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Preparing for Possibly, Maybe,
Handling PHI at the Broad Institute
IQPC 13th Laboratory Informatics Summit
Boston, MA
2016/12/06, v3
About the Speaker
Bruce Kozuma is a projectprogram manager in
the Broad Information Technology Services (BITS)
department with experience in software
development, operations, and IT in industries
such as manufacturing, telecommunications,
biotechnology, and biomedical research
Overview
• Title of this presentation was originally “Preparing
Laboratory Data at the Broad Institute for HIPAA
Compliance”
• It’s morphed, much like things at the Broad
• If you were expecting to hear about a settled plan, I’m sorry
to disappoint you
• The presentation may still be interesting however (you can
tell me at the break if you like)
About the Broad Institute of MIT & Harvard
• Propelling the
understanding and
treatment of disease
• Collaborating deeply
• Reaching globally
• Empowering scientists
• Building partnerships
• Sharing data and
knowledge
• Promoting inclusion
HIPAA and Laboratory Data at the Broad
• Broad is NOT Covered Entity nor a Business Associate
under HIPAA
• However, we collaborate with places that handle PHI, like
HMS, MGH, DFCI, BCH, just to name a few
• There is a big push for translational medicine, including at
the Broad, i.e., a push for both bringing clinical data into
research and delivering therapies more quickly
• Have a variety of laboratory data management solutions
due to:
• Legacy
• Funding sources
• Culture
Towards a Common Solution
Laboratory Data Management
• Project to provide centrally-managed solutions for
management of laboratory data, divided into functions:
• Data capturearchive (instruments and other sources)
• Container inventoryregistration (chemical,
biological, hybrid)sample management
• Core Electronic Laboratory Notebook (ELN, experiment
documentationIP protectionlinking to data)
• Dataworkflow management
• Data analysisvisualization
Context for LDM
• Make using LDM easy for scientists
• Have much of IT processes outside user’s daily work
• Introduce light system controls
• Slowly bring in compliance to enable science
• Had early success identifying those with needs, with
adoption, started down the compliance path
The Plan
• Make using LDM easy for scientists
• Have much of IT processes outside user’s daily work
• Introduce light system controls
• Slowly bring in compliance to enable science
• Had early success identifying those with needs, with
adoption, started down the compliance path
The Plan
LDM Compliance Assessment
• Started as a subset of the overall LDM project
• Goals
• Determine the regulations that most likely apply that relate to LDM,
e.g., HIPAA, CLIA, GxP, FISMA
• Establish baseline understanding of the Broad’s system
management practices with respect to LDM with those regulations
• Have a roadmap for improvement, with aim of being substantially
audit-ready at some point (likely a few years) in the future
• Do as much of the compliance work with as little impact on the
LDM user community as possible
Best Laid Plans of Mice and Men…
So What Now?
• Results is that the need to handle PHI at the Broad, not in
a few years in the future, but now
• Why?
• Researchers are often working at multiple institutions, e.g., HMS,
MGH, and the Broad
• PHI being handled at the partner institutions, resulting in barriers
to research
• Want to enable researchers to have more focus on their research,
and less on information technology and mechanics of meeting IRB
requirements
• Want researchers to do more of their research at the Broad
• Broad is challenged by having early stage offerings for
technical infrastructure and procedural controls for PHI
Practical Immediate Steps
• Ensure PIs are aware of the PHI-related risks they face
and explicitly accept those risks
• Encourage PIs to use resources of collaborators to handle
PHI (e.g., if DFCI has a preferred secure email vendor, use
theirs)
• Document what PIs can do with PHI at the Broad
Practical Immediate Steps
• Ensure PIs are aware of the PHI-related risks they face
and explicitly accept those risks
• Encourage PIs to use resources of collaborators to handle
PHI (e.g., if DFCI has a preferred secure email vendor, use
theirs)
• Document what PIs can do with PHI at the Broad
Longer Terms Steps
• Build on the work of the LDM Compliance Assessment
project/recast it as the PHI Compliance Readiness project
• Implement quality management framework for handling PHI
• Refine risk assessment methodology for outsourced partners
• Execute on plan to address prioritized HIPAA compliance gaps
Longer Terms Steps
• Propose projectsbudgets for technology and process
solutions to offer more services to PIs to streamline their
research by bringing PHI to the Broad
• Implement plan to proactively manage risks, e.g.:
• Implement necessary policies
• Raise awareness of responsibilities
and risks via training
• Establish clear response matrices to
guide people to answers
Things Learned Along the Way
• <>
• Embrace agility and get something out there
Things Learned Along the Way
• Hire outside expertise to parse Federal regulations
Things Learned Along the Way
• Partner with technology vendors who take time to listen
and understand your needs
• Responsive, proactive management makes a lot of things
possible
• Remember that the Broad pushes the edge of possible
• Compliance approach will remain unfinished because the Broad is
not done reinventing itself
• Engaging with the world of regulatory compliance, when the Broad
chooses what boundaries to push, makes things challenging
• Our solution (for now): enter into a continual compliance
conversation, where we can choose what parts of research are
done, by which party, where what capabilities the Broad offers or
should offer is considered

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2016 IQPC 13th Laboratory Informatics Summit Preparing for Possibly, Maybe, Handling PHI at the Broad Institute

  • 1. Preparing for Possibly, Maybe, Handling PHI at the Broad Institute IQPC 13th Laboratory Informatics Summit Boston, MA 2016/12/06, v3
  • 2. About the Speaker Bruce Kozuma is a projectprogram manager in the Broad Information Technology Services (BITS) department with experience in software development, operations, and IT in industries such as manufacturing, telecommunications, biotechnology, and biomedical research
  • 3. Overview • Title of this presentation was originally “Preparing Laboratory Data at the Broad Institute for HIPAA Compliance” • It’s morphed, much like things at the Broad • If you were expecting to hear about a settled plan, I’m sorry to disappoint you • The presentation may still be interesting however (you can tell me at the break if you like)
  • 4. About the Broad Institute of MIT & Harvard • Propelling the understanding and treatment of disease • Collaborating deeply • Reaching globally • Empowering scientists • Building partnerships • Sharing data and knowledge • Promoting inclusion
  • 5. HIPAA and Laboratory Data at the Broad • Broad is NOT Covered Entity nor a Business Associate under HIPAA • However, we collaborate with places that handle PHI, like HMS, MGH, DFCI, BCH, just to name a few • There is a big push for translational medicine, including at the Broad, i.e., a push for both bringing clinical data into research and delivering therapies more quickly • Have a variety of laboratory data management solutions due to: • Legacy • Funding sources • Culture
  • 6. Towards a Common Solution Laboratory Data Management • Project to provide centrally-managed solutions for management of laboratory data, divided into functions: • Data capturearchive (instruments and other sources) • Container inventoryregistration (chemical, biological, hybrid)sample management • Core Electronic Laboratory Notebook (ELN, experiment documentationIP protectionlinking to data) • Dataworkflow management • Data analysisvisualization
  • 8. • Make using LDM easy for scientists • Have much of IT processes outside user’s daily work • Introduce light system controls • Slowly bring in compliance to enable science • Had early success identifying those with needs, with adoption, started down the compliance path The Plan
  • 9. • Make using LDM easy for scientists • Have much of IT processes outside user’s daily work • Introduce light system controls • Slowly bring in compliance to enable science • Had early success identifying those with needs, with adoption, started down the compliance path The Plan
  • 10. LDM Compliance Assessment • Started as a subset of the overall LDM project • Goals • Determine the regulations that most likely apply that relate to LDM, e.g., HIPAA, CLIA, GxP, FISMA • Establish baseline understanding of the Broad’s system management practices with respect to LDM with those regulations • Have a roadmap for improvement, with aim of being substantially audit-ready at some point (likely a few years) in the future • Do as much of the compliance work with as little impact on the LDM user community as possible
  • 11. Best Laid Plans of Mice and Men…
  • 12. So What Now? • Results is that the need to handle PHI at the Broad, not in a few years in the future, but now • Why? • Researchers are often working at multiple institutions, e.g., HMS, MGH, and the Broad • PHI being handled at the partner institutions, resulting in barriers to research • Want to enable researchers to have more focus on their research, and less on information technology and mechanics of meeting IRB requirements • Want researchers to do more of their research at the Broad • Broad is challenged by having early stage offerings for technical infrastructure and procedural controls for PHI
  • 13. Practical Immediate Steps • Ensure PIs are aware of the PHI-related risks they face and explicitly accept those risks • Encourage PIs to use resources of collaborators to handle PHI (e.g., if DFCI has a preferred secure email vendor, use theirs) • Document what PIs can do with PHI at the Broad
  • 14. Practical Immediate Steps • Ensure PIs are aware of the PHI-related risks they face and explicitly accept those risks • Encourage PIs to use resources of collaborators to handle PHI (e.g., if DFCI has a preferred secure email vendor, use theirs) • Document what PIs can do with PHI at the Broad
  • 15. Longer Terms Steps • Build on the work of the LDM Compliance Assessment project/recast it as the PHI Compliance Readiness project • Implement quality management framework for handling PHI • Refine risk assessment methodology for outsourced partners • Execute on plan to address prioritized HIPAA compliance gaps
  • 16. Longer Terms Steps • Propose projectsbudgets for technology and process solutions to offer more services to PIs to streamline their research by bringing PHI to the Broad • Implement plan to proactively manage risks, e.g.: • Implement necessary policies • Raise awareness of responsibilities and risks via training • Establish clear response matrices to guide people to answers
  • 17. Things Learned Along the Way • <> • Embrace agility and get something out there
  • 18. Things Learned Along the Way • Hire outside expertise to parse Federal regulations
  • 19. Things Learned Along the Way • Partner with technology vendors who take time to listen and understand your needs • Responsive, proactive management makes a lot of things possible • Remember that the Broad pushes the edge of possible • Compliance approach will remain unfinished because the Broad is not done reinventing itself • Engaging with the world of regulatory compliance, when the Broad chooses what boundaries to push, makes things challenging • Our solution (for now): enter into a continual compliance conversation, where we can choose what parts of research are done, by which party, where what capabilities the Broad offers or should offer is considered

Editor's Notes

  1. See www.broadinstitute.org for more
  2. HIPAA: Health Insurance Portability and Accountability Act PHI: Protected Health Information HMS: Harvard Medical School MGH: Massachusetts General Hospital DFCI: Dana Farber Cancer Institute BCH: Boston Children’s Hospital
  3. ELN: Electronic Laboratory Notebook JIRA specifically
  4. HIPAA: Health Insurance Portability and Accountability Act CLIA: Clinical Laboratory Improvement Amendments SSAE: Statements on Standards for Attestation Engagements, by American Institute of Certified Public Accountants, Inc. (AICPA) ISAE: International Standard on Assurance Engagements, International Auditing and Assurance Standards Board (IAASB), part of the International Federation of Accountants (IFAC) TIA: Telecommunications Industry Association ISO: International Organization for Standardization FISMA: Federal Information Security Management Act NIST: National Institute of Standards
  5. LDM: Laboratory Data Management
  6. LDM: Laboratory Data Management
  7. LDM: Laboratory Data Management HIPAA: Health Insurance Portability and Accountability Act CLIA: Clinical Laboratory Improvement Amendments GxP: Good x Practice, where the x stands for Laboratory, Clinical, Manufacturing, etc. FISMA: Federal Information Security Management Act
  8. Taken from the Broad’s Facebook feed
  9. PHI: Protected Health Information HMS: Harvard Medical School MGH: Massachusetts General Hospital IRB: Institutional Review Board
  10. PI: Principle Investigators PHI: Protected Health Information DFCI: Dana Farber Cancer Institute
  11. PI: Principle Investigators PHI: Protected Health Information DFCI: Dana Farber Cancer Institute
  12. LDM: Laboratory Data Management PHI: Protected Health Information HIPAA: Health Insurance Portability and Accountability Act
  13. PI: Principle Investigator PHI: Protected Health Information Decision tree image source: https://www.edrawsoft.com/images/examples/decisiontree.png
  14. Department of Health and Human Services Office of Civil Rights Department of Justice (for penalties) Federal Trade Commission (Breach Notification Rule)