Kaiser and Geisinger) has physical possession of the data that they collect. It's unreasonable to expect that all those data (including images) be shipped to the patient for local storage and to ask the patient to release those data each time a provider needs them. Instead, the data should be stored where it is collected.
There is one exception, however: the PHR. All PHR data should always be stored with (i.e., physically possessed by) the patient (preferably, imo, in an encrypted data file), even if collecting data through the PHR is done via a kiosk in a doctor's office or through a provider's web site. Furthermore, all EMR/EHR data (with some possible exceptions, such as a psychotherapist's notes) should be sent automatically to the patient's PHR; and the PHR should have the means to help the patient understand what those clinical data mean.
To deal with the privacy issue, the PHR should possess functionality that enables a patient to identify the particular data able to be shared with particular types of providers. In addition, patients' PHRs should give them guidance and warnings about who should have access to particular data based on their roles and responsibilities. In that way, any data are stored in a provider's database/warehouse could only be shared with third parties when explicitly authorized by the patient.
And please confirm that I understand your proposal: Patient data can be considered an "object" with attribute tags defining those authorized to access data from that object. And you say the object would be stored in a massive data warehouse, but there are problems with determining who should physically own the warehouse database be the "master administrator," as well as the failure for the patient to control who is authorized to add tags to a patient-object. The suggestion is to encrypt the content while allow the master admin to set those authorization tags in accord with the patient's wishes. Using cloud computing principles to support ownership by regional centers and a common interface between them would enable a NHIN.
Assuming my understanding is correct, then what about the following data ownership and exchange model: I agree that patient data ought to be managed as an object. I content that the object ought to be a data file, preferably an encrypted delimited text file (such as comma separated value format) to minimize size and overhead. There would likely be multiple data file objects for each patient, which are stored very locally depending on who entered/collected the data (e.g., on a patient's or clinician's computer, smart phone, memory stick/card, or on a health organization's server, etc.).
For everyday transactions (e.g., when a primary care physician exchanges patient data with the specialists to whom they refer, or when a patient and clinician share data between a PHR and EHR) a desktop or network-based software program would automatically decomposite (break apart) the local data file, extract the authorized data, and ship that data set via an encrypted e-mail attachment using PKI to assure the correct recipient gets it. The recipient can then view those data in a personalized, template-based report A decentralized node-to-node, pub/sub mesh network could do this exceptionally cost-effectively and with minimal complexity, in addition to increasing security and privacy since the nodes' actions are guided by a rules base requiring no human intervention.
Continuing with my proposed model, the NHIN data warehouse would be fed by the same software program in the same manner, with each NHIN server being connected to a node in the network, and with e-mail being the "common interface." When invoking its subscriber function, the NHIN node(s) would automatically retrieve data files sent to it and import those data into its database(s). These files would contain a standardized minimal data set (MDS) based on the CCD/CCR, whereas the data exchanged between healthcare providers, and between patients and providers, would include but not be limited to the MDS. When invoking its publisher function, the NHIN node(s) would send the appropriate data to the appropriate subscriber (provider or researcher) nodes, which may include immunization and disease registry data, biosurveillance data, and de-identified data form cost & quality research. The NHIN would also enable any authorized clinician to access certain patient data residing beyond the confines of the regional data centers. By using these unmanned nodes for carrying out the data exchange processes, the issues of security and privacy are increased, as mentioned above, and the problems associated with a master administrator are eliminated.
The conversation is continued at this link.

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