Certification/MU tweaks to support patient subscriptions

This is a quick description of the minimum requirements to turn patient-mediated “transmit” into a usable system for feeding clinical data to a patient’s preferred endpoints. In my blog post last month, I described a small, incremental “trust tweak” asking ONC and CMS to converge on the Blue Button Patient Trust Bundle, so that any patient anywhere has the capability to send data to any app in the bundle.

This proposal builds on that initial tweak. I should be clear that the ideas here aren’t novel: they borrow very clearly from the Blue Button+ Direct implementation guide (which is not part of certification or MU — but aspects of it ought to be).

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Improving patient access: small steps and patch-ups

In a blog post earlier this month, I advocated for ONC and CMS to adopt a grand scheme to improve patient data access through the SMART on FHIR API. Here, I’ll advocate for a very small scheme that ignores some of the big issues, but aims to patch up one of the most broken aspects of today’s system.

The problem: patient-facing “transmit” is broken

Not to mince words: ONC’s certification program and CMS’s attestation program are out of sync on patient access. As a result, patient portals don’t offer reliable “transmit” capabilities.

2014-certified EHR systems must demonstrate support for portal-based Direct message transmission, but providers don’t need to make these capabilities available for patients in real life. Today, two loopholes prevent patient access:
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SMART Advice on JASON (and PCAST)

As architect for SMART Platforms and community lead for the Blue Button REST API, I’m defining open APIs for health data that spark innovation in patient care, consumer empowerment, clinical research. So I was very pleased last month at an invitation to join a newly-formed Federal Advisory Committee called the JASON Task Force, helping ONC respond to the JASON Report (“A Robust Health Data Infrastructure”).

We’re charged with making recommendations to ONC about how to proceed toward building practical, broad-reaching interoperability in Meaningful Use Stage 3 and beyond. Our committee is still meeting and forming recommendations throughout the summer and into the fall, but I wanted to share my initial thoughts on the scope of the problem; where we are today; and how we can make real progress as we move forward.

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Disturbing state of EHR Security Vulnerability Reporting

Last week I reported on a set of security vulnerabilities that affected multiple EHR vendors and other Health IT systems.

I initially discovered the vulnerability in a single Web-based EHR system and successfully reported it directly to that vendor.

But my subsequent journey into the world of EHR vulnerability reporting left me deeply concerned that our EHR vendors do not have mature reporting systems in place. Patient health data are among the most personal, sensitive aspects of our online presence. They offer an increasingly high-value target for identity theft, blackmail, and ransom. It’s time for EHR vendors to take a page from the playbook of consumer tech companies by instituting the same kinds of security vulnerability reporting programs that are ubiquitous on the consumer Web.

HL7 and EHR Vendors must address security reporting

I’ll lead with the key message here, and provide supporting evidence below: HL7 and EHR vendors need to institute security vulnerability reporting programs!
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Case study: security vulnerabilities in C-CDA display

For background, see my previous blog post describing the details of three security vulnerabilities in C-CDA Display using HL7’s CDA.xsl.

Last month I discovered a set of security vulnerabilities in a well-known commercial EHR product that I’ll pseudonymously call “Friendly Web EHR”. Here’s the story…

The story: discovery and reporting

I was poking around my account in Friendly Web EHR, examining MU2 features like C-CDA display and Direct messaging. I used the “document upload” feature to upload some C-CDAs from SMART’s Sample C-CDA Repository. At the time, I was curious about the user experience. (Specifically, I was bemoaning how clunky the standard XSLT-based C-CDA rendering looks.) I wondered how the C-CDA viewer was embedded into the EHR. Was it by direct DOM insertion? Inline frames? I opened up Chrome Developer Tools to take a look.
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Security vulnerabilities in C-CDA Display using CDA.xsl

TL;DR: If you’re using XSLT stylesheets to render C-CDAs in your EHR, make sure you understand the security implications. Otherwise you could be vulnerable to a data breach.

This blog post describes security issues that have affected well-known 2014 Certified EHRs.. Please note that I’ve already shared this information privately with the Web-based EHR vendors I could identify, and I’ve waited until they were able to investigate the issues and (if needed) repair their systems.

Last month I observed a set of security vulnerabilities in XSLT “stylesheets” used to display externally-supplied C-CDA documents in many EHRs. To be specific: the CDA.xsl stylesheet provided by HL7 (which has been adopted by many EHR vendors) can leave EHRs vulnerable to attacks by maliciously-composed documents.
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How does FHIR express uncertainty and negation?

Last week I received an e-mail asking how FHIR expresses Uncertainty and Negation. It was a general inquiry, but also asked how FHIR might express a specific clinical statement like “Intolerant to opiods, no known other medication ADEs, and no known environmental/food allergens”.

Here’s what I said…
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C-CDA Endoscopy, or
Improving Clinical Document Exchange

SMART C-CDA infographic -- click to enlarge
Click infographic for full-size PDF

By David Kreda and Joshua Mandel

2014 will see wide-scale production and exchange of Consolidated CDA documents among healthcare providers. Indeed, live production of C-CDAs is already underway for anyone using a Meaningful Use 2014 certified EHR. C-CDA documents fuel several aspects of meaningful use, including transitions of care and patient-facing download and transmission.

This impending deluge of documents represents a huge potential for interoperability, but it also presents substantial technical challenges. We forecast these challenges with unusual confidence because of what we learned during the SMART C-CDA Collaborative, an eight-month project conducted with 22 EHR and HIT vendors.

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Improving Clinical Document Exchange”

Understanding “whitelists” in Direct Project secure e-mail

What’s a “Whitelist”?

As a follow-on to the last post about Direct messaging, I want to distinguish the Mass Medical Society’s vision of a “whitelist” from another concept that confusingly shares the “whitelist” moniker. Below, I’ll introduce two distinct terms and try to clarify the distinction:

“OR-gate whitelists” expand the communication pool

Mass Medical Society envisions a kind of per-physician “whitelist” that I’ll call an OR-gate whitelist. The basic premise of an OR-gate whitelist is that a physician can add any Direct address to her OR-gate whitelist via a UI in her EHR or HISP. By doing so, she’d be able to send secure e-mail to that address — regardless of CAs, trust bundles, or pre-existing local policy. An OR-gate whitelist acts like a logical “OR gate,” meaning that a message will be sent if institutional policy allows it, or if a physician’s personal OR-gate whitelist allows it.  With OR-gate whitelists, physicians can send to any Direct endpoint in the world, full stop.

“AND-gate whitelists” restrict the communication pool

The current Massachusetts HIWay has a deployed a different kind of “whitelist” functionality that I’ll call an AND-gate whitelist. Mass HIWay maintains a state-wide AND-gate whitelist of acceptable Direct addresses to which HIWay users are allowed to send Direct messages. An AND-gate whitelist acts like a logical “AND gate,” meaning that a message will be sent only if institutional trust bundles allow it (i.e. the recipient’s cert is signed by a CA that the organization trusts) and the institution’s AND-gate whitelist allows it. So Mass HIWay’s state-wide AND-gate whitelist is a way to avoid allowing, say, “all eClinicalWorks users across the whole country” into the pool at once. Instead, access can be restricted to the intersection of two sets: “All eClinicalWorks users across the whole country” and “Users on the Mass HIWay AND-gate whitelist.”

Direct Project: Secure e-mail in MU2

MU2 is here, and with it: secure e-mail

As Meaningful Use 2014 EHRs come online this winter, clinicians across the country gain access the host of new features included in the MU 2014 Certification Requirements. In this post, we’ll dig into one of these features: EHR-based secure e-mail capabilities that operate using the “Direct Project” specification. (If you’re new to this world: when you hear “Direct Project,” you should think “secure e-mail for healthcare.”)

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