Child fatality review: recommendations for state coordination and cooperation

Preventable childhood injuries and deaths are a major public health problem in the United States. In 2000, the most recent year for which mortality data are available, over 10,000 children from birth to age 18 died from unintentional injuries in the United States and nearly 3,000 from the same age group died from homicide or suicide. According to theChildhood Injury Fact Sheetproduced by the Centers for Disease Control and Prevention (CDC), “unintentional injuries are the leading cause of death for children one to 21 years of age.”

Preventing child fatalities requires further understanding of the causes and circumstances surrounding child deaths. One mechanism for doing this is multidisciplinary child fatality review teams. These teams exist at the state and local level and perform the functions of identifying, reviewing, and recommending preventive measures to reduce the number of preventable child deaths and life-threatening injuries.

Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians.

Imaging databases and neuroscience

Brain atlases are equivalent to neuroimage databases provided an appropriate coordinate system to enable multisubject comparisons, along with comprehensive descriptions of the data, are included. Warping tools, visualization, and statistical analyses that accommodate the various neuroimaging modalities can be used to integrate diverse data and form comprehensive maps describing a particular subpopulation's brain structure and function. By linking task performance and genetic information to brain morphology, complex interrelations between genotype, phenotype, and behavior can be established. Several examples of these multimodal, multisubject atlases, including those that are dynamic, are presented.

Data registers in respiratory medicine: a pilot project evaluating compliance with privacy laws and the National Statement on Ethical Conduct in Research Involving Humans

This article reports on data from a small pilot survey evaluating the compliance of voluntary databases in respiratory medicine with privacy laws and the National Health and Medical Research Council's National Statement on Ethical Conduct in Research Involving Humans. The increasing complexity of privacy law, including the recent private sector amendments, creates many challenges for database administrators. The impact of privacy laws upon voluntary or non-statutory databases, and upon doctors reporting patient data to such databases, is far from straightforward. The article suggests way in which the law might be adapted in order to better facilitate the role of voluntary data registers in health research and public health surveillance, while still protecting the privacy of patient information. The article also briefly considers how database administrators might "future-proof" their existing data holdings to ensure compliance with legal and ethical standards.

Government registries containing sensitive health data and the implementation of EU directive on the protection of personal data in Finland

Legislation on the protection of personal data was first enacted in Finland in 1987 (Act 471/1987) and revised in 1999 (Act 523/1999). The Personal Registries Act of 1987 established a special authority, the "data protection ombudsman" to ensure that a citizen's right to privacy would be maintained despite increased usage of computerised registries containing sensitive data. Health care and medical research, however, have been largely outside the scope of effective scrutiny due to special legislation that gives health care authorities the right to gather and register information on the medical history of an individual citizen. In Finland, the National Research and Development Centre for Welfare and Health (STAKES)--which works in close co-operation with the Ministry of Social Affairs and Health--maintains or supervises several centralised registries containing sensitive data. These registries which are based on an exemption (Act 556/1989) from the general data protection legislation, contain in practice a complete database on all Finnish citizens that have used public health care services. Furthrmore, additional personal information is added into these databases. For example, the central registry on abortions contains not only the identification data of a subject who has had an abortion but also information on the reason for abortion and on the methods of contraception she used. It is noteworthy that these registers are not accessible to the physicians who treat the patient whose data is registered, but are used by the governmental authorities only. At the moment it is unclear whether the recent implementation of an EU directive into the Finnish legislation and the constitutional right to privacy in the revised Finnish constitution (effective from March 1, 2000 onwards) will have any impact on the content or usage of these centralised registers.

Draft secure medical database standard

Medical database security is a particularly important issue for all Healthcare establishments. Medical information systems are intended to support a wide range of pertinent health issues today, for example: assure the quality of care, support effective management of the health services institutions, monitor and contain the cost of care, implement technology into care without violating social values, ensure the equity and availability of care, preserve humanity despite the proliferation of technology etc.. In this context, medical database security aims primarily to support: high availability, accuracy and consistency of the stored data, the medical professional secrecy and confidentiality, and the protection of the privacy of the patient. These properties, though of technical nature, basically require that the system is actually helpful for medical care and not harmful to patients. These later properties require in turn not only that fundamental ethical principles are not violated by employing database systems, but instead, are effectively enforced by technical means. This document reviews the existing and emerging work on the security of medical database systems. It presents in detail the related problems and requirements related to medical database security. It addresses the problems of medical database security policies, secure design methodologies and implementation techniques. It also describes the current legal framework and regulatory requirements for medical database security. The issue of medical database security guidelines is also examined in detailed. The current national and international efforts in the area are studied. It also gives an overview of the research work in the area. The document also presents in detail the most complete to our knowledge set of security guidelines for the development and operation of medical database systems.

Pharmacoepidemiology--an Irish perspective

The Irish healthcare system is a mixture of free, state-supported and private medicine. The state-supported General Medical Services (GMS) scheme maintains a large prescription database, which has been used to conduct pharmacoepidemiological studies in Ireland. The dataset is anonymized thus maintaining patient and prescriber confidentiality. Three recent studies using this data are described, two of which outline the effect of regulatory advice and the media on prescribing patterns and one which describes the development of an index of prescribing quality which may be applied to prescription data. The GMS prescription database is presently being complemented by a database for some 0.7 million people who seek reimbursement for prescriptions from individuals or families in excess of 42 Pounds per month which together will have an important role for the continued development of pharmacoepidemiology in Ireland.

Conducting pharmacoepidemiologic research in Denmark

Denmark has one of the worlds most comprehensive registration of its citizens' use of medical and social services. Most databases are population-based and of very high quality. Virtually all employ a mutual person identifier, which renders it technically possible to link any of them with others. There are two prescription registries of interest for research, the OPED and the NJPD, each covering 0.5 million persons. The content of these are described in brief. The most recent Danish data protection act can be viewed as a liberalization of prevailing registry practice. Our most important obstacles for performing record-linkage studies are costs, academic resources and a lack of generally accepted guidelines on the ethics of observational research.

Intellectual property. Europe's database experiment

Database protection laws in Europe may have produced a modest, one-time growth spurt for commercial providers. Unfortunately, Europe's new database laws have also produced significant problems including overprotection of low-value data (e.g., telephone books), new barriers to database integration, and further erosion of the public domain. The authors of this Policy Forum caution that these problems could cripple commercial and academic science.

Anticircumvention rules: threat to science

Scientists who study encryption or computer security or otherwise reverse engineer technical measures, who make tools enabling them to do this work, and who report the results of their research face new risks of legal liability because of recently adopted rules prohibiting the circumvention of technical measures and manufacture or distribution of circumvention tools. Because all data in digital form can be technically protected, the impact of these rules goes far beyond encryption and computer security research. The scientific community must recognize the harms these rules pose and provide guidance about how to improve the anticircumvention rules.

Medical privacy and research

Medical records are increasingly kept in electronic form. The existence of large medical databases raises new questions about privacy and control over that information. When records exist in a form that can easily be shared with others, there are legitimate privacy concerns. This paper argues that this fear is not properly a privacy issue, but rather concerns the viability of social norms that govern the doctor-patient relationship and the use of medical information that is obtained within that relationship. When medical information is used for research purposes, the information is transformed into data elements and is no longer about the individuals. Information obtained either in the ordinary course of providing medical care or in the course of conducting research studies for which individuals have given their informed consent does not require further consent to be used as data in research files as long as it is not individually identifiable.

Criminal DNA databases: the European situation

In the last 5 years, a number of European countries have successfully introduced national databases holding the DNA profiles from suspected and convicted criminal offenders as well as from biological stain materials from unsolved crime cases. At present, DNA databases are fully or partially in operation in the UK, The Netherlands, Austria, Germany, Finland, Norway, Denmark, Switzerland and Sweden. Furthermore, in the other European countries, specific legislation will be enacted soon, or the introduction of such databases is being discussed to initiate a legislative process. Numerous differences exist regarding the criteria for a criminal offender to be included in the database, the storage periods and the possibility to remove database records, the possibility to keep reference samples from the offenders as long as their respective records are being held, and the role of judges in the process of entering a database record or to perform a database search. Nevertheless, harmonization has been achieved regarding the DNA information stored in national databases, and a European standard set of genetic systems has been recommended which is included either in part or completely in the DNA profiles of offenders and crime stains for all European databases. This facilitates the exchange of information from database records to allow the investigation of crime cases across national borders.

A brief history of the formation of DNA databases in forensic science within Europe

The introduction of DNA analysis to forensic science brought with it a number of choices for analysis, not all of which were compatible. As laboratories throughout Europe were eager to use the new technology different systems became routine in different laboratories and consequently, there was no basis for the exchange of results. A period of co-operation then started in which a nucleus of forensic scientists agreed on an uniform system. This collaboration spread to incorporate most of the established forensic science laboratories in Europe and continued through two major changes in the technology. At each step agreement was reached on which systems to use. From the beginning it was realised that DNA databases would provide the criminal justice systems with an efficient way of crime solving and consequently some local databases were created. It was not until the introduction of the amplification technology linked to the analysis of short tandem repeats that a sufficiently sensitive and robust system was available for the formation of efficient and effective DNA databases. Comprehensive legislation enacted in the UK in 1995 enabled forensic scientists to set up the first national DNA database which would hold both personal DNA profiles together with results obtained from crime scenes. Other countries quickly followed but in some the legislation has severely restricted the amount and type of data which can be retained and, therefore, effectiveness of the databases is limited. The widespread use of commercially produced multiplex kits has produced a situation in which nearly all European laboratories are using compatible systems and there is, therefore, the potential for the introduction of a pan-European DNA database. However, the exchange of results between countries is hampered by the various legislations which currently exist.

The Icelandic genome debate

Three of the central issues in contemporary debates about the commodification of the human body are those of property, ownership, and access. This article uses the case of the central medical database on Icelanders to discuss contesting claims about the ownership of the human genome, with respect to the rapid development of biotechnology, human genome projects and DNA collections. We emphasize the contrast between commercial and communitarian perspectives and to illustrate our argument we explore debates about the Icelandic database. These debates have been intense, focusing on a range of issues, including ethics, academic freedom, public health and, last but not least, the control and ownership of medical records, genetic information and genealogical data. This article should be seen primarily as an anthropological commentary on ongoing developments.