1 the nhs, standards, security & identity management dr. mark ferrar director of infrastructure...

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The NHS, Standards, Security & Identity Management

Dr. Mark FerrarDirector of InfrastructureNHS Connecting for Health

OASIS Adoption Forum – 28 November 2006

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Agenda

NHS• NPfIT in context

Standards (used by NPfIT)• How do we use them?• How important are they?• Benefits & drawbacks

Security (of Information in NPfIT)• Overview• Standards

Identity Management• Standards• Challenges

Summary

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NHS: NPfIT in context

Setting the context for the National Programme for IT

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Strategic objectives

To deliver a 21st century health service through efficient use of technology to:

• Enable and improve Access and Choice• Enable care pathways and patient focus• Improve accuracy in treatment• Create opportunities for improved efficiency• Create opportunities for real NHS reform

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Where’s your medical record kept?

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Did someone take a back-up?

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• Largest civil IT project in the world

• 40,000 GPs• 80,000 other

doctors• 350,000 nurses• 300+ hospitals• 10 year programme• 50m+ patients• 1.344m healthcare

workersSouth

West

North East

East

London

chooseandbookchooseandbook

Electronic Prescriptions Service

Electronic Prescriptions Service

NHSmailNHSmail

National & Local Care Record Services

N3

HealthspaceHealthspace

Scope for NHS Connecting for Health

Picture Archiving & Communications Service

Picture Archiving & Communications Service

Secure E-mail for all NHS workers

Web Access for Patients

Secondary Uses ServiceSecondary Uses Service

Analysing National Health Trends

New National Network

Patient Choice

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Architecture Overview

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Messaging/Integration Backbone (TMS)

LSP Data Centre

Local ApplicationInstance

EPR

Local Application Integration


EPR

Local DataWarehouse

MI

Terminology/Decision Support

Terms &Drug dB

LSP User Domain

Primary User Secondary User Tertiary User Community User

ICRS NASP Data Warehouse

SUS

SUS

SUS

CAB NASP Domain

CAB Data Store

E-Booking Application

Booking Management

Service

Telephone

ebX

ML

/ HL

7 V3

HL

7 V3

ICRS NASP Domain

SSB

PDSPSIS

SDS

ACF

Secondary Care Application

EPS

(Security & Access )

Enhanced Retained Legacy Systems

Primary User Secondary User

SecurityInfrastructure

Primary CareApplication

EPR

Secondary CareApplication

EPR

Event Engine/Integration Layer

Event Engine/Integration Layer

Integration Overview

LSP Data Centre


EPR



EPR

Local DataWarehouse

MI


Terms &Drug dB

LSP User Domain


LSP Data Centre


EPR



EPR

Local DataWarehouse

MI


Terms &Drug dB

LSP User Domain


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In a typical NHS week…

• 6 million people visit their GP• Over 800,000 outpatients are treated• Over 10,000 babies are delivered by the NHS • Over 50,000 emergency journeys in NHS ambulances• District nurses make over 600,000 home visits • Pharmacists dispense ~8.5 million items• NHS surgeons performing ~1,200 hip operations,

3,000 heart operations and 1,050 kidney operations• Labs and associated services provide millions of tests

results

In other words, 3 million critical transactions each day!

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National Programmes deliver…

• 15,642 bookings a day through Choose & Book

• 1.7 million bookings made so far in total

• 7,605,966 prescriptions have been made electronically through ETP

• 354,488 prescription messages in the last week

• 16,053 (site) connections to the N3 network

• 98% of GPs connected

• 60 PACS installations from NHS CFH now live

• 90,261,214 images have been stored from over 4,583,163 patient studies

• 797,987 messages a day over NHSmail from 213,485 users (inc. NHS CFH)

• 296,526 Smart Cards issued and in use

• GP payments enabled by QMAS total over £1.7billion

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And while we’re talking about scale…

• 600,000 PC and 850,000 computer users in the NHS (in England)

• NHSmail will have over 1.5 million users• World’s largest private, fully-featured, secure, single-domain e-mail service

• NHSmail Relay Service processes 4,000,000 messages/day and activity bursts of 100 messages a second.

• N3 network transacts almost 100 terabytes of data each month• That’s equivalent to the entire 32 volume set of the Encyclopaedia Britannica

every 40 seconds

• The processing power of the “Spine” and its test environments would put it in the top 100 supercomputers ever built

• And it has over 300 terabytes of storage - equivalent to the contents of a book shelf 3000km long

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For a typical week this results in…

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Role & Importance of Standards

The role and importance of

Standards to the NPfIT

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Standards and the National Programme

Standards adopted as a matter of…

• Policy• e-GIF• NHS STEP – STandards Enforcement in Procurement• W3C/WAI• NHS Information Standards Board (“ISB”)

• Preference• Contractual preference to support commercial flexibility

• Need• Practical need in order to support inter-operability

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ISB definition of an Information Standard

"NHS Information Standards are information and communication technologies1, which achieve interoperability between independent computer systems [functional interoperability] and between independent users of data particularly patients, clinicians and managers [semantic interoperability] when using computer systems as part of NHS commissioned and provided care."

Focus on safety, fitness for purpose, interoperability and implementation, ensuring both a specification and implementation guidance exist, meaning implementation is required before a standard is adopted or approved.

1 "Health Technology is an internationally recognised term covering any method used by those working in health services to promote health, prevent and treat disease and improve rehabilitation and long-term care. "Technologies" in this context are not confined to new drugs or pieces of sophisticated equipment." (http://www.hta.nhsweb.nhs.uk/FAQ/).

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Examples of ISB Information Standards

Some examples of NHS Information Standards include:

•Data standards such as datasets for national audits, statistics or commissioning

•Message standards such as messages communicating patient allergy information between a GP system and the national ‘spine’

•Record content standards such as the ambulance service patient report form

•Interface standards such as how date and time are displayed on the computer screen

•Health related classifications and terminologies such as ICD-10 and SNOMED CT

•Technical standards that facilitate communication and between systems and ensure effective operating, for example, network standards

•Information governance standards: technical and behavioural standards that support safe, secure and confidential management of information.

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Types & Stages of Standard

Types

Process manages each of three types with appropriate degrees of rigour.

•An Operational standard is a detailed and precisely defined standard for operational use within a specific area of the NHS. The bulk of the standards considered by ISB are operational standards

•A Fundamental standard is one which encompasses many distinct areas and will have multiple instantiations of operational standards

•A Framework standard is an 'overarching' structure which can be employed to develop Operational and / or Fundamental standards

Stages

Three sequential stages, each ensuring that developer and sponsor provide evidence through testing that standard is needed, fit for purpose, can be implemented and integrated.

•At Requirement standard stage, ISB assures a defined need within the NHS and that development and implementation plan is funded

•At Draft standard stage, ISB assures early evidence of benefits delivery described in the 'Requirement' through testing

•At Full standard stage, ISB assures evidence of ability to be implemented, interoperability and safety and is supported by a maintenance and update process

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External Interface Specification (EIS)

Within the National Programme, interoperability and integration is specified in the EIS, which describes interfaces for the following national services:

•Electronic Transfer of Prescriptions (ETP)•eBooking Service (EBS)•GP to GP (GP2GP) - EHR transfer service•Gazetteer Service•Spine Directory Service (SDS)•Spine Security Broker (SSB)•Personal Demographics Service (PDS)•Legitimate Relationship Service (LRS)•Personal Spine Information Services (PSIS)

Also provides protocol and message format standard for the exchange of HL7/XML messages between a service client and a national service.

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EIS references various standards

Adopts standards from various consortia as defined in their respective formal definitions.

Implementers should1 always refer to the standards for detailed guidance.

Where conflicts exist between specification and standard, the standard takes precedence.

The following key standards have been adopted:

•HL7 Version 3.•XML family of standards, W3C.•OASIS ebXML Message Services Specification.•OASIS ebXML Collaboration-Protocol Profile and Agreement Specification.•SOAP, W3C Recommendation.•HTTP, IETF RFC.•XML-Signature, W3C Recommendation.•LDAP, IETF RFC.•Assertions and Protocol for OASIS Security Assertions Markup Language (SAML v1.1).

(1) The keywords MUST, MAY, RECOMMENDED, and SHOULD are to be interpreted as described in RFC2119

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EIS relates to NASP & LSP services

EIS describes external interfaces from a technical perspective.

Targeted at architects, designers and builders responsible for delivery of Local Service Provider (LSP) systems, national service systems and the ICRS Spine.

Assumes familiarity with:

•HL7•XML•ebXML•XML Security•SOAP•HTTP•LDAP•Single Sign-on (SSO)•SAML•UML

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EIS References

Ref. Version or Doc. No. Description

[Ballot6] Ballot6 HL7 Version 3 Messaging Standard, Ballot6, December 2003.

[BT-Mbeh] 5 Draft B 2086 Message Handling Service Behavioural Patterns, Document Number, Issue 5, 18th January 2006.

[BT-CP] 2.1 Draft A 2088 Release ebXML Contract Properties, Issue 2.1 Draft A, 24th August 2006.

[ebXML-BPSS] 1.01 OASIS ebXML Business Process Specification Schema, Version 1.01, 11 May 2001.

[ebXML-MS] 2.0 OASIS ebXML Message Services Specification, Version 2.0, 1 April 2002.

[ebXML-CPA] 2.0 OASIS ebXML Collaboration-Protocol Profile and Agreement Specification, Version 2.0, 23rd September, 2002

[EIS5.5] 5.5 External Interface Specification, CDT D 0002, Issue 5.5, 22nd February 2006.

[EIS6.4] 6.4 External Interface Specification, CDT D 0002, Issue 6.4, 28th October 2005.

[ESR] 0.2 Microsoft Excel Worksheet ESR Staff Group, Sub-group and Job Role Codes DRAFT 0.2

[ETP-SS] 1.0 ETP Supplementary Specification – ETP v2 Implementation Strategy, Issue 1.0, Document Number 2052

[HL7-ebXML] 1 Transport Specification—ebXML, Release 1, Draft Standard for Trial Use, Candidate #1, 24th November 2003.

[HL7-WS] 1.0 Web Services—SOAP/WSDL Profile 1.0, 30th November 2003.

[HL7-WSA] 0.96 Web Services Address Profile, Ruggeri, Cabrera, Regio.

[HTTP] 1.1 RFC 2616 HTTP, Version 1.1

[LDAP-1823] The LDAP Application Program Interface

[LDAP-2251] RFC 2251 Lightweight Directory Access Protocol (v3)

[LDAP-2252] RFC 2252 Lightweight Directory Access Protocol (v3): Attribute Syntax Definitions

[LDAP-2253] RFC 2253 Lightweight Directory Access Protocol (v3): UTF-8 String Representation of Distinguished Names

[LDAP-2254] RFC 2254 The String Representation of LDAP Search Filters

[LDAP-2255] RFC 2255 The LDAP URL Format

[NASP-XML] 5 Draft F NASPXMLPackage, Version 5F 2006-08-24

[MIM4.1.04] 4.1.04 NPfIT Message Implementation Manual, Version 4.1.04, Issue date 16/08/2006

[MIM4.1.02] 4.1.02 NPfIT Message Implementation Manual, Version 4.1.02, Issue date 05/05/2006

[MIM3.1.11] 3.1.11 NPfIT Message Implementation Manual, Version 3.1.11, Issue date 04-08-2005




[MIM2.3] 2.3 NPfIT Message Implementation Manual, Version 2.3

[RBAC] 6.0 Information Governance Programme Role-Base Access Control Requirements (RBAC) (NPFIT NDA GEN IG0252) v6.0. 17th Feb

[RFC-2119] Key words for use in RFCs to Indicate Requirement Levels

[SOAP] 1.1 SOAP, Version 1.1, W3C Note, 8th May 2000

[SOAP-Att] SOAP Messages with Attachments, 11th November 2000.

[SSB SAML] IG D0014 Spine Security Broker – SAML Assertion Structure

[WS-A] 1.0 Web Services Addressing—Core, W3C Working Draft, 15th February 2005, Issue 1.0

Web Services Addressing—SOAP Binding, W3C Working Draft, 15th February 2005, Issue 1.0

[WSI] 1.0a Basic Profile 1.0a—Final Specification, Web Service Interoperability Organisation, 8th August 2003

[WSI-ATT] 1.0 Attachments Profile 1.0, Web Service Interoperability Organisation, 24th August 2004.

[XLINK] XML Linking Recommendation, W3C Recommendation, 27th June 2001.

[XMLdsig] XML-Signature Syntax and Processing: W3C Recommendation 12 February 2000

[XMLSchema] XML Schema Part 1: Structures, W3C Recommendation, 2nd May 2001

XML Schema Part 2: Datatypes, W3C Recommendation, 2nd May 2001

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Other standards adopted by NPfIT

NPfIT also relies on various other international standards not described by (or relevant to) the EIS, but just as important

Medical Terminology• SNOMED-CT

Various other infrastructure standards (not already mentioned)• TCP/IP v4• DNS• TLS / SSL• X.509• IEEE 802.3• IEEE 802.11• 3DES• AES• RC4• IMAP• Etc…

In fact, standards of one sort or another pervade most elements of the programme.

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Standards we’re developing ourselves

HL7 NHS Extensions• Being adopted into mainstream HL7

Common User Interface (CUI)•Design Guide for components of the clinical UI

•Licensed for use outside the NHS•Collaborative development via Participation Agreement•Focus on Patient Safety & Clinical Efficiency•Independent of application development environment or language•Some taken through the NHS ISB processes

•Toolkit•Implementation of DG in Microsoft .NET v2

•(Desktop & Infrastructure)

•(Office)

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Benefits & Drawbacks of Standards

Benefits and drawbacks to using standards

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Benefits

Interoperability•End to end service delivered using different brands and products•Service delivered using different versions of same products in different parts of the organisation•Service interoperates with other organisation’s services (that use same or compatible standards or interfaces)

Longevity•Protection against innovation obsolescence when combined with SOA•Commercial firms “innovate” to improve product (fix bugs, enhance performance) AND generate steady revenues (make users upgrade)•A long term (10 year) programme must manage product innovation alongside long term sustained service delivery and stability.

Flexibility•Add or delete a product from the service mix•Add or delete a service•Avoiding vendor lock-in•Avoid Service Provider lock-in•Extend organisation or enterprise (integrate 3rd party business services)

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Thanks to Patrick Gannon for the following reference:

US DoD Open Technology Development, A Roadmap Plan, April 2006

“As software becomes increasingly networked, design and engineering methodologies have evolved towards services-based architectures that communicate through open and standardized interfaces. Often, these services and interfaces are provided with OSS reference implementations. Once this type of open, service based architecture is implemented, the system naturally decomposes into a modular design ― each service is free to improve and evolve independently as long as it communicates through the standard interfaces.”

http://www.acq.osd.mil/asc/

But this should apply equally to proprietary systems built to comply with open standard interfaces – each service is free to improve and evolve independently so long as the interface standard remains stable and is adhered to.

Benefits

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Drawbacks

Implementation variation•Proprietary implementations of the “standard” may fail to interoperate•Heavily customised implementations of complex applications built on equally complex standards become bespoke (almost proprietary) solutions•E.g. Java engine variations•E.g. smart card “standards”

Implementation quality•E.g. Bluetooth used in Assistive Technology / Telecare / Telemedicine

Performance disadvantage against “tuned” proprietary solutions•E.g. IMAP clients versus proprietary e-mail client / server protocols

Obsolescence when the standard changes•E.g. SAML v1.1 versus SAML v2.0

Competing Standards•That’s the thing about standards, there are always so many to choose from•E.g. ebXML business process and modelling standards overlap with HL7 standards specific to healthcare – which should the NHS choose to implement?

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Security Architecture of NPfIT

Security Architecture of the National Programme

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Key security challenges

• How do you ensure only those who need access gain access to any one of 50 million patient records?

• How do you provide single sign-on with >10 service providers, >50 applications and 12,000 separate NOS installations?

• How do you provide e-GIF Level 3 2-factor authentication with 30% of your users outside your organisation and network?

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From patient and clinician perspectives

Who’s been accessing my

record?

How can I be sure that people who do have a

need to access my medical record only get

access to what they need?

Can I be sure people who have no

need to see my medical record will not be able to see

it?

I need secure access to

clinical systems and patient information

I need a single way of proving

my identity to all systems that I

use

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Our Data Protection Act obligations

• DPA defines much of the data held on NCRS systems as “sensitive personal data”

• We have a duty of care to protect data appropriately

• Government guidelines say the release of “personally … sensitive data to third parties” requires Registration at Level 3, via which “the registrant’s real world identity is verified beyond reasonable doubt”

• Guidelines also say Registration at Level 3 should be combined with Authentication at the same level

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NCRS security components overview

Security Architecture Confidentiality Architecture

Role Based Access Control

Patient Consent

Registration and Authentication

LegitimateRelationships

Sealed Envelopes

Clinician Patient

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Role Based Access Control

“Can I be sure that people who do have a need to access my medical records only get access to what they need?”

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Why Role Based Access Control?

• Well understood approach with proven success in large business systems

• The NHS is a business with complex role-to-task and task-to-business process mapping

• Most existing health applications incorporate some form of Role Based Access Control

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Roles Based Access Control model

Healthcare Professional

Organisation(s) Job Role(s) Activity/ Business

Function(s)

xxxx

xxxx

xxxx

xxxx

xxxx

Etc.

National Care Records Service

(NCRS)

Choose and Book(CAB)

Electronic Transmission of

Prescriptions(ETP)

Secondary Uses Service(SUS)

Etc.

CFH Applications

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However, RBAC alone is not enough…

• The functions people perform can cross job boundaries

• Some functions are available only to certain users in a particular job

• Some functions are not related to a user’s “day job” at all

• Different NHS organisations have different ideas about what someone in a particular role can do

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Enhancements to RBAC are needed

• Transparent to the choice of service provider supporting the real world “things” people do.

• Uses the role concept for the majority of rights a user has, so that Registration Authorities are not faced with the individual nomination of every separate detailed access right.

• Provides the flexibility needed to support policy change.

• Permits policy variation across the NHS, controlled in a manner that preserves a common understanding of Job Roles and the rights they carry.

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Legitimate Relationships

“Can I be sure that people who have no need to see my medical record will not be able to see it?”

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What is a Legitimate Relationship?

• The Legitimate Relationship Service (LRS) enables systems to verify a permitted relationship exists between the system user and the patient before allowing access to requested data

• A user cannot access a patient's clinical record without a Legitimate Relationship (LR)

• Many different types of LR, but almost all are invisible to the user and are triggered by patient-related events

• Legitimate Relationships have lifecycles (they can expire)

• Creating Workgroups and assigning users to them is a vital function for NHS organisations and to the LRS

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LR Workgroups – how they work

WG

Clinician (User) permitted access to patient record as valid LR exists via the

Workgroup to patient

Clinician (User) is member of the Workgroup

Additionally, there can be direct LRs between individual User Role Profiles (clinicians) and Patients – these are ‘Self-claimed’ and ‘Colleague-granted’ LRs – e.g. in A&E.

Patient has LR with the Workgroup, e.g. all GPs in a given Surgery – established

when a patient registers with a GP

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Sealed Envelopes

“Can I be sure that people who see my record will not be able to see particularly sensitive medical details which I want to keep secret only to myself and any specialists treating me?”

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What is a Sealed Envelope?

• Patients will be able to select parts of their record to which they wish access to be restricted

• They can require that only nominated people can see these parts

• This can be overridden (with an alert) if the patient’s life is in danger and the patient cannot be asked

• Clinicians will also be able to seal off parts of the record from the patient (e.g. where knowledge by the patient may lead them to harm themselves or others).

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Authentication

“How do I know who has access to my medical records?”

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NHS Smartcards

• A secure “Chip and Pin” card to hold a user’s unique identity (digital certificates)

• Supports 2 factor authentication required by e-GIF Level 3:• Something you have (the Smartcard)• Something you know (the Passcode)

• Passcode only stored on the card

• Certificate is validated to ensure currency as the user authenticates

• Any magnetic strip on the card is not used for authentication or to hold digital signatures

• Future support for biometrics and proximity

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3-step registration process

Present Documents

Register User

User Registered

Smart Card Assigned

Smart Card Created

Smart Card Issued

CMSCMS

Spine Directory Service

SUDCard Management

System

1 - Validation of application to register

• Complete an application form (RA01)• Have identity vouched for by sponsor or present suitable documentary evidence of

identity• Obtain sponsorship for appropriate job profile

2 - Registration into the Spine User Directory (SUD), a sub-component of the Spine Directory Service (SDS)

• Search for user and ensure no duplicates created

• Create a basic user profile• Associate with organisation(s)• Assign correct role(s)

3 - Smartcard issue from Card Management System (CMS)

• Import person from SUD• Take clear image of

applicant with Webcam• Print and issue the card• Test the card

Sponsor

CA AgentUser

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The user login experience

Insert SmartCard into Card Reader

Enter Passcode

Authentication Confirmed

Set Session Role

Start Relevant

User Application

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Logon “behind the scenes”

1. User inserts smart card or attempts access to a protected resource.

2. Identity Agent (IA) prompts User for (smart card and) Passcode.

3. Spine Security Broker (SSB) Service validates credentials and, if successful, establishes a Session.

SSB creates Single Sign-On (SSO) Token that includes:

1. Unique User ID (UID)

2. Token ID

3. Session attributes, e.g. max_idle_time

Also creates Attribute Assertion including:

• Name, UID, OCS Code, Default Role, Job Role(s), Organisation(s), Business Function(s), Area of work(s), Workgroup(s)

4. SSB also establishes a Token

• ID passed to IA, stored in memory on User’s PC and points to SSO Token held in ID Server.

5. User starts application.

6. Application obtains Token ID from IA

7. Application checks validity of token with ID Server.

• Applications can also retrieve session information using the Token ID to get SSO Token values.

8. Application Access control Decision Function (ADF) gets/parses SAML Assertion for attributes

• Application ADF processes User requests in its own context based on user information in SSO Token and Assertion.

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Logging & auditing

• Access to records & actions performed are logged against an individual’s identity (via their smart card ID), not against the Workgroup (which enables the RBAC)

• Claiming of a LR (or attempting access without a LR) generates an alert

• Alerts are dealt with by Caldicott Guardians – an existing role within the NHS – the safeguards of patient confidentiality

• Access logs are kept as long as the EMR

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The Identity Management Challenge

The Identity Management Challenge

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NHS Directories

Spine Directory Services

280,000 smartcard users today growing to over 1,000,000 in full deployment

NHSmail Directory

>210,000 nhs.net entries today and

over 1,000,000 synchronised

addresses already

12,000 separate NOS Directories

Other Application Servers

Web Application Servers

ESRElectronicStaff Record(Database)

Each “realm” contains a separate electronic identity.

Each identity must be validated and managed.

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Multiple Directory Technologies…

• Spine Directory uses Sun One• NHSmail uses CA eTrust• 65% of 12,000 NOS use Microsoft AD (or NT4!)• 35% of 12,000 NOS use Novell eDirectory (or NDS!)• ESR is Oracle database for most (but not all) NHS

workers

• There are unknown number of application services holding their own username & password lists

• Plus ID badges and building access “swipecards”

• All with different administration and standards

No realm’s membership is wholly congruent with another.

3rd parties add significantly to the total (e.g. pharmacists).

NHS is one brand across 1000’s of discrete organisations.

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Multiple Identities - example

• Mark Ferrar is registered in:• SPINE as 027649566234 via SmartCard• NHSMail as [email protected]• NOS at location A as [email protected]• NOS at location B as \\nhsia\markf• Local Business Application as MarFer• Etc..

• On average an typical NHS user has between 5 – 8 electronic identities stored on different systems

(Only email & NOS A are real in this example – but this is typical!)

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Our identity integration challenge…

• Reduce user and administrator effort by integrating multiple identities belonging to the same person

• Synchronise some identity information

• Federate some directory services

• Deliver “self-administration” portals for users

• Establish provision/de-provision links and processes

• Validate identity at the highest level (e-GIF Level 3)

• Ensure people can access the things they need to do their jobs, but only the records to which they’ve been granted access

Manage 5 - 8 Million User IDs

Need to prove some IDs “beyond reasonable doubt”

Challenge to and of Federation

Challenge of Data (Attribute) Synchronisation

Challenge of (Self) Administration

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Summary

• Open standards an integral part of the National Programme for IT in the NHS

• In fact, NPfIT not possible without open, accessible, interoperable and “implementable” standards

• But products that implement same standards must also be compatible and efficient

• Inefficient, incomplete or incompatible implementation are less than useful – in fact its expensive & dangerous

• FINAL THOUGHT: What responsibility does the standards community take to ensure effective & efficient implementation?