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Ransomware, Interoperability, Power Outages, Natural Disasters, Oh My!

flying cadeuciiQuestion: What do ransomware, malware, the lack of medical record interoperability, power outages, floods, hurricanes and tornadoes have in common?

Answer:  They make it impossible for doctors to access their patients’ electronic medical records — which can have disastrous and costly consequences for individual patients, families and our society as a whole.

The irony is that this is an unintended consequence of one of the most successful, albeit forced, programs to quickly move an entire industry from paper records into the modern age of electronic records.  The theory was that when all providers keep electronic records and they are linked together via electronic networks, patient records will be instantly available anytime, anywhere patients require care.  Regrettably, it’s not that simple.

The theory didn’t anticipate the problems that have emerged and, despite the fact that taxpayers spent $31 billion to fund this program and care providers invested perhaps another $150 billion to make it work, it doesn’t.  And it doesn’t appear that we are even close to solving these problems.

We have focused almost exclusively on linking provider record systems to achieve interoperability but aren’t even close to achieving it on a national scale.  Hospital CIOs have attempted to defeat malware by locking their systems but this doesn’t always work and may even block their providers from accessing important patient information.  We are now paying attention to ransomware but have no real solution short of paying a ransom.  And we have all but ignored the effects of natural disasters which are happening with increasing frequency and disastrous consequences.We just accept them.

So where does that leave us?  We can “stay the course” which, I submit, will never ensure that  patients’ records will always be available when they are needed, or we can look for a different approach that does.

Happily, there is an approach that not only solves these problems in one fell swoop but will have highly desirable additional “intended” consequences.  And the best news is that such an approach is readily available today!

The approach is to give patients copies of their records from all their providers that they can conveniently carry with them and give to care providers anytime, anywhere they need care. It’s just that simple!  It is the ultimate “distributed” solution and can work in any unexpected situation as long as an available computer has power or can be recharged.

The “intended consequences” are even better.  Providers can enjoy total interoperability and deliver better, coordinated, lower-cost care.  And patients can participate in their care decisions and save deductibles and copays when mistakes and unnecessary visits, tests and procedures are avoided.

In short, by “giving power to the people” — in this case their medical records — we can overcome the problems that make it impossible today for care providers to access their patients’ medical records and deliver quality care, and everyone benefits!

Merle Bushkin is Founder & CEO of Health Record Corporation, creator of MedKaz®, the patient-focused personal health record you carry in your pocket. Prior to entering the world of healthcare IT, he enjoyed an extensive career as an investment banker with Bushkin Associates, specializing in mergers and acquisitions, and earlier as a corporate executive and management consultant. He graduated from Harvard College with an AB in Economics and Harvard Business School with an MBA degree.

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Paul @ Pivot ConsultingLLCAllanmbushkinAdrian Gropper, MDJohn Irvine Recent comment authors
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mbushkin
Member

Just returned from HIMSS16 where I heard endless talk about the need for doctors to be able to share and exchange records and the expectation that such sharing will be possible sometime in the future: some say by 2018, some by 2020, others by 2024. But the only example of true and total interoperability that is available today was in my pocket where I have copies of all my records from more than 40 providers located in six cities and three states, spanning the past 30+ years, in all formats—from paper to every major and many minor EMR systems; and… Read more »

Allan
Member
Allan

Merle, it is not just clear that I don’t like government mandating the adoption of EMR’s, it is clear that the mandate was counterproductive. As I told you earlier, I like electronic records and have experience with them in my own practice almost since their beginning. The difference is who the record is for and how the record should be created, bottom up or top down? What you bring to the table interests me because the patient becomes an important feature. The top down EMR is not water over the dam rather a continuous drain on society and the benefits… Read more »

mbushkin
Member

Allan, You asked “Is there anyone that knows more medicine or the patient better than the treating physician at the bedside?” I suspect your answer is, no. My answer depending upon the illness, is maybe and often might be absolutely. Why? because every doc at a patient’s bedside is not all-knowing about all illnesses or about the care the patient is receiving or has received from other providers. That’s why there are specialists and researchers, and why it is important to be able to access the patient’s complete record to know how other providers are treating her. I’m not suggesting… Read more »

Allan
Member
Allan

“That’s why there are specialists and researchers, and why it is important to be able to access the patient’s complete record to know how other providers are treating her.” Merle, I hope you realize that most specialists are physicians at the bedside. Researchers aren’t and don’t generally deal with specific patients. Once again you are talking about the transmission of information and not the information itself. Transmission is not generally a problem. That can occur using a multiplicity of methods. The concern should be the quality of the record and the quality of the care which is dependent upon the… Read more »

mbushkin
Member

Allan, I’m not suggesting that patient records or EMR systems are more important in the care of a patient than the physician. But certainly the more informed a physician is about his patient, the better, lower-cost care he can deliver. And this is where “transmission,” as you refer to it, does count. If a patient’s records exist but aren’t available at the point of care, they are of no value to physician or patient, and costly mistakes can result. That is why we need a transmission system that works in all situations even during power outages, irrespective of what causes… Read more »

Allan
Member
Allan

“the more informed a physician is about his patient, the better, lower-cost care he can deliver.” Merle, that is true, but there is a benefits vs cost ratio to the EMR created by government and the costs have exceeded the benefits by a mile. When I say costs I mean dollar cost, time cost, quality cost, frustration cost, intellectual cost, security cost and I am sure a host of other costs as well. I have no problem with new ways of transmitting data as long as it doesn’t negatively impact healthcare like the EMR record seems to be doing because… Read more »

Allan
Member
Allan

mbushkin, People can draw all sorts of conclusions desired, but the one thing lawyers always want is the medical records. They would gladly cull through any records presented to them in order to look for a cause of action. I can’t prove this one way or the other, but neither can he. The difference is I am the one that ultimately gets sued. He might say that he is in the same position, but maybe the way he writes his notes changes his risks. Do we now debate who writes better notes? “ yearning for the good old days ”… Read more »

Allan
Member
Allan

mbushkin, I believe we have basic agreement as to the centrality of the patient regarding his records. I hope we agree that the release of his information should require his informed consent. The records should only be used by those given that consent and only for the time frame necessary to complete the task for which the consent was given. Where I think we have disagreement is in our perceptions of how physicians actually utilize records that are available. Firstly we both agree that it is a good thing to have records available in the easiest way possible. They can… Read more »

mbushkin
Member

Allan, WRT informed consent: we agree and in our system when the patient enters his or her password allowing a provider to access his or her records, that is informed consent. And if the provider wants to download a copy of another doctor’s record(s), the patient must enter his or her password before the record can be downloaded. WRT to litigation: Just heard a presentation today at HIMSS16 by a doc from Oregon affiliated with the OpenNotes program. He stated that their experience has been exactly opposite of what you and Dr. Palmer suggest—the amount of litigation has actually declined!… Read more »

Paul @ Pivot ConsultingLLC
Member

The concept for this is fantastic…..patient controlled as well as extraordinarily inexpensive to implement. Likely, it is too simple, too inexpensive and too patient-centered to gain traction as the powers that be prefer massively expensive top-down, mandated solutions that can be rolled out system-wide with little or no evidence they work to control costs or improve quality…and end up damaging cost control and quality of care…. (ACO, EHR etc.).

William Palmer MD
Member
William Palmer MD

I think I understand your idea now. The patient is the only vault for this aggregated data. Otherwise it resides in a particulate form with each provider who generated it. If this is correct, what do you think will happen to the rate of litigation if patients have all this data at home and they marinate and soak in it whilst communicating in normal social interactions with nurses and docs and attorneys and other knowledgeable folks and friends in health care? Aren’t they or their friends bound to say: ” Hey, Charlie, they should have tested you for B-12 deficiency,… Read more »

mbushkin
Member

Dr. Palmer, You’ve got it! Each provider has his or her records for each patient, and each patient has copies of all their records from each provider which are aggregated in only one place: on a device the patient carries in their pocket—not on web or Internet-accessible servers. I understand your concern about how patient access to their complete records might fuel litigation, but there is little evidence to support it. In fact, there is evidence to the contrary. HIPAA and subsequent legislation requires that providers electronically deliver copies of a patient records to the patient, so the question about… Read more »

Allan
Member
Allan

mbushkin, thanks for your reply. From the medical perspective I don’t think all this data collection is that meaningful even though it would be nice to have such access. The problem among other things is the cost and disruption. As I mentioned earlier I had the ability to get certain information from my computer via telephone in the mid 80’s. Almost all the information I needed from my personal records (Internist treating mostly an aged and very ill population) amounted to less than this response. Before I computerized some of my sickest patients carried a license sized picture of their… Read more »

mbushkin
Member

Allan, You raise several important points. I like your idea of doctors talking to one another, but in today’s world where a PCP typically has 7 to 12 minutes with a patient, that’s unrealistic. That’s why it is so important for the doc to have quick, easy access to their patient’s complete record — including complete progress notes not just summaries — when they are with their patient. Your concern about “unwieldy” records is certainly valid. Progress notes today can run 20 or 30 pages, and no doc has time to rummage through them. The solution to this problem, in… Read more »

William Palmer MD
Member
William Palmer MD

I agree with Allan. In fact, it might be better from a qaly-improvement standpoint to have all providers NOT communicating with one another and have them all approach the patient in a fresh de novo way. Of course, the costs, you say…think of costs. But If we extrapolate and hypothetically say that all lab and imaging is free, then why wouldn’t this anti-operability be the best way to go? The only objection here might be that you desire the ideas and histories of those providers who came before you to be widely heard. And it is not pleasant for the… Read more »

mbushkin
Member

Dr. Palmer, Don’t throw out the baby with the bath water. You clearly see value in providers sharing records so don’t trash the idea just because it’s hard to do. Instead look for a better way. If you connect all providers via an electronic network, the approach the country has been pursuing unsuccessfully for years, your “truism” that you make it “easier for all hackers” to breach the network, is certainly true. And they surely will, to show they can and/or to make money. But if each provider instead gives his/her patients copies of their records, the only place they… Read more »

BobbyGvegas
Member

“If you connect all providers via an electronic network, the approach the country has been pursuing unsuccessfully for years, your “truism” that you make it “easier for all hackers” to breach the network, is certainly true.”
__

Straw man. That’s not what’s being proposed. Both APIs and “standard data” (my preference) assume the continuation of (mostly incumbent) heterogeneous end-point platforms.

Allan
Member
Allan

.

mbushkin
Member

Allan, Thanks for asking the most critical, important question of all: What is the “value” of interoperability? My answer is that it enables care providers to deliver better, coordinated, lower-cost care in virtually every care setting, not simply emergencies. In my opinion, its benefits are so enormous that we can’t afford to wait one extra minute. We need total interoperability now. Waiting until 2024 is not acceptable! I’m sure anyone with a serious health issue agrees, whether they have cancer, a serious heart condition, diabetes, or other chronic illnesses. PCPs need to know the care their patients are receiving or… Read more »

Allan
Member
Allan

Reading this discussion makes me think of an over engineered Rube Goldberg machine that makes getting a ball from point A to point B very complicated. I asked, where is the value? There was no response. We are left with a Ruble Goldberg apparatus costing billions and making a mess of the physician’s working atmosphere. Since the patient travels the short path of A to B it sounds quite ingenious to me that the patient be the carrier of necessary information.

mbushkin
Member

Allan, Thanks for asking the most critical, important question of all: What is the “value” of interoperability? My answer is that it enables care providers to deliver better, coordinated, lower-cost care in virtually every care setting, not simply emergencies. In my opinion, its benefits are so enormous that we can’t afford to wait one extra minute. We need total interoperability now. Waiting until 2024 is not acceptable! I’m sure anyone with a serious health issue agrees, whether they have cancer, a serious heart condition, diabetes, or other chronic illnesses. PCPs need to know the care their patients are receiving or… Read more »

mbushkin
Member

See below.

BobbyGvegas
Member

You have a point. Margalit is also on record as characterizing “interoperability” as perhaps a chronic case of “Tail Wags Dog.”

Adrian Gropper, MD
Member
Adrian Gropper, MD

The risks of a monoculture on something as critical and dynamic as one’s health records are immense. We need to be careful to design standards that are simple enough to be relatively secure and distributed in the sense that a vulnerability affects only one or a few thousand patients. We also need to design redundancy into the system. The principles of sound privacy and security design are not a mystery. One principle however is core to the security and interoperability of critical infrastructure. It’s open source software. Much of the problem with how the HITECH stimulus was spent and much… Read more »

mbushkin
Member

Adrian, I can’t agree that redundancy is the solution to interoperability first, because we don’t have anything close to total interoperability now and having redundancy still won’t solve the problem and, second, because redundant facilities are uneconomic. Even Netflix and other major sites were shut down for as much as 24 hours when Amazon’s Web Services failed. A simpler approach is to give the patient his or her records. That way they can be available under any and all conditions, and the risk of a security or privacy breach is limited to a single individual — assuming a hacker finds… Read more »

John Irvine
Member

I get the point you’re trying to make and I think it has to do with your own solution.
But this is actually an argument for interoperability. Not against it.

Am I missing something?

The internet was originally conceived to prevent these kinds of data blackouts by making it possible to share information during moments of crisis.

We’ve had the technology for thirty years.

BobbyGvegas
Member

Where’s the “SPONSORED POST” tagline here? 😉

John Irvine
Member

It’s not sponsored. But he is advocating for his product.

There’s nothing wrong with that, mind you. If you’ve developed a technology and you believe in your product, why wouldn’t you? I’d rather have people be upfront about their biases and let me decide.

On the other hand, I don’t think the solution works.

I’m going to take some convincing.

BobbyGvegas
Member

Just snark, man… But, when I see your “Sponsored Content” posts, I simply won’t read them. That advertorial stuff is starting to infiltrate most online media.

mbushkin
Member

John,

Hope my response above starts you down the path of becoming a believer that there really is a better way!

mbushkin
Member

John, We didn’t design a solution to the problem of medical record accessibility and interoperability in a vacuum or as an added feature to a system designed for billing and other purposes. We started from scratch, looked at the need today that I think everyone agrees isn’t being met whether in daily use, simple power outages, natural disasters (and now shutdowns for ransom), analyzed why and formulated a very different kind of solution that does work. Frankly, the fact that it is an out-of-the-box solution makes it hard to grasp for those focused on the conventional approach. The fact is… Read more »

William Palmer MD
Member
William Palmer MD

I don’t understand. Do you want the EHR to be a legal document? or not? If the patient has ownership of his record or Read and Write privileges, he is going to be motivated to remove evidence of his own contributory negligence isn’t he? (E.g. I forgot to take my warfarin). If you want both provider and the patient to have read and write privileges, then you have to kill the lawyers. :-).

BobbyGvegas
Member

Looking for the “like” button again…

mbushkin
Member

Dr. Palmer, I’m NOT advocating that providers do away with their records. What I am advocating is that every provider give his or her patients copies of their records which can be stored on a device the patient owns and carries with him or her and gives to any provider they see — so the provider can understand their issues and coordinate their care. (In the system our company has designed, the doctor, hospital, ACO or other provider is paid for doing so thereby giving them a substantial new source of revenue.) This way, you as a provider have your… Read more »

BobbyGvegas
Member

“Providers can enjoy total interoperability”
__

Assumes that a patient’s data can and will autopopulate any given EHR. Otherwise, it’s not “interoperability,” and no amount of intoning the word will make it so. The inconvenient IEEE definition clause “without special effort on the part of the user” always gets lopped off in these “data exchange” discussions.

mbushkin
Member

Bobby, In the patient-centric system I propose, any provider (with their patient’s OK) can download another provider’s record or records from the patient’s device and import them into their own EMR system. All it takes is an API interface or, if the provider’s EMR vendor won’t provide an interface, it can be downloaded as a PDF and uploaded into the provider’s system just as is done today when a patient brings a paper record to a provider. WRT definitions of interoperability, the only one that counts for me is not at all technical. If any provider can electronically access a… Read more »

BobbyGvegas
Member

“it can be downloaded as a PDF and uploaded into the provider’s system just as is done today when a patient brings a paper record to a provider” __ Seriously? You call that “interoperability”? MEGO. “All it takes is an API interface” ALL it takes? Seriously? So, which vendors have provided your product with APIs? Do they map to all of the variables in the source EHR’s data dictionary? Again, if it’s “plug & play” so that the data will autopopulate a destination EHR, then you can argue you’ve met the definition of “interoperability.” Short of that you’re still stuck… Read more »

mbushkin
Member

Bobby, We seem to have different objectives, define interoperability very differently, and look to a different standard to achieve our objective. Our objective is to enable any care provider to access a patient’s complete medical record at the point of care anytime, anywhere. When we can do that by whatever approach, we will have achieved total interoperability — perhaps not by your standard but by the standard of care providers and patients. The patient-focused system I’ve described does that in spades and does so today. It works because it focuses on how records are managed, not on how they are… Read more »

BobbyGvegas
Member

Will you be at HIMSS16 next week? Maybe we can discuss it further then.

mbushkin
Member

Yes. I will be there and would love to meet you. What would be a good time and place?

BobbyGvegas
Member

Good. Still working out my date/time/sessions agenda. I am attending on a press pass, so we could find time in the media room. Email is bobbyg@bgladd.com

Allan
Member
Allan

Bobby, I am not a computer junky so bear with me. To me interoperability is extremely risky from a security point of view as interoperability makes it easier and more desirable for large scale theft to occur. Why must patient records provide more than the generic text data and graphics data that can be placed on a thumb drive or something else? From the physician’s vantage point not much data is truly helpful. In the 80’s I communicated to my office computer and was able to get the small bit of information I thought was needed in an emergency and… Read more »

BobbyGvegas
Member

“interoperability is extremely risky from a security point of view as interoperability makes it easier and more desirable for large scale theft to occur.” __ Perhaps an interesting point, but, you still have to breach a given system. The metadata RDBMS “typing” of the patient data within a given system is not material to the hacking expertise required to penetrate the compiled source code of the system itself. Medical data thieves, in the aggregate, don’t give a flip about, say, your vitals or lab values or active meds list or PMH, or ROS data, etc. They want financial-related stuff, just… Read more »

Allan
Member
Allan

Bobby, I understand your defense of interoperability, though there is a lot more than the things you mention that one should be worried about. The health status of certain individuals is extremely valuable and apparently made very easy to get when all in one place.

My question is where is the value? I thought the main value was supposed to be to help the patient especially in an emergency, but as I have said the amount of information actually needed, if any, is quite small.

Why are we so all consumed about interoperability? Is it for the patient or not?