Welcome to EMR and HIPAA

I don’t usually like to post blanket statements like the above, but I’ve really fallen in love with facial recognition. I absolutely love my facial recognition. I’ve been working lately with Sensible Vision a vendor of facial recognition software getting the single sign on to work with my EMR package called Medicat. It’s pretty impressive.

I brought in the director of the health center to take a look at the single sign on. I opened my EMR application and it pretty much goes straight into the application. The director of the health center pulled one of those “Ohhh!” because she was surprised at how quick it was.

I showed one of the front desk personnel and she said, “When do we get that?” As soon as possible was my answer.

I just can’t get over how smart it is. Continuous authentication is the best type of security you can have on your PC. Facial recognition constantly is looking for your face and making sure that you haven’t left. It’s the very best feature.

I only have one more thing I have to get working properly and we’ll be putting into our clinical environment. We have to still make it so that two people can use the computer. Too bad our application isn’t browser based because then it wouldn’t be an issue at all. Unfortunately, my application is in VB and so there’s a little more programming to get the facial recognition software to logoff the application if someone forgot to do that.

I’ll let you know once I have it in the clinic.

I’ve been working on some of our HIPAA policies and I started to create a list of things that should be done to all of our workstations to ensure HIPAA compliance. Here’s the list that I started. I’m sure I’m missing something, but take a look:

-Password enabled screen savers

-Disclosure Notice at Windows Login

-Logged off after 25 minutes

-Adware/Spyware

-Windows Update

-Updated virus software

· Weekly workstation scans of local hard drives;

· Daily checks for updates to their virus definition files.

Anyone have suggestions for things that I’m missing? I think there are a ton of other Windows options that I’d like to have done but aren’t necessarily HIPAA requirements. I just need some more time to do some more research into what you have to do to the workstation to make the Windows policies persist across users. In my counseling center I found the options for disabling the recycle bin and the automatic logoff also.

Also, does anyone have a good disclosure notice that they use when the computer starts up? Is it even necessary? They seem mostly useless, but all the HIPAA documents I’ve seen suggest it. Is it a legal requirement because they could argue you never told them not to use it?

I found a website that listed a number of Privacy Violations. The page is quite outdated since it’s latest case was in 2002, but I thought that many of the examples could just as easily apply today. In fact, with computers it makes many of the cases much easier to accomplish and easier to track misdoing. Does that mean we are going to have more HIPAA lawsuits coming? I think it’s only just a matter of time.

Does EMR affect this? Probably not directly, but indirectly many of these cases could be related to your use of an EMR system.

Here’s 2 examples that I found quite interesting from the HIPAA privacy violations article:

# A psychiatrist from New Hampshire was fined $1,000 for repeatedly looking at the medical records of an acquaintance without permission. Because there was no state law making it a crime to breach the confidentiality of medical records, the case was brought under a law against misusing a computer. (”Psychiatrist Convicted of Snooping in Records,” The Associated Press State & Local Wire, May 5, 1999)

# A jury in Waukesha, Wisconsin, found that an emergency medical technician (EMT) invaded the privacy of an overdose patient when she told the patient’s co-worker about the overdose. The co-worker then told nurses at West Allis Memorial Hospital, where both she and the patient were nurses. The EMT claimed that she called the patient’s co-worker out of concern for the patient. The jury, however, found that regardless of her intentions, the EMT had no right to disclose confidential and sensitive medical information, and directed the EMT and her employer to pay $3,000 for the invasion of privacy. (L. Sink, “Jurors Decide Patient Privacy Was Invaded,” Milwaukee Journal Sentinel, May 9, 2002)

My biggest comfort with HIPAA is that it doesn’t seem like they are really out headhunting. If you are an honest person who makes a bad choice then HIPAA is kinder to you then those that blatantly misuse the information. However, in our sue happy world that might be changing.

I briefly mentioned Face Authentication in a previous post. As a result of that post the vendor from Sensible Vision contacted me and got me a demo model right away. I must admit that their service was impeccable. All the way up the scale I’ve been impressed with the company and all I did was a demo.

Today they issued pricing on their FastAccess product that is very reasonable compared to other biometric devices. I’ve attached the release below and here’s a short review of the product with certainly more details to come as I continue to use it.

Setup
Setting up the FastAccess was a piece of cake. I got the box with only 15 minutes before I had to be somewhere. I unboxed the product, read the instructions(yes I always feel I must read the instructions on new products) and installed it on my computer. In 15 minutes I had it recognize my face and automatically log me in. The other nice part is that the set was really nothing but plug the camera in and run the CD install file. On restart it starts learning who you are when you log in. Couldn’t have been simpler. I repeated this process on my laptop so I could show my wife and had it set up in 5 minutes(booting my computer took longer than setup).

Facial Recognition/Training
Training facial recognition is much different than other biometrics. Fingerprint biometrics requires you to “train” it to know your fingerprint. Facial recognition(at least with FastAccess) is continually updating every time you login. In fact, it stores 90-100 different biometric “faces” that identify you. The biggest fault with this model is that initially the recognition is poorer than fingerprint recognition. However, with time I’ve seen that it actually is more reliable and recognizes you quicker than fingerprint. Not to mention it recognizes you just coming into view. No need to reach and hold your finger or eye to something. The lazy part of me loves that.

Active Directory Integration
FastAccess has very nice integration with active directory. The best part is that they have two methods of implementing active directory integration. First, they can extend the active directory schema. While this is a common practice, it is difficult to convince my system administrator to do since it can’t be rolled back if we decide we don’t want to do it anymore. Second, FastAccess can be implemented using existing active directory fields. This means that you can test the active directory implementation without extending the schema. I plan on doing this in the near future and you can expect a review of it soon.

Strong Audit Controls
Looking over the audit logs they are pretty standard for what you would need to satisfy HIPAA. Having active directory manage this type of audit control would be key to me.

Continuous Security
The biggest advantage to facial recognition is that it is continuously verifying your access. My biggest problem with fingerprint biometrics had to do with not having a way to easily lock the workstation. Facial recognition biometrics is constantly monitoring to see you are the authorized person. If you leave then it locks the computer. This really changes the way you deal with authentication since it can create a true single sign on.

Security Screen Capture
This idea is inegnious. Since you have a camera you might as well capture a picture of the person that was signed on to a machine. Imagine them saying they didn’t log in and you can show them the picture taken when they did log in. Fantastic!! There is also talk of using this technology as a digital signature. I’d love that with my EMR.

Pictures and Twins
I tried to see what I could do to fool the camera and nothing really worked. I imagine this is theoretically possible, but it would have to be a picture in the exact same place as the biometric match. FastAccess tells me that they add in environmental variables(such as light) which makes it much more difficult to fool. So far so good. The idea of twins is addressed in the documentation. I’ll be testing it on my wife and her twin sister to see how that goes. Sometimes it freaks me out how much they look alike.

Accuracy
In an EMR or healthcare environment FastAccess has designed it properly. Sometimes it didn’t recognize me and so it required me to enter my password and then after logging in, it stores another biometric image. While this could be annoying to some doctors, I see this as an essential key to proper authentication.

Instant Desktop Switching
This seems like it is a somewhat new module being developed by Sensible Vision. The idea is that multiple people can log in to the same account and have a different desktop. This currently works espescially well with Internet Explorer and a few other selected applications. I imagine this list will grow over time. They offered to make it work for my favorite apps. One interesting note is that they have it working for Cerner’s EMR. I’ll be having them develop it for Medicat EMR(my EMR)

Random Points
Since FastAccess is constantly checking for facial recognition, when you answer the phone that changes what your face looks like. This isn’t really a problem since they store 90-100 different biometric “prints”. You just have to “train” it to know what you look like with a phone in hand.

One nice feature is that you can turn off continuous facial recognition when you have a presentation. It lets you disable the recognition for a specified period of time. It also recognizes any keyboard or mouse input and disables locking when it sees either.

Here’s the Press Release:
Sensible Vision Innovates Biometric Facial Recognition for Continuous Computer Access Control and Authentication

FastAccess Virtually Eliminates Passwords, Makes Computer Easier to Use and Ensures Privacy Compliance and Identity Management

Introductory Pricing of $99 per Desktop License

Covert, Michigan, April 3, 2006 – Sensible Vision, an innovator of continuous authentication solutions, today revolutionized computer access control and authentication by replacing a user’s password with their face. Sensible Vision’s FastAccess™ is a powerful yet simple solution that uses patent-pending biometric facial recognition to automatically and continuously authenticate user log-in and instantly secure the computer when the user leaves. This virtually eliminates login passwords, makes the computer significantly more secure and easier to use, and strengthens access control auditing for privacy and identity management policies.

“Because a person’s face is unique and always with them, it is ultimately the ideal password and the best way of continuously ensuring who is accessing the computer,” said George Brostoff, CEO of Sensible Vision. “This is a new paradigm for secure and simplified computer access that goes well beyond initial log-in and inactivity timers. FastAccess identifies and authenticates users in less time than it takes to enter a password and knows the second they leave their computers. These breakthroughs make it a simple, secure and low-cost approach for securing the computer and network.”

Read more…

Security
Biometrics Security is pretty impressive. We’ve joked a few times about what happens if you lose your finger (the situation at Wendy’s comes to mind). Let’s just say that the chances are good that this won’t be a problem. More importantly the biometrics people have really given you quite a few options on keeping it secure. One example is that with the biometrics you can also store a pin number that people can use. If I wasn’t so lazy in this moment I would pull out the part of HIPAA that says something about dual authentication methods. Your finger and a pin number sounds like dual to me. When you add in my previous article about False Acceptance Rate and False Reject Rate, then biometrics is a great option for securing EMR.

One other really nice feature with biometrics security is that you can choose to restrict people from using a password to get into certain programs. While this could be scary if something happens to the biometrics device it is an interesting concept. Since it is all managed by group policy in active directory I could train my end users on just using their fingerprints and never having them know their password(see below for password change policy). I would of course want to be able to use a password or biometrics, but there might be a few cases where you could literally restrict access to EMR to a fingerprint. Now that’s security!

Password Change Policy
One other impressive feature that I had never considered is how does biometrics handle the wonderful password change policies required by HIPAA? It’s not like your fingerprint can be changed. The units I’m testing can take care of this for you as part of the templates you create for each application. In fact, if you don’t want to have users know the password at all you can even have the biometrics software generate a password. I think this might be a little scary since then if the biometric device breaks or some other problem then you have no way of getting into your EMR program(or other application as desired).

I’ve doing more reading on EMR and the likes since I finished a business plan I was writing. Here’s a few articles/blog posts that I found interesting:

Face Authentication Software
The Healthcare IT Guy posted an interesting review of some auto-recognition and auto-login system for healthcare workstations called FastAccess by Sensible Vision. A standard web cam, easily installed software that can recognize my face to log me in. I need to get me a demo so I can try it out.

US Healthcare System
This is a nice article saying that although the media describes the US Healthcare system as broken down, many “better” healthcare systems aren’t immune to problems.

Mirth Project
I really like the idea of an open source project that supports HL7 messaging. I just can’t get my head around what exactly this means and how they are making the wretched HL7 messaging any easier.

Multiple Users
In my continuing Biometrics experience I found some interesting problems when multiple people use the same computer. This isn’t a problem when you have a tablet or convertible that is dedicated to a specific doctor or nurse. Once you place a computer in an exam room and want mutliple doctors and nurses to use EMR on the same computer you have a major problem.

The worst solution is to make each doctor or nurse log in and out of windows. Otherwise, the biometrics software can only allow the person who logged into windows log into the EMR. We all know how long it takes for Windows to log in and out and so that’s not an option. By the time you are logged in and out of Windows you will have no need for the computer, because your visit with the patient will be done. This is ideal for those counseling centers using EMR. It’s not unreasonable for them to log in and out because they don’t share computers as much and often are going to spend a long period of time charting their clients.

What’s the solution? The key is that you want the computer locked so you have good security, but you don’t want to have to log the windows user in and out of the system. My friends (at least they better be friends since I’m writing such nice things about them) at Digital Persona have a solution they’ve created for just this problem. It’s been termed to me as their “kiosk” software.

This kiosk software was described to me as being able to have a generic windows login to a “kiosk” computer. This “kiosk” computer in our example would be a computer in an exam room. Many of you HIPAA experts out there may be ready to scream VIOLATION at the thought of a generic login shared by multiple users. Have no fear! This isn’t the EMR and HIPAA log for nothing. A generic windows login really isn’t a problem in this case because it is all integrated with active directory. You set a group policy that allows a group of users access to that generic login. Only those users will be able to use the generic login and unlock the computer. Furthermore, every time the generic login is used it is all nicely logged by the biometrics software for future security needs. Isn’t that great?

One caveat is that Digital Persona’s “kiosk” software must be tied to their active directory server software which I’ve mentioned before.

The best summary is one computer used by multiple users using biometrics to securely log into EMR.

If you’ve been reading my blog for some time you know that I’m currently testing some great biometrics products from DigitalPersona. I’ve been pretty impressed with what they have to offer and their support. In fact, I’ve been taking it around to everyone showing them how cool it is. It still amazes me each time it recognizes my fingerprint and no one elses.

Now that I’m past that emotional connection I’ve started at looking at biometrics accuracy and security. This is a huge issue, because I don’t want anyone not getting in that shouldn’t be in. Possibly more important (unless you’re the HIPAA police reading) is you being the correct person and the reader not recognizing who you are. As usual these two items are at odds. You can’t keep everyone out and still ensure that it will ALWAYS recognize your fingerprint. You’ll always have a tradeoff.

In my conversations with DigitalPersona I was introduced to 2 terms FAR - False Accept Rate and FRR - False Reject Rate. I’m told this is a common term used by all biometrics companies. Essentially this tells you how many times you can expect to get an unauthorized use accessing a machine or the number of times an authorized user can’t access a machine. As you increase the FAR for security then the FRR will increase and vice versa.

The coolest part of this all is that you get to actually choose what FRR and FAR you want (at least with the biometrics I’m testing). From my limited knowledge biometrics is matching the points and curves on your fingerprint and then exporting it to a binary file. Then, in the future it creates another binary file and matches those points. If you increase the number of points it has to match then the False Reject Rate goes up, but the False Accept Rate goes down.

What does this mean for an EMR wanting to use biometrics? You are going to have to decide what FRR and FAR you are ok with. In the end if you have documented a well thought out reason then HIPAA security issues won’t be a problem. However, if you just say I always want to let my users get in regardless of the security implementation then you might have a HIPAA problem. My suggestion would be to follow the biometrics vendor’s suggestion and use their skill as the basis for your security. Never go under what the vendor suggests for security. That should raise a huge red flag. Otherwise, biometrics is a great technology with great security benefits and less password support requests.

The HIPAA enforcement rule is published.

Rick Brady mentioned that “HIPAA has no teeth.” I agree in principle. Martin Jensen mentioned that he used to agree with it not having teeth until he had a conversation with one of the regulators.

I think there are really a few important points. The penalties really are rather small and incosequential compared to the costs of compliancy. Every good business has to weigh those two factors. However, the more difficult concept to calculate is the shame of a HIPAA violation. I can tell you now that this is something for which people are very interested. The most often google search I get is for HIPAA Lawsuits. People are scared of this possibility and want to know who is going to take the fall at HIPAA’s hands. I really feel like I’m stuck between a rock and a hard place. HIPAA compliancy and budgeting.

My only relief is in the following excerpt:

[A] civil money penalty may not be imposed ‘‘if it is established to the satisfaction of the Secretary that the person liable for the penalty did not know, and by exercising reasonable diligence would not have known, that such person violated the provision’’,…if the failure to comply was due ‘‘to reasonable cause and not to willful neglect’’ and is corrected within a certain time, [and] a civil money penalty may be reduced or entirely waived ‘‘to the extent that the payment of such penalty would be excessive relative to the compliance failure involved.’’

A recent article in the Washington Post described a new program where the reports of blood sugar testing had to be reported to the city. I don’t think the writer really knows what they’re talking about since they said

Specifically, if you live in New York and have trouble resisting sweets, your doctor may soon receive a call from the health department suggesting that he or she needs to persuade you to change your lifestyle.

There is no way this is going to happen. It goes against all privacy policies and the city has no business doing it. This information is only going to be used for cumulative general information on trends within the city.

Regardless of this reporter’s inability to report what’s really going to happen he does make a good point

The emerging question is whether medical privacy is a basic right or something more akin to a privilege for which those who want it should pay, rather than shifting the cost to others.

It brings out two fundamental points. First, is it a fundamental(and I would say constitutional) right for someone to have their patient information kept private? I can’t say I’ve really formed an opinion on the subject. I really feel that it definitely can avoid a lot of problems. We all know the example of a parent who finds out about a child’s bad behavior. There are many more that I’m sure you’ve all heard. This is important, but often I’ve personally wondered why most people would really care. Don’t get me wrong, I don’t want my patient information flopping around like it is the recent basketball scores. However, if my information is useful to help make progress in the health arena then why not? Not to mention I really have nothing to hide. If you asked me I’d probably just tell you anyway. The real question is how do you define which organizations are going to use it for “good” and who is going to do untold things with that data? I sure wish I had the answer to that question.

The second point I found even more interesting. I don’t really care too much about my electronic medical record being private. Many people I’m sure have very strong feelings about their medical privacy. If this is the case, then let them pay for that right. Not an easy task to set up, but I think many people faced with a stack of money versus the security of their patient history would probably take the money. Put money on the line and you really get to see what people find important.

It’s a very complex issue that I don’t have the answers to(and quite frankly I could easily change my opinion either way at this point), but I thought these points were some good food for thought.