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

[Eve Maler]

(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://en.wikipedia.org/wiki/Identity_verification_service>
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://www.forgerock.com> with UMA support
<https://www.forgerock.com/platform/user-managed-access/> and an OpenUMA
community <https://forgerock.org/openuma/>!

On Mon, Feb 1, 2016 at 7:12 PM, Adrian Gropper <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> wrote:
>
>> Below, with less pertinent stuff elided:
>>
>>
>> *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://www.forgerock.com> with UMA
>> support <https://www.forgerock.com/platform/user-managed-access/> and an OpenUMA
>> community <https://forgerock.org/openuma/>!
>>
>> On Sat, Jan 30, 2016 at 3:01 PM, Adrian Gropper <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://docs.google.com/document/d/1IvbdWerdvMuA1dQ-KQvVKqIBrAas7FoenNVUtgpqYrw/edit?usp=sharing>,
>> 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
>> <http://www.xmlgrrl.com/blog/2009/12/31/how-to-rest-assured/> that may
>> be of interest. And heres the very latest version of the canonical LOA
>> specification
>> <http://nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-63-2.pdf>
>> .)
>>
>> 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>
>>> 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
>>>> "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 | Skype: xmlgrrl | Twitter: @xmlgrrl
>>>> New ForgeRock Identity Platform <https://www.forgerock.com> with UMA
>>>> support <https://www.forgerock.com/platform/user-managed-access/> and
>>>> an OpenUMA community <https://forgerock.org/openuma/>!
>>>>
>>>> On Sat, Jan 30, 2016 at 1:29 PM, Adrian Gropper <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!
> HELP us fight for the right to control personal health data.
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>
>
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