today.9 In the longer term, health care organizations should pursue the use of technologies and products that support interorganizational (i.e., global) audit trails that allow all patient-identifiable health information to be traced as it passes through the health care complex. Examples of such technologies include the cryptographic envelopes and electronic watermarking technologies described in Chapter 4. These technologies are still in their infancy and will require additional research and development to become commercially viable (see Recommendation 5).

Electronic Authentication of Records. All health care organizations that use computerized electronic systems for order entry, discharge summaries, and other critical records should incorporate technologies for electronic signatures. At a minimum, such systems should record the log-on identifier of the user that enters or modifies data in an electronic record. Such capabilities are possible today and should be incorporated into all new systems brought on-line after 1999. Whether or not a cryptographic digital signature is used is not as important as the capability to identify the individual who enters or alters each element of information in the electronic record. Organizations that wish to use such signatures to establish evidentiary trails admissible in a court of law must pay attention to the legal requirements of the states in which they operate. This recommendation is not intended to support or undercut various existing or proposed digital signature laws at the state level, although the federal Health Insurance Portability and Accountability Act of 1996 mandates the development of standards for electronic signatures by February 1998.

Creating an Industry-wide Security Infrastructure

Although individual organizations can make considerable progress in improving patient privacy and the security of health information by implementing the policies, practices, and procedures outlined in Recommendation 1 above, additional efforts must be taken at the industry level to facilitate long-term advances in privacy and security. To date, most health care organizations have attempted to assess the vulnerabilities of their electronic health information systems and to develop solutions in isolation, without benefiting from the experience of others. Greater collaboration in both of these areas promises long-term improvements in privacy and security throughout the industry.


A regulation to promote these audit trails could be structured to allow adequate time for the development of such systems and to avoid costly retrofitting by requiring only that information systems deployed by health care organizations after 1999 have the functionality necessary to support audit trails.

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