Category Archives: healthcare

Showcase with EXTENSION at HIMSS 2010

We’ll be at HIMSS 2010 next week with EXTENSION Inc., showing the EXTENSION HealthID product:

HIMSS 2010
Monday March 1st – Thursday March 4th

Booth #5955
Atlanta, Georgia World Congress Centre

Show Hours Are:

  • Monday, March 1, 12:30 pm – 5:30 pm
  • Tuesday, March 2, 10:00 am – 1:00 pm and 2:30 pm – 5:30 pm
  • Wednesday, March 3, 10:00 am – 1:00 pm and 2:30 pm – 5:30 pm

If you are at HIMSS this year, we’ll look forward to talking with you.

Bureaucrats with Badges

There was a peculiar piece in the American Spectator online last week, a “Special Report” by Mark Hyman. The author lists a number of unfortunate circumstances by which harmless passengers, many times military personnel, have been delayed or hassled by TSA and airport security protocols. He blames these anecdotal mishaps on “government bureaucrats armed with ‘rules, policies and procedures’ and employing no commonsense.”

He goes on to question a number of security and procedural policies in government and military institutions, which he thinks are unnecessary and demeaning to the personnel at these institutions. As a primary example, Hyman makes the case that the rules for issuing and renewing CACs (Common Access Cards) are unneeded and absurd.

He is miffed because he did not renew his CAC before it expired and he had to go though a bureaucratic process to straighten this out:

“My CAC had expired days earlier so I contacted an issuing office to get a replacement. A clerk in the ID card office informed me that all appointments had to be made online using the intranet. Yet, my expired CAC prevented me from using the intranet system. In spite of my predicament the clerk told me, “Our policy requires all appointments to be scheduled online. If you are unable to use the intranet, then there is nothing more I can do.” It sounded like the beginning of an Abbott and Costello routine.”

“Rather than fight this particular battle, I decided to renew my CAC at another issuing office. While there, I was asked to produce a picture ID. I showed my state driver’s license. I was then asked for a second form of ID and was told the CAC was not acceptable since it expired five days earlier. A week earlier it would have been valid, but on this day it was deemed worthless. So I showed the clerk my company-issued ID card that looked as though it was made on an office computer and laminated at the local Kinko’s. As a matter of fact, that was exactly how that ID was manufactured. But it was good enough. The clerk accepted the flimsy company ID over the just-expired military CAC.”

Hyman concludes,

“What makes this episode even sadder is that the military CAC is generally not accepted as a valid form of identification for use by visitors to the Pentagon. Visitors must also have a Pentagon-issued ID or another form of identification such as a state driver’s license. The reason, according to a security officer, is that at least one machine that manufactures CACs and several hundred blank CACs are missing and presumed to have been stolen. Security officials do not know which CAC is valid and which is a forgery.”

The latter claim is nonsensical and shows that the security officials Hyman chats with are miss informing him about how his CAC works. This too, expresses a common misconception— that possession of the card is the only thing that verifies identity.

To his point about the pains of standing in line to renew something only to find that you don’t have the right materials: I can empathize with this, but I cannot gather what rules Hyman thinks are silly, and which are reasonable. Is he arguing that he shouldn’t have to have a CAC, or that he should be able to use his expired CAC, by itself, for renewal? And what does this have to do with policy created by top-level military and government officials?

What is clear from reading the piece is that he doesn’t like the rules much because he doesn’t understand why they are in place. He wanted an exception so he could use his expired CAC. Similarly, in another of his examples, he complains that his wife couldn’t renew her own CAC using an expired passport.

There are two fundamental questions that would help Hyman better appreciate these rules: Why are identification badges, such as CAC cards, used? And, how is the true identity of a badge-holder verified? In other words, what is a CAC good for anyways?

The military provides several resources for answering these questions. In fact, had Hyman consulted these, or unofficial resources, anytime before his CAC expired he would have had less of a hassle renewing it.

Identity, and the privileges we associate with it, is an abstract thing that is difficult to verify. The best way for a large institutions to verify a person’s identity is to gather the various artifacts of identity, such as a state driver’s license, for this person and grade the validity of these items and the authority of the institution who gave the item.  The bureaucratic pronouncements on this process (i.e. presidential directives and policies) say that the best way to verify the identity and authorization of millions of people is to create a system of rules that make the procedures repeatable, reliable, and safe. (One such rule may reason that an expired identity artifact should not be considered valid, even if it was valid yesterday.)

Now, the process of using a CAC card is not as simple as it could be. Systems that use badges for the identification of people and the verification of people’s permissions and authority are complex and imperfect, but this is not a problem of bureaucracy. It’s more a matter of improving these systems for most users and reminding users, like Hyman, why they were given a badge to begin with.

Healthcare PKI in Denmark

In this post, I muse on Denmark’s implementation of a country-wide system for secure, up-to-date sharing of EMRs and patient identity federation. But I primarily want to share a links  for those interested in what they are doing:

A Cute Introduction

Last week Barack Obama visited Copenhagen to support his home city’s bid to have the 2016 Olympics hosted in Chicago. Later this year the U.S. President will meet with international leaders in Copenhagen for a UN summit, negotiating the successor to the Kyoto protocol.

In U.S. political news, the international happenings in Denmark have offered a nice break from the ongoing, rancorous national debate over reforming the U.S. health care system. Political events have stirred a broader conversation about the overall state of American health care, such as the cost and effectiveness of the current system. In a moment of free association, the events in Denmark reminded me of some interesting things about that nation’s health care system: the Danes are rather progressive—no, not because they’ve socialized, I’ll entirely leave this matter aside—in regards to they’re health care IT infrastructure.

What is Denmark Doing?

Denmark’s system is interesting so I’ll share what I’ve learned of the nation’s overall approach to health care IT and, in greater detail, discuss their implementation of PKI.

There are many Danish organizations involved with the reform of health care IT. Foremost are MedCom, the Danish Centre for Health Telematics, who is the coordinating organization for health care in Denmark and manager of the Danish Health Data Network; the National Board of Health for Denmark, who developed the data model and terminology server for the system, and leads the country’s overall health IT stragegy; and the Ministry of Science, Technology and Innovation (MTVU) in Denmark, who develops most of Denmark’s technical standards and recommended a standard for Service-Oriented Architecture (SOA) identity federation to be used in various Danish systems.

The National Board of Health’s stated goal for the reformed system was “to provide a connected health care sector in which health professionals have access to all relevant EHR data regardless of where citizens seek treatment and no matter where or when this information was registered.” Lofty, indeed 1. Unlike most countries, though, Denmark has robust broadband access in most of the country. And most general practices and hospitals already use electronic medical records (EMRs). The National Board of Health knew it would need to implement a nationwide SOA for the secure web sharing of data.

Implementation of PKI

Denmark built it’s PKI on top of it’s existing virtual private network (VPN) architecture, which is made available to all health care providers in the country, and it was already in use by many for remote collaboration. At the behest of  MVTU,  SAML was selected as the framework for identity federation and the exchange of authentication assertions. Health care professionals are issued DanID, a X.509 certificate from the Danish OECS CA. The following step explain how authentication is performed between Danish health systems 2:

  1. User authenticates as part of login to local EHR system and a digitally signed, SAML assertion is created.
    – this is a SAML security token, referred to as a virtual health professional identity card.
  2. A direct request is made to a central security token service (STS), which checks the validity of the local system’s digital signature, the user’s signature, certificate validity and revocation status, and core certificate attributes3.
  3. STS signs the SAML token and sends a response to the local system.
  4. The SAML security token can be used until it expires (after 24 hours).

Denmark PKI

I’m not sure what plans Denmark has for the authentication of everyday citizens to health care services and portals4. The foundations are certainly in place. The infrastructure for the clinical exchange of medical records, which utilizes the Danish Central Person Registry (number), provides a unique identifier for all national patients. is a public portal for Danish citizens where patients can access (some) of their health information, receive online consultation, schedule health services, and renew prescriptions/treatments. While Denmark does not issue electronic ID cards, each citizen is given a digital certificate, which is automatically derived from that citizen’s CPR number. With a combination of these parts, each Danish citizen could use their digital certificate for authentication to and for the signing of health documents.

Lesson from Denmark’s System?

What can be learned from Denmark? Well, one could try to point out the things Denmark has done right, as Gartner did in their study, which will be either unmissable or made up: Denmark used a “[g]radual approach with realistic time frames”; they gave “Incentives to vendors”; they used a “project-based approach”; they “[kept] an appropriate balance between central coordination and local leadership.”; the country has a “culture of consensus”.

As all observers have pointed out, its too early to tell what improvements the reformed IT changes have made. What Denmark seems to have done right is to start with a basic, but sound architecture that makes use of existing infrastructure and technologies. They have similarly, worked to make the systems simple, affordable, and feasible for all of the country’s health providers, using open standards and technologies.

Beyond the broader success of the program, I was interested to understand how adoption and use of the PKI has been. But, it seem too early to ascertain the problems with the reformed system or understand the parts of the systems that will need to be improved. From TrustBearer’s perspective, we are interested in problems experienced while deploying and using PKI,  issues such as interoperability between relying systems, certificate policies, certificate validation, and renewal, distinguishing between levels of identity assurance, and usability for end-users. I could not find much information in regard to these issues in the Danish system, so this will be a topic left for future blog posts. One thing of note was that developers involved in the Danish project found some things lacking in the the SAML/XML schema, because its was not possible to express certain types of requirements and policies as part of an authentication/authorization assertion5. (This is related, rather loosely, to a problem TrustBearer was trying to solve in another context, signifying the strength of an authentication method in the OpenID Provider Authentication Policy Extension.)

1. A Federation of Web Services for Danish Health Care

2. As outlined in A Federation of Web Services for Danish Health Care.

3. Exchange of tokens over SOAP.

4. There is a least one pilot of software-certificate-based PKI access for out patients.