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| Ignacio Valdez, a psychiatrist in Houston TX, has been charged with implementing VistA for a chain of psychiatric facilities. He has posted his progress on the Hardhats discussion group. Some of the threads are reproduced here.
| | Astronaut, LLC [http://astronautvista.com] has been charged with implementing VistA for a psychiatric hospital. Posted is the progress on the Hardhats discussion group [http://groups.google.com/group/Hardhats/topics?hl=en&start=]. Some of the threads are reproduced here. |
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| ==Episode 2== [[Episode2|Multiple Sign-ons]]
| | The traditional method for implementing a new VistA instance has been likened to an old-fashioned barn-raising: at the appointed time the holders of "institutional memory" would gather and put the thing together. There was no written blueprint, yet at the end of the day there would be a solid, usable structure in place. |
| Ignacio Valdes
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|
| |
| Date: Mon, 14 Jul 2008 13:56:40 -0500
| |
| Subject: The Intracare Implementation Log Episode 2: How does one handle Active Directory ID's?
| |
|
| |
|
| Greetings,
| | The ultimate goal of this is not just a new VistA instance, but also a blueprint for how to do it. |
|
| |
|
| So we already have people with Active Directory ID's. How does one
| | Note that this page is a work in progress; see Hardhats [http://groups.google.com/group/Hardhats/topics?hl=en&start=] for logs that do not appear here. |
| generally manage Active Directory ID's and VistA ID's?
| | [[Category:Cambridge / Intracare Implementation Log]] |
|
| |
|
| -- IV
| | ==[[Ignacio Valdes Implementation Log/Episode1|Episode 1 The Layer Cake]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode2|Episode 2 Multiple Sign-ons]]== |
| I, Valdes
| | ==[[Ignacio Valdes Implementation Log/Episode3|Episode 3 IPv4 vs. IPv6]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode4|Episode 4 Billing/Management Keane Records integration/population]]== |
| I will answer for myself: There is no direct equivalent of Active
| | ==[[Ignacio Valdes Implementation Log/Episode5|Episode 5 Patient picture?]] == |
| Directory Id's in VistA. While this may seem like a handicap, it is
| | ==[[Ignacio Valdes Implementation Log/Episode6|Episode 6 Implementation funding?]] == |
| also an advantage in that the system is independent of Active
| | ==[[Ignacio Valdes Implementation Log/Episode7|Episode 7 iptables and other useful port commands]] == |
| Directory which makes it both more secure and easier in some ways to
| | ==[[Ignacio Valdes Implementation Log/Episode8|Episode 8 Power outage restart]] == |
| roam to other workstations. -- IV
| | ==[[Ignacio Valdes Implementation Log/Episode9|Episode 9 Initial hospital configuration terminal session]]== |
|
| | ==[[Ignacio Valdes Implementation Log/Episode10|Episode 10 Psychiatry specific DSM Axis II-V diagnosis, precaution ordering]]== |
| fred trotter
| | ==[[Ignacio Valdes Implementation Log/Episode11|Episode 11 VistA configuration Utility, KIDS Patch Install]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode12|Episode 12 How do you create a new patient?]]== |
| Generally, if you want to integrate with Active Directory you should
| | ==[[Ignacio Valdes Implementation Log/Episode13|Episode 13 Ordering Configuration]] == |
| use LDAP. This is how unix does it.
| | ==[[Ignacio Valdes Implementation Log/Episode14|Episode 14 Hardware, multi-user systems?]] == |
| | | ==[[Ignacio Valdes Implementation Log/Episode15|Episode 15 Non-proprietary signature consenting of patients]] == |
| http://onlinepill.in/order-mentat-online-en.html?q=mentat
| | ==[[Ignacio Valdes Implementation Log/Episode16|Episode 16 KIDs VA DHCP style login How to]] == |
| | | ==[[Ignacio Valdes Implementation Log/Episode17|Episode 17 KIDs Patch Install Best Practice.]] == |
| It seems to me that you should be able to use LDAP for the VistA
| | ==[[Ignacio Valdes Implementation Log/Episode18|Episode 18 Adding Locations to Hospital Location File Using Fileman.]]== |
| authentication instead of the internal VistA user system. This is how
| | ==[[Ignacio Valdes Implementation Log/Episode19|Episode 19 Adding Locations to Hospital Location File Using Fileman.]]== |
| ClearHealth works.
| | ==[[Ignacio Valdes Implementation Log/Episode20|Episode 20 Location for Current Activities Dialog Box]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode21|Episode 21 Little graphics in templates?]]== |
| Does VistA integrate with LDAP?
| | ==[[Ignacio Valdes Implementation Log/Episode22|Episode 22 How to allow editing of Template Fields.]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode23|Episode 23 AIMS Examination template?]]== |
| -FT
| | ==[[Ignacio Valdes Implementation Log/Episode24|Episode 24 Changing Intro Message]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode25|Episode 25 Demystifying Templating, Document Classes and Titles for Dummies.]]== |
| kdtop
| | ==[[Ignacio Valdes Implementation Log/Episode26|Episode 26 Scheduling patients for a Clinic]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode27|Episode 27 Suppressing WORK COPY -- NOT FOR MEDICAL RECORD]]== |
| I don't understand your question. Are you wanting to have a single
| | ==[[Ignacio Valdes Implementation Log/Episode28|Episode 28 Easy template importing and exporting]]== |
| sign-in situation? Where the network access guarantees VistA
| | ==[[Ignacio Valdes Implementation Log/Episode29|Episode 29 Adding Appointment Schedule Menu to Clerk ID.]]== |
| access?? I thought that Active Directory stuff had to do with access
| | ==[[Ignacio Valdes Implementation Log/Episode30|Episode 30 Change Access/Verify code text to UserID/Password?]]== |
| to network drives, whereas VistA access has to do with access to an
| | ==[[Ignacio Valdes Implementation Log/Episode31|Episode 31 'Cowboy' System Backup]]== |
| EMR.
| | ==[[Ignacio Valdes Implementation Log/Episode32|Episode 32 Merge Records?]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode33|Episode 33 The Whole Enchilada Admissions Workflow]]== |
| Aren't these separate issues?
| | ==[[Ignacio Valdes Implementation Log/Episode34|Episode 34 Entering Insurance Information?]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode35|Episode 35 CPRS options, Number of Days, Default Date?]]== |
| Kevin
| | ==[[Ignacio Valdes Implementation Log/Episode36|Episode 36 Patient movement and tracking?]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode37|Episode 37 Maximum number of users already signed on to this processor]] == |
|
| | ==[[Ignacio Valdes Implementation Log/Episode38|Episode 38 Hospital Electronic Signature Policy?]]== |
| Steven McPhelan
| | ==[[Ignacio Valdes Implementation Log/Episode39|Episode 39 Patient lab reports connection]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode40|Episode 40 Kevin Toppenberg's GUI_Config easy(er) install package.]]== |
| I disagree with the concept of single sign-on for the medical environment at
| | ==[[Ignacio Valdes Implementation Log/Episode41|Episode 41 Option to Security Key mapping, Granting of a Key or Keys, Key management menus.]]== |
| this time. At such time that all people in the world are honorable and
| | ==[[Ignacio Valdes Implementation Log/Episode42|Episode 42 Is there such a thing as: Introduction to programming vista with mumps?]]== |
| adhering to good and safe and secure computing habits, then perhaps single
| | ==[[Ignacio Valdes Implementation Log/Episode43|Episode 43 Pharmacy.]]== |
| sign-on will be feasible (think of the walk-away problem). I do believe
| | ==[[Ignacio Valdes Implementation Log/Episode44|Episode 44 Editable CPRS handout for clinicians.]]== |
| that LDAP can still be used. Instead of just using a specific technology
| | ==[[Ignacio Valdes Implementation Log/Episode45|Episode 45 Page number printout revisited.]]== |
| like LDAP, I prefer the term network authentication. VistA should still
| | ==[[Ignacio Valdes Implementation Log/Episode46|Episode 46 A (Very) brief Programming VistA with MUMPS page numbering example]]== |
| challenge the user for sign-on credentials even though the network sign-on
| | ==[[Ignacio Valdes Implementation Log/Episode47|Episode 47 Slow text login problem and a resolution]]== |
| has already occurred. Where and how they authenticate those sign-on
| | ==[[Ignacio Valdes Implementation Log/Episode48|Episode 48 Updating software on a production system?]]== |
| credentials is another matter that technology can address.
| | ==[[Ignacio Valdes Implementation Log/Episode49|Episode 49 Destination unreachable (Host administratively prohibited)]]== |
| --
| | ==[[Ignacio Valdes Implementation Log/Episode50|Episode 50 KIDs Patch Creation?]]== |
| Steve
| | ==[[Ignacio Valdes Implementation Log/Episode51|Episode 51 Extreme training/development tip with screen/cloud/Astronaut.)]]== |
| It's so much easier to suggest solutions when you don't know too much about
| | ==[[Ignacio Valdes Implementation Log/Episode52|Episode 52 Death of a Patient.]]== |
| the problem." -- Malcolm Forbes
| | ==[[Ignacio Valdes Implementation Log/Episode53|Episode 53 User Roles and Permissions Management.]]== |
|
| | ==[[Ignacio Valdes Implementation Log/Episode54|Episode 54 Discharge Summaries]]== |
| r...
| | ==[[Ignacio Valdes Implementation Log/Episode55|Episode 55 Consult Service|Consult Service.]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode56|Episode 56 Same Access Code Disentangling.]]== |
| I find that I am in agreement with Stephen. While the Wow and convenience
| | ==[[Ignacio Valdes Implementation Log/Episode57|Episode 57 Appropriate keys for a social worker id?]]== |
| factors are high, the potential for abuse is even higher.
| | ==[[Ignacio Valdes Implementation Log/Episode58|Episode 58 Printed Labels?]]== |
|
| | ==[[Ignacio Valdes Implementation Log/Episode59|Episode 59 Linking a Template with a Title]]== |
| fred trotter
| | ==[[Ignacio Valdes Implementation Log/Episode60|Episode 60 Example of setting Institution file Station Number]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode61|Episode 61 Bringing CPRS, TMG-CPRS back onto the screen when it is off screen]]== |
| With all due respect, we are not asking if you think it is a good
| | ==[[Ignacio Valdes Implementation Log/Episode62|Episode 62 Hardware Price/Performance as of 6/29/2010]]== |
| idea. We are asking if it is possible. Is it possible to use LDAP for
| | ==[[Ignacio Valdes Implementation Log/Episode63|Episode 63 Non-provider and their assistant co-signing?]]== |
| authentication from within VistA?
| | ==[[Ignacio Valdes Implementation Log/Episode64|Episode 64 Setting user Electronic Signature Code through Text Based Interface.]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode65|Episode 65 Template title ascending sort]]== |
| To be clear, we are not asking if we can set it up so that LDAP
| | ==[[Ignacio Valdes Implementation Log/Episode66|Episode 66 Windows 7 TMG-CPRS formatted text printer truncation problem/solution.]]== |
| authentication of an operating system/network session can be extended
| | ==[[Ignacio Valdes Implementation Log/Episode67|Episode 67 Taskman Job Limit Exceeded.]]== |
| to have "loginless" access to VistA by passing along credentials; we
| | ==[[Ignacio Valdes Implementation Log/Episode68|Episode 68 Provider appear on Primary Provider Selection Box?]]== |
| are asking if the VistA system can be configured to check LDAP rather
| | ==[[Ignacio Valdes Implementation Log/Episode69|Episode 69 Aftercare Interdisciplinary note editing and signing?]]== |
| than its own user database when it receives the username and password
| | ==[[Ignacio Valdes Implementation Log/Episode70|Episode 70 Listing Installed KIDS builds or patches.]]== |
| as it normally does.
| | ==[[Ignacio Valdes Implementation Log/Episode71|Episode 71 Deleting the WorldVistA drug file.]]== |
| | | ==[[Ignacio Valdes Implementation Log/Episode72|Episode 72 Taskman Cleanup.]]== |
| As to whether it is a good idea: Having a single username and password
| | ==[[Ignacio Valdes Implementation Log/Episode73|Episode 73 More Taskman Cleanup.]]== |
| has nothing to do with the "walk-away problem" that is a problem in
| | ==[[Ignacio Valdes Implementation Log/Episode74|Episode 74 Medication Ordering Keys.]]== |
| any case. The issue is whether users have to remember two passwords or
| | ==[[Ignacio Valdes Implementation Log/Episode75|Episode 75 List of unsigned notes by provider.]]== |
| not. If they must remember two passwords, then they will start writing
| | ==[[Ignacio Valdes Implementation Log/Episode76|Episode 76 Set CPRS Timeout Value.]]== |
| them down. That is a serious breach. Further, having two places to
| | ==[[Ignacio Valdes Implementation Log/Episode77|Episode 77 Add/Change Patient Data Object.]]== |
| administer user accounts is an administration problem. It doubles all
| | ==[[Ignacio Valdes Implementation Log/Episode78|Episode 78 ePrescribing(eRX) Certification with NewCrop]]== |
| of the administration work and creates a serious risk that when an
| | ==[[Ignacio Valdes Implementation Log/Episode79|Episode 79 Report Creation for the CPRS Reports Tab]]== |
| employee leaves the clinic/hospital and the administrators only
| | ==[[Ignacio Valdes Implementation Log/Episode80|Episode 80 Purge or Clear Access Verify Code History]]== |
| remember to remove one of the two user accounts but not the other.
| |
| | |
| I make these points not in the hopes that I would convince you that
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| single sign-on is a good idea, but to point out that it is a debate,
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| and we are not foolish for wanting to have it.
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| | |
| For the time being, however, we would be happy to know if it were
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| possible at all.
| |
| --
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| Fred Trotter
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|
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| rga...@tampabay.rr.com
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| | |
| X.500 is not implemented in VistA, nor do I think it is possible without OS intervention.
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|
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|
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| Steven McPhelan
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| | |
| Of course network authentication is possible with the proper modifications
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| to VistA and the proper network authorization. When has there ever been a | |
| technical problem such as this where someone could not figure out a
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| solution. Heck who would have thought that CAV could have developed a
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| program that would convert the M based VistA system to a Java based SQL
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| compliant system (non-M)?
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| | |
| In my response, I am using the most common definition of single sign-on
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| which is a user signs in ONCE and then all single signon compliant
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| applications automatically let the user into the application which they
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| launch provided that the centralized roles and privileges authorizes that
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| user to run that application. That is what I do not agree with. For an
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| EMR, I want the user to "reauthenicate" for that application before letting
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| that user into that application.
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| | |
| The common definition for single sign-on was around before VistA pursued
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| single sign-on. That is why I prefer the term network authentication versus
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| single sign-on so that the hearer does not get any false assumptions about
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| what features would and would not be available.
| |
| | |
| --
| |
| Steve
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| It's so much easier to suggest solutions when you don't know too much about
| |
| the problem." -- Malcolm Forbes
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|
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| fred trotter
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| | |
| You are right... there do seem to be two ways to talk, and think about
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| this. I will try to be clearer...
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| | |
| --
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| Fred Trotter
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|
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| kdtop
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| | |
| Steven,
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| | |
| As a physician, I hate multiple sign-ons. I have never had a chance
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| to debate this issue with anyone, so I'd like to give you an
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| opportunity to convince me.
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| | |
| In our hospital, I have to sign in to the network, then sign into the
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| client that communicates with the computers. And to sign my charts, I
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| have to enter my password another 1-2 times. And each of these
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| passwords expires on a different schedule. So it is a never ending
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| round of confusion. And I see this as a substantial barrier to
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| acceptance and use.
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| | |
| When I see the computers up on the hospital ward, I see nurses called
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| away from their computers all the time. So the solution they have is
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| to make windows drop to a locked screen after inactivity for about 1-2
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| minutes. Then only that user or an administrator can unlock the
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| machine. This seems to solve the walk-away problem.
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| | |
| So once you can be sure that random people don't walk up and start
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| using the computer, then why is it important to have to sign in
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| twice? When entering a building, we usually have one locked door.
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| Not 2-3 locked doors in succession. Why doesn't this security model
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| work for the computer?
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| | |
| Kevin
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|
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| Greg Woodhouse
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| | |
| Good for you Kevin. This is a prime example of an area where debates over
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| usability and functionality are easily clouded by implementation concerns.
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| We should start out with the customer (in this case, the healthcare
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| provider) and the functionality that they want or need. In the case of
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| single-signon, it is possible that AFTER analysis, you may conclude that it
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| cannot be made secure (I am not convinced). But to dismiss it a priori is
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| like well, dismissing MUMPS (or maybe Scheme or ML!) as an implementation
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| language because we simply assume is not going to be a feasible choice.
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| | |
| I realize that this is a sensitive subject, so let me ask the developers and
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| analysts out there a couple of quick questions: Are you thoroughly
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| considering the requirements here and performing a full analysis, or are you
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| following accepted convention? Are you willing to try to be innovative? Have
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| you performed an analysis of physician workflow? We'd never think about
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| building a factory automation system without first trying to understand the
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| processes we are trying to automate, both through consulting with SMEs and
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| observing the process ourselves. To the physicans and other healthcare
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| professionals out there: Do the people you are working with understand your
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| work environment? Have you considered arranging a site visit? If this is not
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| possible (e.g., due to privacy concerns), what about a simulated environment
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| similar to (but expanding upon) VeHU's virtual hospital? Developers cannot
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| build systems that meet your needs unless they first understand them.
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|
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| Steven McPhelan
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| | |
| Kevin, those are valid questions. There is a difference between a small (or
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| single) doctor's office and a large multi-physician practice or a hospital.
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| For instance, what should be the behavior of a common terminal at a nurse's
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| station where there may be 5,10,20 people who use that terminal in a one
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| hour period. The item mentioned here was why could not LDAP authentication
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| be used. If network authentication is being used then the problem of
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| different passwords expiring at different times is not an issue. Network
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| authenticating applications would all validate against a single network
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| source. Since it is a single source, then the timing of the change of
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| password would be localized and controlled by that single system.
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| | |
| *There is not one solution that adequately covers every situation*. Take
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| that hospital nursing station, is it desirable to require each user to log
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| off the network on that terminal when they are done thus requiring the next
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| user to log onto the network? Think about how long it takes today from
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| username logon to a usable desktop. This is probably not the place to go
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| into this topic.
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| | |
| Until the technology is there for these common workstations to allow an
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| individuals to logon to their own partition in a matter of seconds, the way
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| to attempt to implement single signon will continue to be burdensome. For
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| example, it may be the hospital policy that these common workstations have a | |
| limited set of applications available to them so that individuals do not
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| have to log in and out of the network. If this was the case, then it might
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| be prudent to require those individual applications to "reauthenicate
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| sign-on". In other words, the app prompts for username and password and
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| authenticates against the network independent of the username that was used
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| to "Boot" the workstation to a desktop.
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| | |
| Remember the common understanding of single sign-on. Whoever is at that
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| terminal has all the credentials and privileges of whomever signed onto the
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| network. Obviously using locking screen savers in a private physicians
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| office may work but it would not work at the nurse's station.
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| | |
| --
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| Steve
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| It's so much easier to suggest solutions when you don't know too much about
| |
| the problem." -- Malcolm Forbes
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|
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| rga...
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| | |
| The user signs on to the computer (enter the first door), the user then is
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| going to document personal health information (enter the second door), the
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| user then is going to send a secure communication requiring the inclusion of
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| PPI (enter the third door). All doors can have the same codes, like a card
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| swiped or a retina scanned.
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| | |
| Let's say a user authenticates on to their PC, they need to use an EHR, but
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| the EHR needs to know who the user is, allowing the user to enter their name
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| is unacceptable because I can document your patients. There needs to be
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| some mechanism in place which identifies the user before they start to treat
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| the patient.
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| | |
| The signatures on notes, etc, is a safeguard to ensure the document is
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| reviewed before it becomes part of the official medical record.
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| | |
| Hey, it's a start...
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| | |
|
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| kdtop
| |
| | |
| Thanks all for the replies so far.
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| | |
| I think the real issue here is one of verify-ability. Right beside
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| the nurses computer station, with all it's passwords, is the paper
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| chart that has absolutely no passwords at all. And why is this OK?
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| Well, the staff will notice if a stranger comes in and starts looking
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| at the chart. So there is a bit of access control that might be lost
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| if the records are electronic and can be access from North Korea etc.
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| Next, every doctor has a unique handwriting. So 5 yrs from now I
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| would be able to say with confidence in a court of law that I wrote
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| this, or didn't write that. That's pretty much impossible with
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| ASCII. But outside of legal debate when people get to pointing
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| fingers at each other, all this security is not so important. We've
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| cared for many a sick patient with paper charts for more than a few
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| years now.
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| | |
| So here's a thought. Why not equip the terminals with webcams and
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| have them take quick pictures every 15 sec or so, and marry that image
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| with the text. Or perhaps combine it with some other technology like
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| keystroke patterns that some say are fairly unique among various
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| users. That way let the user sign the record however they want (using
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| the honor system, as they do in the paper chart), but still have the
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| ability to very the accuracy of the claimed name etc. I'm sure there
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| are good reasons why this wouldn't work. But I can dream.
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| | |
| On a slightly different point, let me just throw one other point out
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| here (wearing my physician hat now). I feel that software engineers
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| have a propensity to get carried away with projects. Or perhaps it is
| |
| the managers that hire them. Anyway, it seems that when a | |
| technological solution is provided, it tries to do too much. For
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| example, there is a push to replace paper prescriptions. Well it is
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| not good enough to allow typed prescriptions. No, while we're at it,
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| let's throw in checking for drug interactions. And let's check with
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| their insurance to see if the drug is covered. And lets have the
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| communication channel be bidirectional with the pharmacy. And let's
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| make the channels to be secure. And so on and so on. And suddenly we
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| have an amazingly complex technology that is difficult to implement,
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| is hard to master, may disrupt workflow, and is expensive. So
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| providers stay away in droves. When I implemented VistA for my 15-
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| provider group, I specifically planned for allowing physicians to | |
| continuing practicing exactly the way they always have. But also I
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| explained the tool and how it could benefit them. So used it, other's
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| stayed with a transcription module.
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| | |
| Anyway, thanks for the feedback on the need for multiple logins.
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| | |
| Kevin
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|
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| Joel
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| | |
| There are ways in which silent logins can be used within VistA. In
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| addition there were other attempts to provide this. A Kernel patch
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| was set for release to implement what we then called an enterprise
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| single sign-on (at least to VistA) a number of years ago. Just before
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| its release, we were told that OCIS would provide an enterprise single
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| sign-on and we should not release ours. They still haven't provided
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| it. That patch used the user's identity to Windows via an
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| authentication server known to the VistA system and that contacted the
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| VistA system to authenticate the user and match the identity with the
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| entry in the NEW PERSON file.
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| | |
| Auto Sign-On requires the user sign into VistA, but subsequent
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| applications connecting are signed on as the current user
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| automatically. Sites that want to can turn on the Auto Sign-On and
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| must have the client agent (clagent.exe) active on the workstations
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| (although it should not be used on clients connected to terminal
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| servers). Some sites use this heavily, while others seem to give it
| |
| only to the IT staff. This can be turned on using the DEFAULT AUTO
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| SIGN-ON field (#218) in the KERNEL SYSTEM PARAMETERS file (#8989.3).
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| The possible values are 0=NO, 1=YES, and d=DISABLED. If YES is
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| selected, auto sign-on is turned on for all users. If DISABLED is
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| selected, auto sign-on is turned off for all users. If NO is
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| selected, the use of auto sign-on is regulated by the AUTO SIGN-ON
| |
| field (#200.18) in the NEW PERSON file (#200), where the options are
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| YES and NO.
| |
| | |
| While requiring an investment in Infrastructure, but the use of CCOW
| |
| User Context provides for GUI applications, when compiled with one of
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| more recent versions of the RPCBroker to use the user's identification
| |
| in the CCOW Vault to authenticate the user on second and subsequent
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| connections to a VistA server. It should be noted that CPRS added
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| command line arguments which would permit this functionality to be
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| turned off in locations, such as busy clinics, where multiple
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| individuals might use the same workstation, since an individual might
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| be identified as the user currently authenticated to the VistA server.
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| | |
| Groups within the VA are also evaluating other mechanisms for
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| authentication and authorization for the future as well.
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|
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| Roy Gaber
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| It is not so much the developers (I may have a bias seeing how I am one) but
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| the steering committees, or SME's that dictate the policy, it is the
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| developers job to turn those directives into code.
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| | |
| The bottom line is, the physician is responsible for the care and associated
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| documentation of the patient, it is my belief that they can approach the
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| issues surrounding HIPPA in whatever way they see fit.
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