Private medical records offered for sale

Private medical records have been offered for sale in the U.K.

And quite cheaply, too...

e-Health Insider (Europe)
Private Medical Records Offered for Sale
Oct. 20, 2009

Medical records of patients treated at a private British hospital, The London Clinic, have been illegally sold to undercover investigators.

The revelations were made in ITV’s Tonight Programme report, Health Records For Sale, broadcast last night.

The programme reported that hundreds of files containing details of patients’ conditions, home addresses and dates of birth were offered to undercover reporters for just £4 each by sales executives from India, contacted online.

That's about $6.56 U.S. each. A genuine bargain for those intrepid medical identity thieves, and pesky government death panels ...

The records offered for sale appear to have been medical records that consultants working at the London Clinic, the hospital processes its own records internally, who contracted with a firm called DGL (DGL) Information Technologies UK to digitise their records.

DGL is then claimed to have sub-contracted to another firm, Scanning and Data Solutions (SDS), which scanned them into computers in the UK. SDS in turn is said to have sub-contracted further work on the files to a company in Pune, India, which had signed tight confidentiality agreements.

With all this contracting and subcontracting - four layers? - adding potential security breach possibilities, and if this is not an uncommon practice, perhaps paper is safer than electronic health records?

... The reporters bought more than 100 records belonging to UK patients but were told they could obtain up to 30,000 more on demand. Confidential records were offered by condition such as particular cancers.

Of 116 files bought by ITV, 100 of which were confirmed as genuine, were for patients who had been treated in private hospitals. Although not NHS records they did contain some NHS data, including referral letters from GPs.

The potential abuses resulting from such sales are of great concern. If it happened in the UK, it can happen in the U.S.

One patient whose record was affected by the security breach said in the documentary that the data breach was ‘one step up from grave-robbing’.

I agree with that assessment.

These practices call for the most severe penalties, and if the authorities lack the will, confidence in EMR privacy, confidentiality and security will suffer, along with the physician-patient relationship.

The old ST:TOS line "Sometimes a man will tell his bartender things he'll never tell his doctor" could become too applicable for comfort.

Sometimes a man will tell his bartender things he'll never tell his doctor ... especially if they suspect their data is for sale to the Talosians, Captain ...

-- SS

From Down Under: The Story of the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck?

I'd opine that bad luck had little to do with it.

A paper by an Australian professor of informatics about travails with a new ED EHR, manufactured by a large American HIT vendor, appeared recently (it is currently unavailable.) I remind that the issues affect a most critical area, the ED's in over 200 hospitals in Australia's most populous state, New South Wales (NSW). The paper is here.

[10/24 note: not available at present at this link or from its author in Australia; I pulled it from the Drexel U. server in the U.S. at the author's request while his right to post it on his department's server in Australia is being discussed Down Under - ed.]

[Jan. 2010 followup: an attempted censorship situation was resolved. See this update. Current paper in ver. 6 is here - PDF.]

Highlights:

... One criticism of [new ED EHR] is that the clinical documentation is built on the American model which doesn't fit the Australian workflow. In the same vein another commentator said it was a "system designed by administrators for administrators with no understanding whatsoever of clinical workflow and need".

... At the operational level in EDs staff dislike the software for various reasons such as: too many keystrokes to load data, hence, too complicated search pathways to find data, plus they are unable to get extraction of reports.

Their dislike has reached very intense levels with many staff dismissive of its usefulness. In more than one hospital the system was credited with causing a 50% decrease in the number of patients seen by a doctor in the first 20 minutes of arrival at the ED. In at least one hospital the direct data entry of clinical notes as done with [old ED EHR] [an earlier system - ed.] has been abandoned and transferred to paper as the [new ED EHR] process was seen as too cumbersome and time costly.

... Other comments about [new ED EHR] were: "I prefer looking at a paper result than the counter-intuitive waste of my time trolling through the system.

... I keep forgetting how the damn thing is supposed to work and find it more a time waster than a help."

... Similarly, "every single user *hates* it with a passion ... ENTERING the data is a pure nightmare"

And another:

... "it is exclusively used by the nurses and entirely ignored by the doctors"

And another:

... "Clumsy, complicated (not complex), user hostile, and above all slow at any task I tried".

... “We stated the system was dangerous (multiple reasons) and that we would not use it in its current state. We also got agreement that the nurse practitioner not use it for clinical details."

... “We in X and Y had a major confrontation with the NSW ‘gurus’ and refused to use it in ED in its current state. A clinician produced a well researched document to support our claims of its cumbersome stupidity. “People present (at the meeting) were local vmos, nurse practitioner who works in ED and the local ceo etc, plus reps from [new ED EHR vendor] , NSW health etc. One clinician was present by videoconference. Nurses presented a long document detailing multiple concerns.

“The meeting was quite emotional and heated as they tried over and over again to pull the wool over our eyes. For example, they started out offering “more support”. One clinician replied that this was like giving us a defective car then sending out someone to show us how to drive it.

I asked was the support available at 3 A.M.? Blank faces.

They dissimulated info that “other doctors” in small country hospitals were trialing the system and had “no problems”. When asked which hospitals and which doctors again blank faces. They finally came up with a name who one of our partners rang that night and found him to be furious his name was used and that they were about to dump the system too...

The conclusion probably sounds familiar to HC Renewal readers:

... I wish to make a salient point about the nature of the delivered software with respect to the whole process of change management in the introduction of new IT infrastructure. In these situations there is always a great deal of noise and attention given to the processes of systems review, workflow redesign, and staff training.

In many ways this is paying attention to the smoke rather than the fire. The actual design and operation of the software is fundamental to the successful introduction of information technology. It is a necessary condition that the software works in a fashion that optimally fits the activities and workflow of the recipient organisation, and this fit is the single largest determinant of a successful system wide implementation. Like any foundation if it is not properly designed and constructed the edifice above it will collapse no matter what amount of attention and details you put into it. The delivered software is the foundation of any clinical information system. It would seem that in this case this understanding has not been grasped by authorities in NSW.

... Without optimal design and implementation there will be no cost efficiencies and productivity gains delivered by IT, but rather, it will contribute to the spiralling expense. We can only hope that Government will understand that a modest investment in R&D for clinical information systems is needed to create the desired improvements in productivity, cost reduction and patient safety.

I believe our own government here could learn from this.

Read the whole thing, including the series of ethical issues the author raises. I believe the lessons apply not just to the one vendor mentioned, but to most HIT vendors, especially the large ones.

Also note the observations from another Australian, Dr David G More MB, PhD, FACHI in an essay entitled "The Blight on the Landscape Health IT Awards" at this link.

-- SS

News Flash: 1945 Law Allows Concentration of Power in US Health Insurance

Last week, some media reports noted that US Congressional Democrats countered an insurance industry study suggesting health care reform would cost much more than estimated by threatening a repeal of the McCarran-Ferguson Act's anti-trust exemption for health insurance. For example, in the New York Times Prescriptions Blog:

In a rare appearance as a witness at a Senate hearing, the majority leader, Harry Reid of Nevada, told the Judiciary Committee on Wednesday that it should repeal a 1945 law that granted the insurance industry limited exemption to national antitrust laws by allowing states to regulate insurers.

The law, the McCarran-Ferguson Act, is often cited by Mr. Reid and other critics of the health insurance industry as a reason why coverage can be so expensive for many people. They say the law allows insurers to monopolize markets and fix prices in ways that are usually illegal.

'Since 1945, the insurance industry has enjoyed exemption from federal antitrust laws because of the McCarran-Ferguson Act,' Mr. Reid said.

'Providing an exemption for insurance companies to antitrust laws has been anticompetitive and damaging to the American economy,' Mr. Reid continued. 'Health insurance premiums have continued to rise at a rapid rate, forcing businesses to cut back on health insurance coverage and forcing many families to choose between health insurance and basic necessities.'

He added: 'Insurance companies have become so large they dominate entire regions of the country. They have become so powerful they block start-up businesses from entering the market, and they put smaller companies out of business. They have become so dominant that they dictate business practices. They are so influential that they exert tremendous influence over public policy.'

Also, the chief anti-trust enforcement officer in Obama administration weighed in with similar sentiments, as reported by Bloomberg News via the Philadelphia Inquirer:

Christine Varney, the Obama administration's chief antitrust enforcer, told lawmakers yesterday that repealing the insurance industry's antitrust exemption would spur competition and further the drive to control the cost of health insurance.

Varney, head of the Justice Department's antitrust division, told the Senate Judiciary Committee that ending the exemption would 'allow competition to have a greater role in reforming health and medical malpractice insurance markets.'

So why would this discussion be relevant to Health Care Renewal? First of all, the exemption of insurance companies from anti-trust laws (US laws designed to prevent monopolies and other anti-competitive business practices) may have allowed these companies to grow into business behemoths, and for individual companies to dominate local insurance markets. In some locales, businesses and individuals have very few health insurance policies available because only a few companies dominate the market. In fact, every recent year, the US American Medical Association (AMA) has put out a report on insurance market consolidation decrying concentration among power in local markets among few companies.

For example, the AMA news release for the 2009 report said:

The vast majority of health insurance markets in the U.S. are dominated by one or two health insurers, according to a new study by the American Medical Association (AMA) that examined insurer competition in markets across the country. Most alarmingly, in nearly all 314 metropolitan areas studied, there is evidence that patients and physicians have fewer options and are left vulnerable to the demands of the health insurer.

So this does seem to be a case of concentration, if not necessarily abuse of power in health care.

Why this is real news however, is that the 1945 McCarran-Ferguson Act, its baleful influence, and calls for its repeal are not old news. In fact, up to now, they have not been news, or part of health care policy discussions at all.

My first response to the news articles above was "the McCarran what act?" I had never heard of this 64 year old law, and never heard it cited as an enabler of concentration of power in health insurance, and never heard a call for its repeal.

Maybe that means I am no expert in this field. But, the first 10 pages of a Google Scholar search for the terms "McCarran Ferguson health insurance exemption" revealed precisely one article in the health care / services/ policy research literature that discussed this act (from 1998, in Health Affairs,(1) and without clearly relating the act to concentration of power in health insurance.) Similarly, a PubMed search, using the term "McCarran-Ferguson Act" produced nine articles, none in mainstream health care/ services/ policy research journals, much less general medical journals (three were in the Am J Law Med, 2 in AIDS Policy Law, one in Benefits Q, one in J Am Osteopath Assoc, one in J Pediatr Health Care, one in Am J Hosp Pharm, the most recent published in 2004, all the others in 1999 or earlier. There was nothing except the article above in Health Affars, nothing in Medical Care, nothing in Health Services Research, and nothing in any of the big general medical journals.)

Therefore, maybe the 1945 McCarran-Ferguson Act was a major cause of consolidation in the health insurance market, and this consolidation may be an important contributor to high health care costs and poor health care access. But this notion apparently has not appeared in any major medical or health care/ services/ policy research journal in the last 20 years.

If the McCarran-Ferguson Act has been around for 64 years, and is a major cause of rising health care costs and declining health care access, why has no one bothered to discuss it where any physician or health care/ policy researcher might see it?

It seems that the failure to bring the McCarran-Ferguson Act into polite conversation is another example of the anechoic effect. We have noted again and again that for physicians or health care professionals to discuss certain aspects of our dysfunctional health care system, often aspects that relate high costs, declining access, and poor costs to concentration and abuse of power, is "just not done." So it seems like discussing how a federal law from another era barred government action to prevent concentration of power in the health care industry, concentration of power that made some people very rich, was "just not done."

Of course, if there was any discussion of this law and its effects, maybe someone would have called for its repeal before 2009.

Dr Aubrey Blumsohn provided a reminder from the UK to us in the US: ""the desire to maintain decorum and status in medicine seems also to overwhelm all standards of decency. Our profession is inclined to fixate on the irrelevant while ignoring some very bad things."

If we really want to improve health care here in the US, and around the world, a modest beginning would be to begin open discussion of the various skeletons rattling around in the health care closet.

Reference

1. Nichols LM, Blumberg LJ. A different kind of ‘New Federalism’? the Health Insurance Portability And Accountability Act of 1996. Health Aff 1998; 17 (3): 25. [Link here.]

HHS to promote low-cost electronic health record software packages including the VA's VistA

If I were a proprietary health IT vendor, the following bolded passage in the new Healthcare Bill (PDF here) would make me a bit nervous:

SEC. 1102. ENCOURAGING MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS.

(a) STUDY.—The Secretary of Health and Human Services shall conduct a study of methods that can be employed by qualified health benefits plans offered through an exchange to encourage increased meaningful use of electronic health records by health care providers, including—

(1) payment systems established by qualified health benefit plans that provide higher rates of reimbursement for health care providers that engage in meaningful use of electronic health records; and
(2) promotion of low-cost electronic health record software packages that are available for use by health care providers, including software packages that are available to health care providers through the Veterans Administration.

The VA system, VistA/CPRS ("computerized patient record system"), was developed with taxpayer money and is freely available. A free working demo is downloadable here (Windows only).

This represents a needed "public option" for healthcare IT, the estimates of cost of adoption of proprietary systems now at somewhere between $20 and $50 billion dollars, give or take. (I believe the actual figure to be far higher due to IT sector dyscompetence in HIT as I wrote at my post "Fuzzy Math Indeed.") To put that figure in context, $50 billion is enough to build approximately five hundred shiny new 100-bed hospitals, or one hundred 500-bed hospitals, at ~$1 million per bed.

Entrepreneurial companies have sprung up to adopt it for the private healthcare sector such as WorldVista. They probably won't be charging the multimillion dollar rates that the private HIT sector does, and the quality will likely be higher.

-- SS

A Little Hiatus

I'm going to a conference next week, followed by a little vacation. I've written two posts that will publish automatically while I'm gone. I may or may not respond to comments for the next two weeks. I probably won't respond to e-mails. I'll resume the malocclusion series when I get back.