Manipulation of 12,000 Medical Records Made Easy by EHR

This from a hospital in Canberra, Australia using a common ED EHR in that part of the world, iSOFT:

Canberra Hospital embroiled in data scandal
SBI Magazine (Secure Business Intelligence)
Jul 5, 2012 

A Canberra Hospital executive has admitted to manipulating Emergency Department records to make wait times and stays appear shorter than they were.

The executive told the Director-General of the Health Directorate they had made "approximately 20 to 30 changes to hospital records" a day from "late 2010" onwards.

ABC [Australian Broadcasting Corp.] News reported that the matter has been referred to police, while the executive has been suspended without pay.

Though the data manipulation was initially said to be motivated by concerns over job security, changes in 2011 and early 2012 were said to have been made due to "managerial pressure" to improve publicly-reported performance statistics.

This raises the issue that data manipulation might have been performed not just to improve reported statistics, but to cover up medical error, computer related or not, and thus deny injured patients or their heirs the right to legal redress.

"The only thing that worked to achieve benchmark targets was to alter the data," the executive later told investigators at PricewaterhouseCoopers (PwC), which was engaged by Health to perform a forensics analysis. The analysis is detailed in a new Auditor-General report (pdf).

In total, PwC found 11,700 performance records - about six percent of all records stored in the hospital's iSOFT emergency department information solution (EDIS) - had been altered.

It is believed more staff at Canberra Hospital altered records than the executive that has so far admitted responsibility.  "While an executive has admitted to changing EDIS records, it is probable that EDIS records have also been manipulated by other persons with access to the system," the federal auditor-general noted overnight.

This is another area where electronic records make possible tasks that are probably impossible with paper.  Altering 11,000+ records would be hard in paper charts, as the alterations would likely stick out in a pronounced manner.

"The executive’s admission to Audit does not appear to account for all of the changes to EDIS records that have been made to improve timeliness performance."

For example, changes to EDIS records, albeit a much smaller number, appear to have been made on days when the executive was on leave (seven days in total in 2010-11 and early 2011-12). 

I am saddened to note, a proper term for this activity might indeed be "conspiracy":  a conspiracy is an agreement between two or more persons to break the law at some time in the future.

User access control, IT security failures

Poor controls such as generic logins and inadequate user and password security made it easy for insiders to game the data.

While EDIS was on approximately 259 workstations across the hospital and 253 users had permission to run the software, there were only 23 user accounts.

Of these user accounts, only eight were in regular use, including four named administrator accounts (specific to administrative staff) and four generic user accounts: CLERK, NURSE, DOCTOR and BEDMAN.

The generic accounts could be used by personnel across the hospital, not just within the Emergency Department.

Passwords for the four generic user accounts were "very poor" and had "never been changed". Password expiry was set at a default 999 days.

Audit logs were equally poor, not proactively checked and unreliable.

The proper term for these arrangements might be "gross mismanagement" of clinical information technology.

"A feature of the logging record is that it logs the changed field in EDIS and a number of other fields simultaneously, while not identifying which field was changed and what its original value was," auditors noted.

"Audit also notes that the logging record is also ineffective, because every entry in EDIS is logged from “Workstation 14”.  

"Although EDIS has been disseminated widely throughout the Canberra Hospital each of these users logs into EDIS using the common “Workstation 14”.

"This practice, combined with the use of generic user accounts, makes the EDIS logging information useless for investigations of unauthorised activity."

Furthermore, it was possible to edit EDIS records up to 72 hours after a patient’s treatment, providing a generous window for later unauthorised changes to the records.

These "features" sound like seller misdesign with regard to the metadata (logging records).

Noticing anomalies

It was only in April this year that a full inquiry was commissioned after "anomalies" in performance figures were spotted by the Australian Institute of Health and Welfare (AIHW).

The AIHW found an unusually high number of emergency patients that were reported to have been seen at exactly within the required time for their illness category.

For example, there was an unusually high number of patients who were reported to have been seen at exactly 30 minutes or 60 minutes.

In addition, an unusually high number of people checked out of the Emergency Department precisely 240 minutes after their recorded arrival.

If you're going to engage in this type of activity, at least be competent at it...instead of setting up a red flag bigger than the flag that used to fly over the Kremlin.

The records that were manipulated mean that publicly reported information relating to the timeliness of access to the Emergency Department and overall length of stay in the Emergency Department have been inaccurately reported.

The report could not ascertain the level of over‐estimation due to the lack of a clear audit trail identifying what were legitimate and what were fabricated entries in patients’ records.  

Timelines can be critical to proving medical negligence in court.  Further, if time data could have been manipulated, it seems clinical data could have been manipulated as well.

EHR data manipulation is of unknown magnitude worldwide, but I can imagine if it's easy to do and the benefits potentially substantial, electronic records could possibly be less trustworthy than paper records.

-- SS

Addendum:  while on the topic of clinical IT Down Under, there's also this:

Coast medical records system 'dangerous'
Stephanie Bedo
Goldcoast.com.au

July 6, 2012

SENIOR doctors say Gold Coast Heath's new multimillion dollar electronic medical record system is 'inadequate and dangerous' and could put patients' lives at risk.

Doctors have complained about the system, saying some patient documents are missing, it has log-in problems and 10-minute delays in accessing critical information.

Gold Coast Health was the first region in the state to move to electronic record-keeping, rolled out progressively from October last year.

Queensland Health spent about $200 million on the electronic medical record roll-out last year, which was delayed by 12 months because of problems with the software provider.

... Hospital cardiologist Dr Greg Aroney raised concerns about the system at a Griffith University forum on the future of health on the Gold Coast this week.

"Our system is totally inadequate and dangerous," Dr Aroney said.

Read the whole story at this link:   http://www.goldcoast.com.au/article/2012/07/06/429621_gold-coast-news.html

A similar story from the states where the doctors' complaints were actually ignored is at my Sept. 2011 post "Blake Medical Center (Bradenton, Fla.) Ignores Health IT Warning Letter From 100 Staff Physicians." 

Let's hope the Australian physicians' complaints are taken more seriously.

-- SS

Banking as the Standard Healthcare Should Look Up To On Medical Information Security?

At past posts "Don't Worry, Your Electronic Medical Records Are Getting Safer With Every Passing Day", "Another Episode of "But Don't Worry, Your Records are Safe..." and "Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure", "Don't Worry, Your Records are Safe - Part IV" and others, I wrote on the issue of medical record security.

Banking has been held as the standard as to which medicine has been compared, with medicine being called archaic and behind the times for its reliance on paper.  Banking security is cited as a reason why electronic medical records can also be secured.

There's this:

Fraud Ring In Hacking Attack On 60 Banks 

June 27, 2012

Some 60m euro is stolen from bank accounts in a massive cyber raid, after fraudsters raid dozens of banks around the world.

By Pete Norman, Sky News Online

Sixty million euro has been stolen from bank accounts in a massive cyber bank raid after fraudsters raided dozens of financial institutions around the world.

According to a joint report by software security firm McAfee and Guardian Analytics, more than 60 firms have suffered from what it has called an "insider level of understanding".

"The fraudsters' objective in these attacks is to siphon large amounts from high balance accounts, hence the name chosen for this research - Operation High Roller," the report said.

"If all of the attempted fraud campaigns were as successful as the Netherlands example we describe in this report, the total attempted fraud could be as high as 2bn euro (£1.6bn)."

The automated malicious software programme was discovered to use servers to process thousands of attempted thefts from both commercial firms and private individuals.

The stolen money was then sent to so-called mule accounts in caches of a few hundreds and 100,000 euro (£80,000) at a time.

Credit unions, large multinational banks and regional banks have all been attacked.

Sky News defence and security editor Sam Kiley said: "It does include British financial institutions and has jumped over to North America and South America.

"What they have done differently from routine attacks is that they have got into the bank servers and constructed software that is automated.

"It can get around some of the mechanisms that alert the banking system to abnormal activity."

The details of the global fraud come just a day after the MI5 boss warned of the new cyber security threat to UK business.

McAfee researchers have been able to track the global fraud, which still continues, across countries and continents.

"They have identified 60 different servers, many of them in Russia, and they have identified one alone that has been used to steal 60m euro," Kiley said.

"There are dozens of servers still grinding away at this fraud – in effect stealing money."

That's all very reassuring.   Let's put all of our personal medical secrets online ASAP.  Don't worry, your information's safe and secure.

-- SS

Don't Worry, Your Electronic Medical Records Are Getting Safer With Every Passing Day

At my Oct. 2011 post "Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure" and others in this query link on medical record privacy, http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy I wrote:

"Don't worry, your medical data's safe."

In Jan 2012 I then posted about Joseph Conn of ModernHealthcare.com's article "2011 Closes on a Note of Electronic Medical Record Privacy Breach Shame."

Don't worry, though; the IT industry's leader, finance, to which medicine is always compared, has gotten closer to getting the situation under control:

From MSNBC:

MasterCard, Visa confirm credit card data theft described as 'massive'
March 30, 2012
By Bob Sullivan

Law enforcement officials are investigating what appears to be a massive theft of U.S. consumers' credit card data, MasterCard and Visa confirmed Friday. The computer security expert who first reported the theft said it might involve as many as 10 million MasterCard and Visa accounts, making it one of the largest known credit card heists.

"MasterCard is currently investigating a potential account data compromise event of a U.S.-based entity and, as a result, we have alerted payment card issuers regarding certain MasterCard accounts that are potentially at risk," that association said in a statement. "Law enforcement has been notified of this matter and the incident is currently the subject of an ongoing forensic review by an independent data security organization."

The theft was first reported by well-known computer security journalist Brian Krebs on his blog, KrebsonSecurity.com. Krebs said the crime involves compromise of a credit card payment processor — a "middle man" that handles transactions between retailers and banks [like these middlemen in medicine? - ed.]

The name of that institution is unknown, but processors have long been a target of identity thieves because of the enormous amounts of data they control. In 2008, Princeton, N.J.,-based Heartland Systems was hacked, exposing tens of millions of credit card account numbers to theft.

Krebs reported that hackers had access to the unknown processors data from Jan 21 through Feb 25, and were able to siphon off enough data to easily create counterfeit cards. His sources called the leak "massive."

... Gartner security expert Avivah Litan said she's been told that the stolen data is already being used on the street by identity thieves.

"I’ve spoken with folks in the card business who are seeing signs of this breach mushroom. Looks like the hackers have started using the stolen card data more recently," she said.

Read the whole article at the link.

Don't let this trouble you, however. The problem is getting closer to a solution with each mega-break in.

They'll have it fixed any day now, so have no fear telling your EHR-equipped doctor all your private and most sensitive medical business.

-- SS

Proposed new Consumer Privacy Bill of Rights: Is It Too Late For Healthcare?

From the White House:

http://www.whitehouse.gov/the-press-office/2012/02/23/fact-sheet-plan-protect-privacy-internet-age-adopting-consumer-privacy-b

The White House
Office of the Press Secretary
For Immediate Release
February 23, 2012

Plan to Protect Privacy in the Internet Age by Adopting a Consumer Privacy Bill of Rights

CONSUMER PRIVACY BILL OF RIGHTS

The Consumer Privacy Bill of Rights applies to personal data, which means any data, including aggregations of data, that is linkable to a specific individual. Personal data may include data that is linked to a specific computer or other device. The Administration supports Federal legislation that adopts the principles of the Consumer Privacy Bill of Rights. Even without legislation, the Administration will convene multi-stakeholder processes that use these rights as a template for codes of conduct that are enforceable by the Federal Trade Commission. These elements—the Consumer Privacy Bill of Rights, codes of conduct, and strong enforcement—will increase interoperability between the U.S. consumer data privacy framework and those of our international partners.

1. INDIVIDUAL CONTROL: Consumers have a right to exercise control over what personal data companies collect from them and how they use it. Companies should provide consumers appropriate control over the personal data that consumers share with others and over how companies collect, use, or disclose personal data. Companies should enable these choices by providing consumers with easily used and accessible mechanisms that reflect the scale, scope, and sensitivity of the personal data that they collect, use, or disclose, as well as the sensitivity of the uses they make of personal data. Companies should offer consumers clear and simple choices, presented at times and in ways that enable consumers to make meaningful decisions about personal data collection, use, and disclosure. Companies should offer consumers means to withdraw or limit consent that are as accessible and easily used as the methods for granting consent in the first place.
2. TRANSPARENCY: Consumers have a right to easily understandable and accessible information about privacy and security practices. At times and in places that are most useful to enabling consumers to gain a meaningful understanding of privacy risks and the ability to exercise Individual Control, companies should provide clear descriptions of what personal data they collect, why they need the data, how they will use it, when they will delete the data or de-identify it from consumers, and whether and for what purposes they may share personal data with third parties.
3. RESPECT FOR CONTEXT: Consumers have a right to expect that companies will collect, use, and disclose personal data in ways that are consistent with the context in which consumers provide the data. Companies should limit their use and disclosure of personal data to those purposes that are consistent with both the relationship that they have with consumers and the context in which consumers originally disclosed the data, unless required by law to do otherwise. If companies will use or disclose personal data for other purposes, they should provide heightened Transparency and Individual Control by disclosing these other purposes in a manner that is prominent and easily actionable by consumers at the time of data collection. If, subsequent to collection, companies decide to use or disclose personal data for purposes that are inconsistent with the context in which the data was disclosed, they must provide heightened measures of Transparency and Individual Choice. Finally, the age and familiarity with technology of consumers who engage with a company are important elements of context. Companies should fulfill the obligations under this principle in ways that are appropriate for the age and sophistication of consumers. In particular, the principles in the Consumer Privacy Bill of Rights may require greater protections for personal data obtained from children and teenagers than for adults.
4. SECURITY: Consumers have a right to secure and responsible handling of personal data. Companies should assess the privacy and security risks associated with their personal data practices and maintain reasonable safeguards to control risks such as loss; unauthorized access, use, destruction, or modification; and improper disclosure.
5. ACCESS AND ACCURACY: Consumers have a right to access and correct personal data in usable formats, in a manner that is appropriate to the sensitivity of the data and the risk of adverse consequences to consumers if the data is inaccurate. Companies should use reasonable measures to ensure they maintain accurate personal data. Companies also should provide consumers with reasonable access to personal data that they collect or maintain about them, as well as the appropriate means and opportunity to correct inaccurate data or request its deletion or use limitation. Companies that handle personal data should construe this principle in a manner consistent with freedom of expression and freedom of the press. In determining what measures they may use to maintain accuracy and to provide access, correction, deletion, or suppression capabilities to consumers, companies may also consider the scale, scope, and sensitivity of the personal data that they collect or maintain and the likelihood that its use may expose consumers to financial, physical, or other material harm.
6. FOCUSED COLLECTION: Consumers have a right to reasonable limits on the personal data that companies collect and retain. Companies should collect only as much personal data as they need to accomplish purposes specified under the Respect for Context principle. Companies should securely dispose of or de-identify personal data once they no longer need it, unless they are under a legal obligation to do otherwise.
7. ACCOUNTABILITY: Consumers have a right to have personal data handled by companies with appropriate measures in place to assure they adhere to the Consumer Privacy Bill of Rights. Companies should be accountable to enforcement authorities and consumers for adhering to these principles. Companies also should hold employees responsible for adhering to these principles. To achieve this end, companies should train their employees as appropriate to handle personal data consistently with these principles and regularly evaluate their performance in this regard. Where appropriate, companies should conduct full audits. Companies that disclose personal data to third parties should at a minimum ensure that the recipients are under enforceable contractual obligations to adhere to these principles, unless they are required by law to do otherwise.

For an example of some of the major problems with healthcare data, see my Oct. 2009 post "Health IT Vendors Trafficking in Patient Data?"

I like the proposals.

The question is, regarding electronic health data: are these Federal proposals too little, too late?

Complex systems such as massive computer networks (with myriad stakeholders seeking to 'game' the system, skirt the boundaries of the law, and make handsome profits) can become uncontrollable.

-- SS

2011 Closes on a Note of Electronic Medical Record Privacy Breach Shame

At my Oct. 2011 post "Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure" and others in this query link on medical record privacy, http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy I wrote:

"Don't worry, your medical data's safe."

Joseph Conn of ModernHealthcare.com apparently disagrees (with my sarcasm, that is) and states the obvious outright. I post his story with few comments and several emphases which are mine:

Year closes on a note of breach shame
Modern Healthcare
Dec. 2012

Three-eighty. Three-eighty. Do I hear four hundred?

With 2011 winding down, there are now 380 major data breaches involving 500 or more patients' records listed on the "wall of shame" website kept by HHS' Office for Civil Rights.

So far, from the first wall postings in September 2009 through the latest on Dec. 8 this year, there have been 18,059,831 "individuals affected," and even that massive number is an undercount of the breach problem.

First, the civil rights office hasn't yet released the records of tens of thousands of breaches it has received under a federal reporting mandate on breaches affecting fewer than 500 patients per incident. I've been asking for electronic copies of those records since June. I hope to hear soon on an appeal of a decision last fall by HHS, claiming that the civil rights office can hide those reports while it "investigates" an estimated 30,000 or more breaches they describe.

Second, even the OCR's posted numbers are low.

A Nov. 4 public notice on a breach reported by the UCLA Health System states that "some personal information on 16,288 patients" was stolen, but the wall of shame lists the "individuals affected" in the UCLA incident as 2,761.

UCLA spokeswoman Dale Tate said in an e-mail that the nearly six-times-larger number in its notice "represents the number of individuals who had some information on the hard drive," while the 2,761 figure sent to the OCR "represents the number of people that met the specific criteria" under the federal breach notification rule.

Under the federal rule, Tate says, "the information for these individuals could possibly cause more than a minimal amount of financial, reputational or other harm." Information on the rest of the individuals, Tate said, did not meet the criteria.

Not to get too harpy, but this breach stuff is long past being ridiculous.

The lawyers are already all over it, and maybe that's what it will take for the industry to finally start addressing the problem. Brian Kabateck, a California lawyer, thinks so.

In the past three months, his Los Angeles law firm has filed a pair class-action breach suits against two of the most highly regarded healthcare systems in the state, University of California, Los Angeles and Stanford, as well as one of the latter's business associates, Multi-Specialty Collection Services.

"I think this is a short blip on the radar," Kabateck said. As the settlement costs pile up, he said, "I think big institutions are going to learn—five years from now, these lawsuits are going to be obsolete."

Class-action lawsuits are needed as much for health IT risk and safety issues causing near-misses, injuries and death as for security breaches, I note.

I think five years is highly overoptimistic as well on the breach issue, considering the degree of "institutional learning" that's occurred on how to do health IT "right" over the past ~ three decades, and considering that the breaches that are increasing, not decreasing, in intensity and severity across all industry sectors. That includes industry sectors far better equipped to manage IT security than hospitals.

Right now, though, Kabateck says, "This is not to the level of being an epidemic, but it's close."

I think it is epidemic.

Rather than being a miracle that will revolutionize medicine, health IT is like any other information and communication technology (ICT): it has unintended consequences (UC's) that can dilute or even negate its advantages. The issue of damaged medical record privacy, confidentiality and security is but one UC of health IT.

-- SS