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

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:

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) Username 1 Password 1 MyChart HealthPartners 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

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 HS from the Agency of Healthcare Research and quality, US Department of Health and Human Services.