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ASTM E1902-02

(Specification)

Standard Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records (Withdrawn 2011)

Standard Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records (Withdrawn 2011)

ABSTRACT
This specification covers management of the confidentiality and security of dictation, transcription, and transcribed health records to protect the documentation during its development, maintenance, transmission, storage, and retrieval. The dictation security policies and procedures are presented in details. The transcription security policies and procedures are presented in details.
SCOPE
1.1 This specification covers a broad description of certain steps that shall be taken by those involved in the processes of dictation and transcription of healthcare documentation to protect the documentation during its development, maintenance, transmission, storage, and retrieval. Variations or exceptions may be appropriate in special situations or because of particular contractual obligations, institutional policies and rules, or provisions of law or regulation.
1.2 Healthcare clients trust and expect that personal health information will be maintained in a confidential and secure manner. This specification has been developed for the purpose of protecting the confidentiality and security of all forms of dictation, transcription, and transcribed healthcare documentation.
1.3 This specification supports the patient's right to confidential, private, and secure healthcare documentation and identifies procedures for preventing breaches of these patient rights.
1.4 This specification seeks to identify certain dictation and transcription practices that may increase the risks of breaching confidentiality, infringing on privacy, and violating security of healthcare documentation.
WITHDRAWN RATIONALE
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this Specification was withdrawn in 2011 in accordance with section 10.5.3.1 of the Regulations Governing ASTM Technical Committees, which requires that standards shall be updated by the end of the eighth year since the last approval date.

General Information

Status
Withdrawn
Publication Date
09-Jun-2002
Withdrawal Date
31-Dec-2010
ICS
35.240.80 - IT applications in health care technology
Technical Committee
E31 - Healthcare Informatics
Drafting Committee
E31.15 - Healthcare Information Capture and Documentation
Current Stage
Ref Project

Relations

Replaces
ASTM E1902-97 - Standard Guide for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records
Effective Date
10-Jun-2002

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ASTM E1902-02 - Standard Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records (Withdrawn 2011)ASTM E1902-02 - Standard Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records (Withdrawn 2011)
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ASTM E1902-02 - Standard Specification for Management of the Confidentiality and Security of Dictation, Transcription, and Transcribed Health Records (Withdrawn 2011)
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Standards Content (Sample)

NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
Contact ASTM International (www.astm.org) for the latest information
An American National Standard
Designation: E1902 – 02
Standard Specification for
Management of the Confidentiality and Security of Dictation,
1
Transcription, and Transcribed Health Records
This standard is issued under the fixed designation E1902; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (´) indicates an editorial change since the last revision or reapproval.
1. Scope E1988 Guide for Training of Persons who have Access to
32
Health Information
1.1 This specification covers a broad description of certain
2
E2017 Guide for Amendments to Health Information
steps that shall be taken by those involved in the processes of
E2084 Specification forAuthentication of Healthcare Infor-
dictation and transcription of healthcare documentation to
32
mation Using Digital Signatures
protect the documentation during its development, mainte-
E2085 Guide on Security Framework for Healthcare Infor-
nance, transmission, storage, and retrieval. Variations or ex-
32
mation
ceptions may be appropriate in special situations or because of
E2147 Specification for Audit and Disclosure Logs for Use
particular contractual obligations, institutional policies and
2
in Health Information Systems
rules, or provisions of law or regulation.
E2184 Specification for Healthcare Document Formats
1.2 Healthcare clients trust and expect that personal health
2.2 Other Documents:
information will be maintained in a confidential and secure
Public Law 104-191 Health Insurance Portability and Ac-
manner. This specification has been developed for the purpose
4
countability Act of 1996 (HIPAA)
of protecting the confidentiality and security of all forms of
45 CFR Part 142 Security and Electronic Signature Stan-
dictation, transcription, and transcribed healthcare documenta-
dards; Proposed Rule, U.S. Department of Health and
tion.
4
Human Services
1.3 This specification supports the patient’s right to confi-
45 CFR, Parts 160-164 Standards for Privacy of Individu-
dential, private, and secure healthcare documentation and
ally Identifiable Health Information; U.S. Department of
identifies procedures for preventing breaches of these patient
4
Health and Human Services, Office of the Secretary
rights.
1.4 This specification seeks to identify certain dictation and
3. Terminology
transcription practices that may increase the risks of breaching
3.1 Definitions:
confidentiality, infringing on privacy, and violating security of
3.1.1 author, n—the person originating content for a health-
healthcare documentation.
care document.
2. Referenced Documents 3.1.2 confidential, adj—status accorded to data or informa-
2 tion indicating that it is sensitive for some reason, and
2.1 ASTM Standards:
therefore, it needs to be protected against theft, disclosure, or
E1762 Guide for Electronic Authentication of Health Care
2 improper use, or a combination thereof, and must be dissemi-
Information
nated only to authorized individuals or organizations with a
E1869 Guide for Confidentiality, Privacy,Access, and Data
need to know. E1869
Security Principles for Health Information Including Elec-
2
3.1.3 confidentiality, n—the property that information is not
tronic Health Records
made available or disclosed to unauthorized individuals, enti-
E1959 GuideforRequestsforProposalsRegardingMedical
2
ties, or processes. 45 CFR Part 142
Transcription Services for Healthcare Institutions
2
3.1.4 individually identifiable health information, n—any
E1985 Guide for User Authentication and Authorization
information, including demographic information collected
E1986 Guide for Information Access Privileges to Health
2
from an individual, that (1) is created or received by a health
Information
care provider, health plan, employer, or health care clearing-
house; and (2) relates to the past, present, or future physical or
1
This specification is under the jurisdiction of ASTM Committee E31 on
3
Healthcare Informatics and is the direct responsibility of Subcommittee E31.15 on Withdrawn. The last approved version of this historical standard is referenced
Health Information Capture and Documentation. on www.astm.org.
4
Current edition approved June 10, 2002. Published July 2002. Originally Available from U.S. Government Printing Office, Superintendent of Docu-
published as E1902–97. Last previous edition E1902–97. DOI: 10.1520/E1902-02. ments, 732 N. Capitol St., NW, Mail Stop: SDE, Washington, DC 20401. See also
2
Annual Book of ASTM Standards, Vol 14.01. http://aspe.hhs.gov/admnsimp
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
1

---------------------- Page: 1 ----------------------
E1902 – 02
mental he
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4.3 Audit reports designed for system access provide a precise capability for healthcare providers, organizations, patients, patient representatives, and advocates to see who has accessed and/or manipulated patient information. Because of the significant risk of medical information manipulation in computing environments by authorized and unauthorized users, the audit report is an important management tool to monitor access and any such manipulation retrospectively. In addition, the access and disclosure logs become powerful support documents for disciplinary and legal actions. Moreover, audit reports are essential components to comprehensive security programs in healthcare and vital for the privacy rights of the individual. A patient has a right to ...
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ASTM E2147-01(2013)(Specification)
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ABSTRACT
This specification describes the security requirements involved in the development and implementation of audit and disclosure logs used in health information systems. It specifies how to design an access audit log to record all access to patient identifiable information maintained in computer systems, and includes principles for developing policies, procedures, and functions of health information logs to document all disclosure of confidential health care information to external users for use in manual and computer systems. This specification provides for two main purposes, namely: to define the nature, role, and function of system access audit logs and their use in health information systems as a technical and procedural tool to help provide security oversight; and to identify principles for establishing a permanent record of disclosure of health information to external users and the data to be recorded in maintaining it.
SIGNIFICANCE AND USE
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SIGNIFICANCE AND USE
Many U.S. healthcare and health information systems leaders believe that electronic health information systems that include computer-based patient records will improve health care. To achieve this goal these systems will need to protect individual privacy of patient data, provide appropriate access, and use adequate data security measures. Sound information policies and practices must be in place prior to the wide-scale deployment of health information systems. Strong enforceable privacy policies must shape the development and implementation of these systems.
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The maintenance of confidentiality in paper-based, electronic, or computer-based health information requires that policies and procedures be in place to protect confidentiality. Confidentiality of information depends on structural and explicit mechanisms to allow persons or systems to define who has access to what, and in what situation that access is granted. For guidelines on the development and implementation of privilege management infrastructures supporting these mechanisms, see Guide E2595.
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This specification describes the security requirements involved in the development and implementation of audit and disclosure logs used in health information systems. It specifies how to design an access audit log to record all access to patient identifiable information maintained in computer systems, and includes principles for developing policies, procedures, and functions of health information logs to document all disclosure of confidential health care information to external users for use in manual and computer systems. This specification provides for two main purposes, namely: to define the nature, role, and function of system access audit logs and their use in health information systems as a technical and procedural tool to help provide security oversight; and to identify principles for establishing a permanent record of disclosure of health information to external users and the data to be recorded in maintaining it.
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This guide serves three purposes:
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1.1 This guide covers:
1.1.1 Defining a document structure for use by electronic signature mechanisms (Section 4),
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1.1.5 Describing acceptable electronic signature mechanisms and technologies (Section 7),
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1.1.7 Outlining technical details for all electronic signature mechanisms in sufficient detail to allow interoperability between systems supporting the same signature mechanism (Section 8 and Appendix X1-Appendix X4).
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Standard Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems

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RADT Object Model as a Basis for Communication—The RADT object model is the first model used to create a common library of consistent entities (objects) and their attributes in the terminology of object analytical models as applied to the healthcare domain. These object models can be used to construct and refine standards relating to healt care information and its management. Since the RADT object model underpins the design and implementation of specific systems, it provides the framework for establishing the systematics of managing observations made during health care. The observations recorded during health care not only become the basis for managing an individual's health care by practitioners but are also used for research and resource management. They define the common language for abstracting and codifying observations. The inconsistency and incompleteness of the data recorded in paper records is well known and has been noted by the Institute of Medicine's study (4). The ability to build the recommended EHR begins with RADT, as noted in Practice E 1239. A more detailed specification of the RADT process and its specific functional domain shall begin with a formal model. Furthermore, following agreement on the initial model, that model shall evolve as knowledge accumulates and the initial view of the healthcare domain extends to other social and psychologic processes that link healthcare with other functional domains of society. The management of lifelong cases of care, such as those of birth defects in newborns, will involve interactions with social work and educational functional domains of experience. It has been recognized for some time (5) that a “healthcare team,” in the broader sense, is involved in dealing with these complex cases. The RADT model is the core to linking these functional domains together in a transparent way. For that reason, the object terminology is used to enable the most global view and vernacular that will facilitate communication amo...
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1.1 This practice is intended to amplify Practice E 1239 and to complement Practice E 1384 by detailing the objects that make up the reservation, registration, admitting, discharge, and transfer (RADT) functional domain of the computer-based record of care (CPR). As identified in Practice E 1239, this domain is seminal to all patient record and ancillary system functions, including messaging functions used in telecommunications. For example, it is applicable to clinical laboratory information management systems, pharmacy information management systems, and radiology, or other image management, information management systems. The object model terminology is used to be compatible with other national and international standards for healthcare data and information systems engineering or telecommunications standards applied to healthcare data or systems. This practice is intended for those familiar with modeling concepts, system design, and implementation. It is not intended for the general computer user or as an initial introduction to the concepts.

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ASTM E2171-02(2008)(Practice)
Standard Practice for Rating-Scale Measures Relevant to the Electronic Health Record

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The simplicity and practicality of Rasch's probabilistic scale-free measurement models have brought within reach universal metrics for educational and psychological tests, and for rating scale-based instruments in general. There are at least 3 implications to the application of Rasch's models to the health-related calibration of universal metrics for each of the variables relevant to the Electronic Health Record (EHR) that are typically measured using rating scale instruments.
First, establishing a single metric standard with a defined range and unit will arrest the burgeoning proliferation of new scale-dependent metrics.
Second, the communication of the information pertaining to patient status represented by these measures (physical, cognitive, and psychosocial health status, quality of life, satisfaction with services, etc.) will be simplified.
Third, common standards of data quality will be used to evaluate and improve instrument performance. The vast majority of test and survey data quality is currently almost completely unknown, and when quality is evaluated, it is via many different methods that are often insufficient to the task, misapplied, misinterpreted, or even contradictory in their aims.
Fourth, currently unavailable economic benefits will accrue from the implementation of measurement methods based on quality-assessed data and widely accepted reference standard metrics. The potential magnitude of these benefits can be seen in an assessment of 12 different metrological improvement studies conducted by the National Science and Technology Council (Subcommittee on Research, 1996). The average return on investment associated with these twelve studies was 147 %. Is there any reason to suppose that similar instrument improvement efforts in the psychosocial sciences will result in markedly lower returns?
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1.3 The VUHID system is designed to represent no, or at least minimal, increased risk to healthcare privacy and security.
1.4 The system should be as cost-effective as possible.
1.5 The system must be created and maintained in a way to provide sustained benefit to healthcare.
1.6 The system should be designed and implemented in a manner that ensures that it can operate indefinitely.
This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory limitations prior to use.

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