Description
We distinguish here between the context of providing health care, which is a highly regulated and complex area, and the specific use case where an individual's information is being sought for use in health care research. The particular case here involves a person whose disease has experimental treatments available. We will assume for this case that the person is both an adult and capable of making decisions for themselves and giving consent. This use case may be extended into the future to account for pediatric research or research involving persons deemed incapable (mental health for example). We also note that there may be a predecessor or stereotypical case - Human Research Consent - that encompasses any research project that has humans as subjects. This could include but is not restricted to areas like human-computer interface research, social sciences research or marketing research.
Narrative
Alice has been diagnosed with cancer and is being treated by her doctor, Carol. Carol is an oncologist with an active research agenda and is aware of a Phase III trial of a new drug for the type of cancer that Alice has. The trial is a randomized unblinded two-armed study that compares the standard of care (the treatment that Alice is currently receiving) vs standard of care plus the new drug.Two-armed means that the patients in the trial will be divided into two groups randomly (hence randomized). It is an unblinded study, which means that patients will know which arm they are on. While Carol is not an investigator on the study, she feels that Alice should be presented with the option of participating in the study. This use case starts after Alice has made the choice, in discussion with Carol, to participate in the study. We note that this narrative elides over whether or not Carol's use of Alice's health information to determine if Alice might be a candidate for research raises its own set of consent and use issues. Carol will provide Alice with treatment, including the experimental drug if Alice ends up on the experimental arm, but will not participate in the study. If Alice consents, the study team will be provided with regular data extracts from Alice's health record for the purposes of their research. To enable this data extract Bob from the study team will seek consent from Alice to participate in the study, using a standardized consent form. Alice will be assigned a study number (typically a random number of some kind.) The study team will regularly extract health data from Alice's health record in accordance with the consent until a defined study end-point is reached or Alice withdraws from the study. Each tranche of data collected by the study team will be de-identified (used) and tagged with Alice's study number. The de-identified data will be sent to the drug manufacturer who is the sponsor of the trial. The drug company will use the de-identified data to evaluate the study results and produce any necessary regulatory or research results.
For the purposes of this discussion group, the consent that Alice agrees to is a 'contract' which can be recorded on a blockchain. It may be the case that each data extraction and/or each transfer of data to the drug sponsor may be recorded as well. Until the data is de-identified, the study team will record access to and uses of the data on the blockchain. These transactions on the blockchain will enable Alice to verify that her data is only being used for the purposes set out in the consent/contract and only by authorized people.
Question for the discussion group: Should the de-identified data, after transfer to the drug company, be included in the use case?
Actors
Actor | Role in the use case |
|---|---|
#Alice | The patient who is the subject of health research and whose consent is required to enable the research. |
#Bob | The person or entity that seeks consent from Alice. They are assumed to be an investigator or worker in the study team. |
| #Carol | The physician who is providing care to Alice and identifies her as a candidate for the study. Whether or not Alice consents to the study, Carol will be providing her standard care and the experimental drug. For this use case, we separate the attending physician and the investigating physician so that there is a clear demarcation between access to health information for treatment and access to health information for research. We recognize that this is a bit of a contrivance but do so nonetheless to clarify the roles and data flows. |
| #Dan | An authenticated and authorized individual or system that is acting for the Study Sponsor and that is not on the Study Team. Typically an analyst or researcher using the data set that includes Alice's data. |
#Mal | Generic bad actor |
| Care Team | The individuals and systems that provide health care services to Alice. Carol is Alice's oncologist and a member of her care team. For the purposes of diagrams and data flows, any member of the care team will be represented as "Carol" |
| Study Sponsor | The organization that receives study data. These individuals or systems use or disclose Alice's health information (presumptively but not necessarily in a de-identified form). For the purpose of diagrams and data flows, any member of the study team will be represented as "Dan" |
| Study Team | The individuals and systems who collect Alice's information at the health organization where she receives care. Bob is a member of the study team. For the purpose of diagrams and data flows, any member of the study team will be represented as "Bob" |
Prerequisites / Assumptions
- Alice, the care team and the study team all have access to a blockchain
- Carol has obtained Alice's consent to use her health information to qualify Alice for research studies
- Alice has been made aware of the study by Carol and has agreed to meet with Bob
- The study has a standard consent form or forms
- Copiesoftheconsentsareavailableat a well-known URL
- Links to current and former versions of the standard forms are stored on a block chain.
(group to discuss what this means, but initial idea is to have URL and an HMAC of the consent)
- The study has ethics board approval
- All data transmissions are secure
- De-identification routines are in compliance with applicable legislation
Use Case Diagram
Steps
The following steps compose the primary use case.
| # | BSC | Description |
|---|---|---|
1 | Carol uses Alice's personal health information (PHI) to determine if she qualifies for the study | |
| 2 | Carol shares a subset of Alice's PHI with Bob | |
| 3 | Bob obtains consent from Alice | |
| 4 | Bob stores a signed copy of Alice's consent | |
| 5 |  | Bob makes a record of Alice's consent on the blockchain |
6 | Carol provides care to Alice, including any study related treatments. | |
| Loop while Alice is on study | ||
| 7 | Bob extracts study data from Alice's health record | |
| 8 | | Data extract data and metadata recorded on blockchain |
| 9 | Bob de-identifies data extract and attaches Alice's study # | |
| 10 | Bob sends Alice's data to Dan | |
| 11 | | Data transmission recorded on blockchain |
| 12 | Dan performs interim analysis | |
| End Loop (study is complete) | ||
13 | Dan completes analysis and publishes results | |
| 14 | Study data is deleted after retention period expires |
Sequence Diagram
End State
The use case ends when the study is over. Even if Alice has withdrawn from the study before it completes, or is taken off study for any reason, it is normal for this kind of research that any of her data that has already been collected will remain in the study data set.
Success
- Alice's data is de-identified
- Alice's consent is respected
- Alice can verify her consent and track her data using blockchain records
Failure
- Privacy breach
- Failure to respect consent for data usage
References
Champion / Stakeholder
Related material
See these resources for related ideas about consent:
Alice Authorizes Clinical Research from HEART (talks about an aggregator subsequently sharing with clinical researchers)
Alice Selectively Shares Health-Related Data with Physicians and Others from HEART (talks about deidentified data)
The GA4GH folks have a committee that created a model data sharing consent form in CommonAccord. There's capacity for it to be signed. (This is perhaps where we want to concentrate our efforts.)
Jim shares this link as a resource for helping with the first use case.
Ethics in human research:
- Ethical Principles and Guidelines for the Protection of Human Subjects of Research (The Belmont Report) - United States
- Ethical Conduct for Research Involving Humans (Tri-Council Policy Statement or TCPS) - Canada
Links
FHIR: Fast Healthcare Interoperability Resources (FHIR, pronounced "Fire") defines a set of "Resources" that represent granular clinical concepts. The resources can be managed in isolation, or aggregated into complex documents. Technically, FHIR is designed for the web; the resources are based on simple XML or JSON structures, with an http-based RESTful protocol where each resource has predictable URL. Where possible, open internet standards are used for data representation.
HEART: The OpenID HEART Working Group intends to harmonize and develop a set of privacy and security specifications that enable an individual to control the authorization of access to RESTful health-related data sharing APIs, and to facilitate the development of interoperable implementations of these specifications by others
Common Accord: CommonAccord is an initiative to create global codes of legal transacting by codifying and automating legal documents, including contracts, permits, organizational documents, and consents. We anticipate that there will be codes for each jurisdiction, in each language. For international dealings and coordination, there will be at least one "global" code. Center for Collaborative Law