# Presentation: 100427

## Sharing a Clinical Abstract: Privacy Considerations in Minnesota

- Donald P. Connelly, MD, PhD
- Daniel T. Routhe, BBA
- University of Minnesota
- AHRQ 2007 Annual Meeting
- September 27, 2007

- Findings from AHRQ’s State Privacy & Security Projects

**Notes:**
The lack of timely transfer of essential clinical information is a major barrier to effective care transitions and can lead to redundant work, conflicting recommendations, errors, and patient confusion and distress.  To lessen information gaps, three partnering healthcare systems, Allina, Fairview and HealthPartners, set out to develop an implementation plan for exchanging an electronic health record (EHR) abstract at the time a patient in transition presents.  The organizations had successfully collaborated on many QI initiatives and had independently selected the same EHR vendor, Epic Systems Corp.  Patient safety, medical, and information technology leaders developed a plan to exchange a clinical record abstract to improve information transfer during care transitions.  A high priority clinical focus was selected (i.e., heart failure) to allow a careful evaluation of the clinical value of clinical information sharing.  A comprehensive implementation proposal that led to a recent AHRQ grant award was completed in 6.5 months.  This project meshes well with the nation’s focus on interconnecting healthcare organizations to support health information exchange which may be the key that unlocks the value of HIT in terms of enhancing healthcare quality and patient safety.  Early achievements suggest that this project will be an important catalyst for improving our community’s standard of care.

Donald P. Connelly, M.D., Ph.D. is Professor and Head of the University of Minnesota’s Health Informatics Division.  His research has focused on clinical decision making and the development of information technology tools that clinicians choose to use in support of their patient care activities.  He obtained MD and PhD degrees from the University of Minnesota.  He is a Fellow of the American College of Medical Informatics, a founding member of the American Medical Informatics Association, and a member of the Minnesota e-Health Initiative Advisory Committee.  He is the Principal Investigator of the AHRQ Implementation Grant awarded to Allina, Fairview and HealthPartners in October, 2005 which focuses on sharing clinical record information among the health systems to support care transitions.

Daniel Routhe, BBA has more than 20 years of information technology experience and has led teams of up to 25 members that have successfully worked across both corporate and business unit boundaries. This experience serves as a backdrop for his current role as AHRQ project coordinator.  Since 2005, Dan has worked closely with Allina, Fairview and HealthPartners to advance the project: A Community-shared Clinical Abstract to Improve Care.  Dan represented the AHRQ project at two Minnesota Privacy and Security Project (MPSP) work groups -- Patient Privacy and 4A – and their invaluable work has been used to move the project forward.

## 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

**Notes:**
HISPC - Health Information Security and Privacy Collaboration 
MPSP – Minnesota Privacy and Security Project

## 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 a
- HealthPartners
- Clinic)

**Buffalo Hospital ER (Allina)**

**MyChart**
- Fairview

- My 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 compliant
- Clinical message

- Pt  Identifier

- Standards compliant
- Clinical message

- (Enrolled in a
- HealthPartners
- 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

**Notes:**
HISPC - Identifying differences in state laws for health info sharing
Working towards a sharable solution to privacy

4A = authentication, authorization, access control and audit

Description: This project is a portion of the Minnesota e-Health Advisory Committee’s work plan, which examines organization-level privacy and security policies and business practices related to health information exchange.  Reliable, timely access to a patient’s health information can improve the quality and efficiency of the health care delivered to the patient.  However, variations in organizations’ privacy and security policies and practices can serve as a barrier to appropriate access to health information.  This project seeks to uncover the rationale underlying the variations, propose solutions to eliminate variations, and develop an implementation plan to standardize the best practices for ensuring privacy protections and patient rights.
Lead organization/association: Minnesota e-Health Advisory Committee and Minnesota Department of Health

HISPC: RTI International established the Health Information Security and Privacy Collaboration (HISPC) under its Privacy and Security Solutions for Interoperable Health Information Exchange contract with the Agency for Healthcare Research and Quality (AHRQ), awarded in September 2005. The contract is co-managed with the Office of the National Coordinator for Health Information Technology (ONC). 

## 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
- AHRQ

- This 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.