The NHS, Standards, Security

1
The NHS, Standards, Security Identity Management

• Dr. Mark Ferrar
• Director of Infrastructure
• NHS Connecting for Health
• OASIS Adoption Forum 28 November 2006

2
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

3
NHS NPfIT in context
Setting the context for the National Programme
for IT
4
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

5
Wheres your medical record kept?
6
Did someone take a back-up?
7
Scope for NHS Connecting for Health
Secondary Uses Service
chooseandbook
Analysing National Health Trends
Patient Choice

• 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 workers

Electronic Prescriptions Service
North East
N3
East
West
London
Picture Archiving Communications Service
New National Network
South
NHSmail
Healthspace
Secure E-mail for all NHS workers
Web Access for Patients
National Local Care Record Services
8
Architecture Overview
9
Integration Overview
HL7 V3
ebXML / HL7 V3
10
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!
11
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

12
And while were talking about scale

• 600,000 PC and 850,000 computer users in the NHS
  (in England)
• NHSmail will have over 1.5 million users
• Worlds 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
• Thats 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

13
For a typical week this results in
14
Role Importance of Standards
The role and importance of Standards to the NPfIT
15
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

16
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/).
17
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.

18
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

19
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.

20
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).

21
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

22
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 SpecificationebXML, Release 1, Draft Standard for Trial Use, Candidate 1, 24th November 2003.
HL7-WS 1.0 Web ServicesSOAP/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
MIM3.1.10 3.1.10 NPfIT Message Implementation Manual, Version 3.1.10, Issue date 30-03-2005
MIM3.1.09 3.1.09 NPfIT Message Implementation Manual, Version 3.1.09, Issue date 14-01-2005
MIM3.1.07 3.1.07 NPfIT Message Implementation Manual, Version 3.1.07, Issue date 29-10-2004
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 AddressingCore, W3C Working Draft, 15th February 2005, Issue 1.0 Web Services AddressingSOAP Binding, W3C Working Draft, 15th February 2005, Issue 1.0
WSI 1.0a Basic Profile 1.0aFinal 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
23
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.

24
Standards were 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)

25
Benefits Drawbacks of Standards
Benefits and drawbacks to using standards
26
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 organisations
  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)

27
Benefits
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.
28
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
• Thats 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?

29
Security Architecture of NPfIT
Security Architecture of the National Programme
30
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 gt10
  service providers, gt50 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?

31
From patient and clinician perspectives
I need secure access to clinical systems and
patient information
How can I be sure that people who do have a need
to access my medical record only get access to
what they need?
Whos been accessing my record?
I need a single way of proving my identity to all
systems that I use
Can I be sure people who have no need to see my
medical record will not be able to see it?
32
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
  registrants real world identity is verified
  beyond reasonable doubt
• Guidelines also say Registration at Level 3
  should be combined with Authentication at the
  same level

33
NCRS security components overview
Security Architecture Confidentiality Architecture

Role Based Access Control Patient Consent
Registration and Authentication LegitimateRelationships
Sealed Envelopes Sealed Envelopes

Clinician Patient
34
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?
35
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

36
Roles Based Access Control model
CFH Applications
Healthcare Professional
Activity/ Business Function(s)
Organisation(s)
Job Role(s)
National Care Records Service (NCRS)
Choose and Book (CAB)
Electronic Transmission of Prescriptions (ETP)
Secondary Uses Service (SUS)
Etc.
Etc.
37
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 users day
  job at all
• Different NHS organisations have different ideas
  about what someone in a particular role can do

38
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.

39
Legitimate Relationships
Can I be sure that people who have no need to
see my medical record will not be able to see it?
40
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

41
LR Workgroups how they work
Patient has LR with the Workgroup, e.g. all GPs
in a given Surgery established when a patient
registers with a GP
Clinician (User) is member of the Workgroup
WG
Clinician (User) permitted access to patient
record as valid LR exists via the Workgroup to
patient
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 AE.
42
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?
43
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
  patients 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).

44
Authentication
How do I know who has access to my medical
records?
45
NHS Smartcards

• A secure Chip and Pin card to hold a users
  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

46
3-step registration process
Sponsor
User
CA Agent

• 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

• 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)

47
The user login experience
Insert SmartCard into Card Reader
Authentication Confirmed
Set Session Role
Start Relevant User Application
Enter Passcode
48
Logon behind the scenes

• User inserts smart card or attempts access to a
  protected resource.
• Identity Agent (IA) prompts User for (smart card
  and) Passcode.
• Spine Security Broker (SSB) Service validates
  credentials and, if successful, establishes a
  Session.
• SSB creates Single Sign-On (SSO) Token that
  includes
• Unique User ID (UID)
• Token ID
• 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)
• SSB also establishes a Token
• ID passed to IA, stored in memory on Users PC
  and points to SSO Token held in ID Server.
• User starts application.
• Application obtains Token ID from IA
• Application checks validity of token with ID
  Server.
• Applications can also retrieve session
  information using the Token ID to get SSO Token
  values.
• 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.

49
Logging auditing

• Access to records actions performed are logged
  against an individuals 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

50
The Identity Management Challenge
The Identity Management Challenge
51
NHS Directories
Each realm contains a separate electronic
identity. Each identity must be validated and
managed.
52
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 realms membership is wholly congruent with
another. 3rd parties add significantly to the
total (e.g. pharmacists). NHS is one brand
across 1000s of discrete organisations.
53
Multiple Identities - example

• Mark Ferrar is registered in
• SPINE as 027649566234 via SmartCard
• NHSMail as Mark.Ferrar_at_nhs.net
• NOS at location A as mafe_at_npfit.nhs.uk
• 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!)

54
Our identity integration challenge
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

• 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
  theyve been granted access

55
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?