phi_attrs

HIPAA compliant PHI access logging for Ruby on Rails.

According to HIPAA Security Rule § 164.312(b), HIPAA covered entities are required to:

Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.

The phi_attrs gem is intended to assist with implementing logging to comply with the access log requirements of § 164.308(a)(1)(ii)(D):

Information system activity review (Required). Implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports.

To do so, phi_attrs extends ActiveRecord models by adding automated logging and explicit access control methods. The access control mechanism creates a separate phi_access_log.

Please Note: while phi_attrs helps facilitate access logging, it still requires due diligence by developers, both in ensuring that models and attributes which store PHI are flagged with phi_model and that calls to allow_phi! properly attribute both a unique identifier and an explicit reason for PHI access.

Please Note: there are other aspects of building a HIPAA secure application which are not addressed by phi_attrs, and as such use of phi_attrs on its own does not ensure HIPAA Compliance. For further reading on how to ensure your application meets the HIPAA security standards, review the HHS Security Series Technical Safeguards and Summary of the HIPAA Security Rule, in addition to consulting your compliance and legal counsel.

Stability

All versions of this project below 1.0.0 should be considered unstable beta software. Even minor-version updates may introduce breaking changes to the public API at this stage. We strongly suggest that you lock the installed version in your Gemfile to avoid unintended breaking updates.

Installation

Add this line to your application's Gemfile:

gem 'phi_attrs'

And then execute:

$ bundle

Or install it yourself as:

$ gem install phi_attrs

Initialize

Create an initializer to configure the PHI log file location. Log rotation can be configured with log_shift_age and log_shift_size (disabled by default).

Example:

config/initializers/phi_attrs.rb

PhiAttrs.configure do |conf|
  conf.log_path = Rails.root.join("log", "phi_access_#{Rails.env}.log")
  conf.log_shift_age  = 10            # how many logs to keep of `log_shift_size` or frequency to rotate ('daily', 'weekly' or 'monthly'). Disable rotation with 0 (default).
  conf.log_shift_size = 100.megabytes # size in bytes when using `log_shift_age` as a number
end

Usage

class PatientInfo < ActiveRecord::Base
  phi_model

  exclude_from_phi :last_name
  include_in_phi :birthday

  def birthday
    Time.current
  end
end

Access is granted on a instance level:

info = PatientInfo.new
info.allow_phi!("[email protected]", "Customer Service")

When using on an instance if you find it in a second place you will need to call allow_phi! again.

or a class:

PatientInfo.allow_phi!("[email protected]", "Customer Service")

As of version 0.1.5, a block syntax is available. As above, this is available on both class and instance levels.

Note the lack of a ! at the end. These methods should not be used alongside the mutating (bang) methods! We recommend using the block syntax for tighter control.

patient = PatientInfo.find(params[:id])
patient.allow_phi('[email protected]', 'Display Customer Data') do
  @data = patient.to_json
end # Access no longer allowed beyond this point

or a block on a class:

PatientInfo.allow_phi('[email protected]', 'Display Customer Data') do
  @data = PatientInfo.find(params[:id]).to_json
end # Access no longer allowed beyond this point

Controlling What Is PHI

When you include phi_model on your active record all fields except the id will be considered PHI.

To remove fields from PHI tracking use exclude_from_phi:

# created_at and updated_at will be accessible as normal
class PatientInfo < ActiveRecord::Base
  phi_model

  exclude_from_phi :created_at, :updated_at
end

To add a method as PHI use include_in_phi. Include takes precedence over exclude so a method that appears in both will be considered PHI.

# birthday and node will throw PHIExceptions if accessed without permission
class PatientInfo < ActiveRecord::Base
  phi_model

  include_in_phi :birthday, :note

  def birthday
    Time.current
  end

  attr_accessor :note
end

Example Usage

Example of exclude_from_phi and include_in_phi with inheritance.

class PatientInfo < ActiveRecord::Base
  phi_model
end

pi = PatientInfo.new(first_name: "Ash", last_name: "Ketchum")
pi.created_at
# PHIAccessException!
pi.last_name
# PHIAccessException!
pi.allow_phi "Ash", "Testing PHI Attrs" { pi.last_name }
# "Ketchum"

class PatientInfoTwo < PatientInfo
  exclude_from_phi :created_at
end

pi = PatientInfoTwo.new(first_name: "Ash", last_name: "Ketchum")
pi.created_at
# current time
pi.last_name
# PHIAccessException!
pi.allow_phi "Ash", "Testing PHI Attrs" { pi.last_name }
# "Ketchum"

class PatientInfoThree < PatientInfoTwo
  include_in_phi :created_at # Changed our mind
end

pi = PatientInfoThree.new(first_name: "Ash", last_name: "Ketchum")
pi.created_at
# PHIAccessException!
pi.last_name
# PHIAccessException!
pi.allow_phi "Ash", "Testing PHI Attrs" { pi.last_name }
# "Ketchum"

Extending PHI Access

Sometimes you'll have a single mental model that is composed of several ActiveRecord models joined by association. In this case, instead of calling allow_phi! on all joined models, we expose a shorthand of extending PHI access to related models.

class PatientInfo < ActiveRecord::Base
  phi_model
end

class Patient < ActiveRecord::Base
  has_one :patient_info

  phi_model

  extend_phi_access :patient_info
end

patient = Patient.new
patient.allow_phi!('[email protected]', 'reason')
patient.patient_info.first_name

NOTE: This is not intended to be used on all relationships! Only those where you intend to grant implicit access based on access to another model. In this use case, we assume that allowed access to Patient implies allowed access to PatientInfo, and therefore does not require an additional allow_phi! check. There are no guaranteed safeguards against circular extend_phi_access calls!

Check If PHI Access Is Allowed

To check if PHI is allowed for a particular instance of a class call phi_allowed?.

patient = Patient.new
patient.phi_allowed? # => false

patient.allow_phi('[email protected]', 'reason') do
  patient.phi_allowed? # => true
end

patient.phi_allowed? # => false

patient.allow_phi!('[email protected]', 'reason')
patient.phi_allowed? # => true

This also works if access was granted at the class level:

patient = Patient.new
patient.phi_allowed? # => false
Patient.allow_phi!('[email protected]', 'reason')
patient.phi_allowed? # => true

There is also a phi_allowed? check available to see at the class level.

Patient.phi_allowed? # => false
Patient.allow_phi!('[email protected]', 'reason')
Patient.phi_allowed? # => true

Note that any instance level access grants will not change class level access:

patient = Patient.new

patient.phi_allowed? # => false
Patient.phi_allowed? # => false

patient.allow_phi!('[email protected]', 'reason')

patient.phi_allowed? # => true
Patient.phi_allowed? # => false

Revoking PHI Access

You can remove access to PHI with disallow_phi!. Each disallow_phi! call removes all access granted by allow_phi! at that level (class or instance).

At a class level:

Patient.disallow_phi!

Or at a instance level:

patient.disallow_phi!

• If access is granted at both class and instance level you will need to call disallow_phi! twice, once for the instance and once for the class.

There is also a block syntax of disallow_phi for temporary suppression phi access to the class or instance level

patient = PatientInfo.find(params[:id])
patient.allow_phi!('[email protected]', 'Display Patient Data')
patient.disallow_phi do
  @data = patient.to_json # PHIAccessException
end # Access is allowed again beyond this point

or a block level on a class:

PatientInfo.allow_phi!('[email protected]', 'Display Patient Data')
PatientInfo.disallow_phi do
  @data = PatientInfo.find(params[:id]).to_json # PHIAccessException
end # Access is allowed again beyond this point

• Reminder instance level phi_allow will take precedent over a class level disallow_phi

Manual PHI Access Logging

If you aren't using phi_record you can still use phi_attrs to manually log phi access in your application. Where ever you are granting PHI access call:

user = '[email protected]'
message = 'accessed list of all patients'
PhiAttrs.log_phi_access(user, message)

Reason Translations

It can get cumbersome to pass around PHI Access reasons. PHI Attrs allows you to use your translations file to keep your code dry. If your translation file contains a reason for the combination of controller, action, and model you can skip passing reason:

module Admin
  class PatientDashboardController < ApplicationController
    def expelliarmus
      patient_info.allow_phi(current_user) do
        # reason tries to use `phi.admin.patient_dashbaord.expelliarmus.patient_info`
      end
    end

    def leviosa
      patient_info.allow_phi(current_user) do
        # reason tries to use `phi.admin.patient_dashbaord.leviosa.patient_info`
      end
    end
  end
end

The following en.yml file would work:

en:
  phi:
    admin:
      patient_dashboard:
        expelliarmus:
          patient_info: "Patient Disarmed"
        leviosa:
          patient_info: "Patient Levitated"

If you have a typo in your en.yml file or you choose not to provide a translation for your phi reasons your code will fail with an ArgumentError. To assist you in debugging PHI Attrs will print a :warn message with the expected location for the missing translation.

If you would like to change from phi to a custom location you can set the path in your initializer.

PhiAttrs.configure do |conf|
  conf.translation_prefix = 'custom_prefix'
end

Default User

Passing around the current user can clutter your code. PHI Attrs allows you to configure a controller method that will be called to get the currently logged in user:

config/initializers/phi_attrs.rb

PhiAttrs.configure do |conf|
  conf.current_user_method = :user_email
end

app/controllers/home_controller.rb

class ApplicationController < ActionController::Base
  private

  def user_email
    current_user&.email
  end
end

With the above code, any call to allow_phi (that starts in a controller derived from ApplicationController) will use the result of user_email as the user argument of allow_phi.

Note that if you have a default user, but choose not to use translations for reasons you'll have to pass nil as the user:

person_phi.allow_phi(nil, "Because I felt like looking at PHI") do
  # Allows PHI
end

Request UUID

It can be helpful to include the Rails request UUID to match up your general application logs to your PHI access logs. The following snippet will prepend your PHI access logs with the request UUID.

app/controllers/application_controller.rb

around_action :tag_phi_log_with_request_id

...

private

def tag_phi_log_with_request_id
  PhiAttrs::Logger.logger.tagged("Request ID: #{request.uuid}") do
    yield
  end
end

Best Practices

• Mix and matching instance, class and block syntaxes for allowing/denying PHI is not recommended.
  • Sticking with one style in your application will make it easier to understand what access is granted and where.

Development

It is recommended to use the provided docker-compose environment for development to help ensure dependency consistency and code isolation from other projects you may be working on.

Begin

$ docker-compose up
$ bin/ssh_to_container

Tests

Tests are written using RSpec and are setup to use Appraisal to run tests over multiple rails versions.

$ bin/run_tests
or for individual tests:
$ bin/ssh_to_container
$ bundle exec appraisal rspec spec/path/to/spec.rb

To run just a particular rails version: $ bundle exec appraisal rails_6.1 rspec $ bundle exec appraisal rails-7.0 rspec

Console

An interactive prompt that will allow you to experiment with the gem.

$ bin/ssh_to_container
$ bin/console

Local Install

Run bin/setup to install dependencies. Then, run bundle exec appraisal rspec to run the tests. You can also run bin/console for an interactive prompt that will allow you to experiment.

To install this gem onto your local machine, run bundle exec rake install.

Versioning

To release a new version, update the version number in version.rb, and then run bundle exec rake release, which will create a git tag for the version, push git commits and tags, and push the .gem file to rubygems.org.

Contributing

Bug reports and pull requests are welcome on GitHub at https://github.com/apsislabs/phi_attrs.

Any PRs should be accompanied with documentation in README.md, and changes documented in CHANGELOG.md.

License

The gem is available as open source under the terms of the MIT License.

Legal Disclaimer

Apsis Labs, LLP is not a law firm and does not provide legal advice. The information in this repo and software does not constitute legal advice, nor does usage of this software create an attorney-client relationship.

Apsis Labs, LLP is not a HIPAA covered entity, and usage of this software does not create a business associate relationship, nor does it enact a business associate agreement.

Full Disclaimer

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Built by Apsis

phi_attrs was built by Apsis Labs. We love sharing what we build! Check out our other libraries on Github, and if you like our work you can hire us to build your vision.