[Openid-specs-heart] CHIME Launches $1M Challenge to Solve Patient ID Problem

Justin Richer jricher at mit.edu
Tue Feb 2 14:43:36 UTC 2016


Identity confirmation and binding are key, here. You cannot trust the identity attributes of a general IdP from the outside and use those to match an internal record. That’s utterly ludicrous, I think we can all easily agree on that. What you *can* do, though, is have a process whereby you are both reasonably sure that the person you’re talking to is the subject of a specific medical record and that that same person can prove control over a specific external IdP account. Thus the federated identity is bound to the medical identity.

It gets a little more interesting when the identity attributes of a specific IdP can be trusted to some extent. Do you want to trust those attributes alone for lookup into a records system? Most likely not. But they can help with the onboarding process.

We’re not the only ones looking to do this kind of situational binding, either. I’ve got another client who’s very interested in combining the attributes of a digital identity from a trusted IdP with in-person verification in order to build a highly assured transactional identity.

 — Justin

> On Feb 2, 2016, at 8:21 AM, Moehrke, John (GE Healthcare) <John.Moehrke at med.ge.com> wrote:
> 
> +1.  Thanks Eve.  I too worry that we must also keep the bad-guys OUT! Medical Identity Fraud is huge.
> 
> The current practice is ‘in person proofing’… as the first encounter with the patient is as a … patient… Now many patients are not at their ‘best’ when they first appear, so the understanding of their identity evolves over the first hours and days and weeks. Thus in healthcare practice we often know the patient by many identifiers that we have either merged or linked. And there are cases where a merged or linked patient needs to be unmerged or unlinked. Very messy business. Ultimately the patient gets billed for the services they have received, and the identity gets confirmation that they paid, thus stronger. This  is just a discussion of the patient id, not the patient as a user.
> 
> The patient as a User usually starts with this in-person relationship. Most often the healthcare organization uses the identity they know, and the billing address to send them postal-mail (covered by strong fraud laws). This kickstarts an online confirmation workflow that binds the human patient identity to a user identity. Unfortunately this often is by way of a hospital managed user account, and not an internet friendly OAuth identity.
> 
> There are increasing cases where an internet friendly OAuth identity is used. However these (Facebook, Google, etc) are very low assurance identities, as anyone can claim to be anyone. To use these in healthcare we elevate the LoA using the above described online confirmation workflow so that the result is an identity that the patient wants to use, elevated to a higher assurance level through the healthcare driven identity confirmation workflow.
> 
> John
> 
> From: Openid-specs-heart [mailto:openid-specs-heart-bounces at lists.openid.net] On Behalf Of Eve Maler
> Sent: Tuesday, February 02, 2016 12:35 AM
> To: Adrian Gropper
> Cc: openid-specs-heart at lists.openid.net
> Subject: Re: [Openid-specs-heart] CHIME Launches $1M Challenge to Solve Patient ID Problem
> 
> (This will have to be my last response on this subject, unless we can stay out of the realm of "unprofilable philosophy".)
> 
> Whether "healthcare is a human right" or not, mitigating risk is still a challenge I thought we mutually agreed is important to solve; otherwise we wouldn't be trying to solve things like the "Adrian clause" in the UMA spec. Therefore, it can't be true that "assurance" is conceptually irrelevant because its very purpose is to mitigate risk by "establishing confidence in user identities electronically presented to an information system" (quoting from NIST Special Publication 800-63-2, called the Electronic Authentication Guideline). The purpose of this spec is emphatically not exclusive to credit or financial use cases. Identity verification <https://urldefense.proofpoint.com/v2/url?u=https-3A__en.wikipedia.org_wiki_Identity-5Fverification-5Fservice&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=tq5n9wHm3N_2ZKRB_NuXwqKW_QZIPAr5g6rkq5ARJnk&e=> that is applied when someone registers with any high-enough-value service (could be an EHR portal or an employer portal or something else, such as regulated online gambling) often use financial and governmental documents, because they are useful for binding real-world people to pre-recorded identities.
> 
> If we're in the realm of pure sovereignty and inalienable human rights vs. "icky financial stuff", then I see that as incompatible with asking questions about governance. But if we're being realistic in trying to stop fraud and abuse by health identity thieves and trying to solve other security and privacy scenarios that are in our remit, then we must concern ourselves with "assurance" and risk mitigation using appropriate identity verification and authentication tools and governance processes.
> 
> I would love to know what the current standards are for becoming "known to a practice", btw.
> 
> Eve Maler
> ForgeRock Office of the CTO | VP Innovation & Emerging Technology
> Cell +1 425.345.6756 | Skype: xmlgrrl | Twitter: @xmlgrrl
> New ForgeRock Identity Platform <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.forgerock.com&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=O83u6syn25hZ8H2CSds0Whb6VXG2pXHU4ilMDQNZGCY&e=> with UMA support <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.forgerock.com_platform_user-2Dmanaged-2Daccess_&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=6J_QBRDTvCsC7nKUk_a4s3hvDB3ZjxshEYhajEG8ixI&e=> and an OpenUMA community <https://urldefense.proofpoint.com/v2/url?u=https-3A__forgerock.org_openuma_&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=hIe4D_M5GXf99DyZ7l9APbwGplAQWE-DyH6sPqFX4UA&e=>!
> 
> 
> On Mon, Feb 1, 2016 at 7:12 PM, Adrian Gropper <agropper at healthurl.com <mailto:agropper at healthurl.com>> wrote:
> I take Vectors of Trust for granted. LOA is irrelevant in the patient ID discussion. Healthcare is not like credit, healthcare is a human right whereas cheaper credit is a privilege. I truly don't understand where our workgroup or Congress are thinking human sovereignty ends.
> 
> If anyone believes that HEART, and consequently FHIR, can assume a floor on human sovereignty in access and control of our personal information (including searchable identifiers, choice of notification end points, right to anonymous or pseudonymous service, institutional limits on a licensed physician's authority, right to be forgotten) then let's start a list of these limits on privacy here, below.
> 
> Keep in mind, that for every item we choose to add to the list we will be called on to suggest an appropriate governance mechanism. Are we going to rewrite HIPAA or just hope for appropriate interpretations?
> 
> <UL>
> 
> Adrian
> 
> On Monday, February 1, 2016, Eve Maler <eve.maler at forgerock.com <mailto:eve.maler at forgerock.com>> wrote:
> Below, with less pertinent stuff elided:
> 
> Eve Maler
> ForgeRock Office of the CTO | VP Innovation & Emerging Technology
> Cell +1 425.345.6756 <tel:%2B1%20425.345.6756> | Skype: xmlgrrl | Twitter: @xmlgrrl
> New ForgeRock Identity Platform <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.forgerock.com&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=O83u6syn25hZ8H2CSds0Whb6VXG2pXHU4ilMDQNZGCY&e=> with UMA support <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.forgerock.com_platform_user-2Dmanaged-2Daccess_&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=6J_QBRDTvCsC7nKUk_a4s3hvDB3ZjxshEYhajEG8ixI&e=> and an OpenUMA community <https://urldefense.proofpoint.com/v2/url?u=https-3A__forgerock.org_openuma_&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=hIe4D_M5GXf99DyZ7l9APbwGplAQWE-DyH6sPqFX4UA&e=>!
> 
> 
> On Sat, Jan 30, 2016 at 3:01 PM, Adrian Gropper <agropper at healthurl.com <mailto:agropper at healthurl.com>> wrote:
> You've lost me again. My 1 - 5 sequence had nothing to do with the strength of authentication for either the RO at the RS, the RO at the AS, or the RqP anywhere. LOA is important, and it comes into play in many places, but I don't understand how it impacts the chain between Resource Registration with an AS at one end and a successful FHIR transfer from the RS to the Client at the other.
> 
> I didn't mention "Resource Registration"; I mentioned "onboarding/registering patients". I couldn't remember what words the WG agreed to use for when a patient first shows up at a practice vs. a service; in fact, now that I look at our first use case <https://urldefense.proofpoint.com/v2/url?u=https-3A__docs.google.com_document_d_1IvbdWerdvMuA1dQ-2DKQvVKqIBrAas7FoenNVUtgpqYrw_edit-3Fusp-3Dsharing&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=sKhVjDy15DJ_SZn-4CLI3q8__K5nPvrwg--TQJOkwXg&e=>, it seems we've taken out some explanatory terminology definition stuff that we used to have in there, and also mixed up our usage in a spot or two, but "registration" is supposed to be reserved for a practice and "onboarding" is supposed to for a service (such as an EHR portal). So: what I meant was "patient identity verification methods when onboarding patients to a service".
> 
> (In the case of actually providing many healthcare services, whether in person or something like telehealth, I wonder: is actual patient pseudonymity really practical? There's a physical body involved.)
> 
> Your #1-#5 process is interesting if you're considering treating biometrics as a body's "persistent username", but, at this point, fairly theoretical vs. how identity is verified today given that financial and governmental documentation is heavily relied on and biometric markers tend not to be, and your list speaks only of the "front-loaded" part, not the routine usage of any credentials. That latter part is where authentication comes in, and also where cross-service assurance leakage (e.g. UMA RS/AS, and client/RqP trust elevation) can potentially happen. LOA definitionally includes routine usage, not just credential creation.
> 
> Doctor IDs do matter too if they are in the position of accessing the patient's data as a requesting party.
> 
> (For those perhaps less technically inclined, here's a very old blog post of mine discussing Levels of Assurance <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.xmlgrrl.com_blog_2009_12_31_how-2Dto-2Drest-2Dassured_&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=CoSrlDdhT-OFe_s-qifJWC8L2oPrHSeL-CAy4uoLVfQ&e=> that may be of interest. And heres the very latest version of the canonical LOA specification <https://urldefense.proofpoint.com/v2/url?u=http-3A__nvlpubs.nist.gov_nistpubs_SpecialPublications_NIST.SP.800-2D63-2D2.pdf&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=rtswsoIIqXRiR-sp8r6R4T0C2m1Lje8bSn2V0QTCrBE&e=>.)
> 
> Trying to net out some conclusions that are relentlessly practical for HEART purposes:
> Without further profiling, "raw" UMA doesn't require that Alice use the same identifier or the same authentication strength at both, say, a PHR resource server and an IRB authorization server.
> The formal LOA standard defines an LOA 1-4 scale that is very rigid, and doesn't allow for pseudonymity once you enter into the levels with any good authentication strength.
> If we wanted that for any use cases, we'd have to get creative (e.g., looking at Justin's "Vectors of Trust" standards work) to split the difference and get some of both.
> 
> Please be more explicit. I know that the standards around authentication events is important and that federating IdPs and LOA may play a role for the doctors and nurses as RqPs but LOA is much less important for the patient authentication. Once again, this thread is about patient ID in the patient matching for FHIR sense. It is not directly about the doctor's ID, or is it?
> 
> Adrian
> 
> On Sat, Jan 30, 2016 at 4:59 PM, Eve Maler <eve.maler at forgerock.com <mailto:eve.maler at forgerock.com>> wrote:
> (Removing wg-uma from this thread as not pertinent -- and anyway, I don't use my same email address/identifier for that list... :-)
> 
> Are biometrics going to become common as a standard as a patient identity verification method when onboarding/registering patients anytime soon and, further, for ongoing authentication once the patient is in the system? Both are needed for high assurance. Just yesterday, I happened to tweet this from a doctor's office...
> 
> https://twitter.com/xmlgrrl/status/693220654611496960 <https://urldefense.proofpoint.com/v2/url?u=https-3A__twitter.com_xmlgrrl_status_693220654611496960&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=lpTLJBujwW6KiWmD4jWA9LAP3w3fiOPSXL1g2NcPWTc&e=>
> "OH at doctor’s office: Nurse to doctor: “Hey, I need your password again.” Why constrained delegated access needs to be easier than *that*."
> 
> (and actually, it was an MA, not a nurse)
> 
> And as I noted previously, biometrics are not the be-all/end-all of authentication, and while certain (not all) biometrics have interesting properties for uniquely identifying a person in the real world, many of them can also be faked by bad guys, and really should be paired with a second factor. It has been observed that "they make a better username than a password".
> 
> As long as various authentication methods are considered equivalently strong, this is where it could be useful to demand that "some individual" simply be able to prove they can log in to some client/RS at strength X and also to the authorization server at equivalent strength X, where it's only necessary for one side to have successfully patient-matched, and where there's a requirement for some magic patient ID to be correlatable/passed between systems if necessary to satisfy regulatory compliance issues.
> 
> Eve Maler
> ForgeRock Office of the CTO | VP Innovation & Emerging Technology
> Cell +1 425.345.6756 <tel:%2B1%20425.345.6756> | Skype: xmlgrrl | Twitter: @xmlgrrl
> New ForgeRock Identity Platform <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.forgerock.com&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=O83u6syn25hZ8H2CSds0Whb6VXG2pXHU4ilMDQNZGCY&e=> with UMA support <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.forgerock.com_platform_user-2Dmanaged-2Daccess_&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=6J_QBRDTvCsC7nKUk_a4s3hvDB3ZjxshEYhajEG8ixI&e=> and an OpenUMA community <https://urldefense.proofpoint.com/v2/url?u=https-3A__forgerock.org_openuma_&d=CwMFaQ&c=IV_clAzoPDE253xZdHuilRgztyh_RiV3wUrLrDQYWSI&r=B4hg7NQHul-cxfpT_e9Lh49ujUftqzJ6q17C2t3eI64&m=S2lF8wqaFBGRf-NBpz_IZjcqA-AI_kAV9hkCLmZvL2Q&s=hIe4D_M5GXf99DyZ7l9APbwGplAQWE-DyH6sPqFX4UA&e=>!
> 
> 
> On Sat, Jan 30, 2016 at 1:29 PM, Adrian Gropper <agropper at healthurl.com <mailto:agropper at healthurl.com>> wrote:
> We're back on track with "Authentication strength/LOA and pairing mechanics could be a matter for HEART profiling."
> 
> The issue becomes, what is the chain of events that drives patient ID in the sense of enabling a patient-level FHIR client to access a patient-level FHIR resource?
> 
> 1 - Although it's not the only way to build this chain, I start with "known to the practice" in the sense that a specific person's biometric can be associated with a specific primary key in either the FHIR client or FHIR resource server. There is no matching yet and the biometric, be it a photo or iris scan, is neither verified nor is it used for matching across the link.
> 
> 2 - The patient provides an identifier to the Client FHIR endpoint that can eventually result in a match at the FHIR resource server. A persona. Depending on jurisdictional and business issues, this identifier may not be subject to any verification at all, verification to ensure correct spelling such as an email confirmation, or verification against a federated authority such as the state DMV.
> 
> 3 - The persona identifier provided to the FHIR Client can be designed in all sorts of different ways.
>      a - It could be globally unique and anonymous like a Bitcoin address.
>      b - It could be globally unique and easily remembered like an email address or mobile number
>      c - It could be globally unique and subject to a federation's jurisdiction like a driver's license number
> 
> 4 - All of a, b, or c are then subject to discovery mechanics and standards such as blockchain, WebFinger or lookup in Surescripts or the state HIE. This eventually turns into an identifier that is unique to the FHIR resource server for that matching patient persona.
> 
> 5 - The FHIR client presents to the FHIR resource server with a patient context and requests access. Hilarity and maybe more UMA ensues.
> 
> Somewhere between 1 and 5 we have patient and requesting party authentications, AS and client registrations, and these touch UMA and HEART more or less directly. I prefer to think of the patient's persona and her UMA AS URI being a unified and key link in his chain of events.
> 
> Adrian
> 
> 
> 
> --
> 
> Adrian Gropper MD
> 
> PROTECT YOUR FUTURE - RESTORE Health Privacy!
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