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There are problems with paper-based systems but they don't affect everyone to the same extent: * I visit another doctor when on holiday - they don't have my rec

There are problems with paper-based systems but they don't affect everyone to the same extent: * I visit another doctor when on holiday - they don't have my records * Certain treatments need the approval of my home doctor, it talkes longer than it should * Harder to collate statistics that are supposed to show the state of the nation's health But there are problems with an electronic system: * A single point of attack * No way to assure people it is ultimately secure, because it can never be * Fluffy exemptions to the protection offer - especially if they are more far-reaching than existing exemptions used for accessing your paper records * Creeping requirements mean that a few years later, the government might change what they can use it for. At the end of the day, neither system can be measured in terms of risk or reward in any meaningful way - many advantages are theoretical and risks are downplayed - so you pretty much have to accept the centralisation of the worlds systems or move to a Banana republic!

Avamander 8y ago
* A single point of attack Totally the same with your data in that one primary doctor's office or whatever * No way to assure people it is ultimately secure, because it can never be Totally same with your paper records, someone could walk in and steal your data, imagine that. * Creeping requirements mean that a few years later, the government might change what they can use it for. Just like paper records, you can't say what they will use them for in the future.
- TheSpiceIsLife 8y ago
  I believe you’ve misunderstood the concept of single point of attack. This means single point of attsck for everyone with an ehealth record. With paper records, or in-house digital records, a hacker / thief, or malicious government, or what have you, has to compromise many systems. The same applies to your paper record comment.
  - Avamander 8y ago
    > I believe you’ve misunderstood the concept of single point of attack. Single point in who's perspective though, OP worded it more like (s)he cares about his/her data not everyone else's (e.g. "I visit another doctor when on holiday - they don't have my records"). But yes, you are right about it being in general a higher risk endeavour. The question now is though, when other commenters here describe how their life and career could get in danger when someone steals their data, which do you think is going to be much harder to breach, your local doctor's office or a central database that's guarded by armed guards and experts?
    - TheSpiceIsLife 8y ago
      > which do you think is going to be much harder to breach, your local doctor's office or a central database that's guarded by armed guards and experts? Who’s going to break in to a doctors office, then scan and upload your medical records? I don’t think thieves in Australia would even bother with doctors offices because no drugs or cash. Rather, it seems certain that this database will be breached and the data sold on the black market, and / or some future government using it outside its intended scope.
- tgb 8y ago
  Electronic records have a single point of attack for the entire country's data versus a breach at your local hospital. Makes beaches much worse while also greatly incentivizing the breach.
  - Avamander 8y ago
    What about greatly incentivizing protecting that data compared to individual actors who won't bother? What about increased redundancy? What about improved medical care? I don't think this is all this black and white as you paint it to be.
- pjc50 8y ago
  This is true "on paper", but in practice our whole industry is built on the fact that electronic records behave qualitively differently from paper records because they're so much easier to handle. You can't steal everyone's paper records all at once in the way you can with electronic records, for example.
  - Avamander 8y ago
    > You can't steal everyone's paper records all at once in the way you can with electronic records, for example. You're assuming you can steal the entire database at once which most certainly will also be noticed and stopped swiftly.
    - j16sdiz 8y ago
      Maybe. But how about those already stolen? Photocopying paper records are slow. If you can get the original copy back quickly, you can be quite confident they are not copied. Not so for e-records.
      - Avamander 8y ago
        > But how about those already stolen? Digital records can most likely be duplicated much more easily.
    - pjc50 8y ago
      History is full of massive data breaches which were only noticed when the dump turned up being sold. Few places have decent exfiltration detection on their IDS. Or there's the classic "health records left on train" incident: http://news.bbc.co.uk/1/hi/uk/7449927.stm http://news.bbc.co.uk/1/hi/uk/7449927.stm
    - justinclift 8y ago
      > ... most certainly will also be noticed and stopped swiftly. That's not necessarily the case. It very much depends on how it's "stolen", the cluefulness of the attackers, etc. For example, if the data is pulled out of the live system via (say) some kind of SQL exploit, then intrusion detection gear has a possibility of noticing and reacting in a reasonable time frame. However, if (again, for example) the data is copied directly from backup tape when the tapes are transported to secondary storage, or are (in)correctly disposed of. That's extremely unlikely to be detected. Ever. There are just so many attack vectors. :/
- Spooky23 8y ago
  Paper records have a better scope. It isn’t economically justifiable to steal paper. Electronic records are easier to steal and cheap to sell, mine or otherwise utilize.
  - Avamander 8y ago
    > Electronic records are easier to steal How are they easier to steal? I would really like to know.
    - Spooky23 8y ago
      It’s easy to bypass whatever security mechanisms are in place by a hospital, physicians office, insurance company, subrogation contractor, pharmacy, billing contractor, branch office of a sprawling health network. The sheer volume scope of custodians is big, and every one of them is a risk, some more than others. Even without a breach, custodians are able to monetize “anonymized” data to third parties, who can often reconstruct it. In olden times, all of our records were in a paper folder. Breaches were more often related to office staff losing said folder. Incidents where a bunch of guys with a truck stole shelves of folders were rare if they ever happened. IMO, with the exception of inpatient orders, prescriptions and referral automation, most of the impact of EMR has been a net negative to the patient. The fact that all of my providers don't trust the system and ask me the same 5-15 questions every time I see them belies that.
- gruez 8y ago
  >Totally the same with your data in that one primary doctor's office or whatever still, it's a huge target compared to thousands of doctor's offices >Totally same with your paper records, someone could walk in and steal your data, imagine that. nowhere near as scaleable compared to hacking a site with everyone's records
  - Avamander 8y ago
    So what you're saying is that someone is going to steal the entire medical database of everyone and that's somehow going to be more "scalable" than stealing paper records? If that database contained everyone's medical data it will not fit on anything that anyone non-state/non-corporate actor can aquire, and if you have state actor or corporate level of budget one could easily scale stealing paper medical records. I'm not so sure it's going to be easier to compromise super-guarded database compared to a lot of paper records, would like some hard numbers, but those are going to be hard to get.
    - gruez 8y ago
      >If that database contained everyone's medical data it will not fit on anything that anyone non-state/non-corporate actor can aquire source? that might be the case if you're including all the high resolution imagery, but I'd imagine all the text records can't be that big. >and if you have state actor or corporate level of budget one could easily scale stealing paper medical records that would either require an operation lasting weeks/months to hit all the doctors offices (with a small crew), or hitting all tho doctors offices at the same time (huge crew). the former increases risk of detection exponentially, as someone is going to notice eventually, and once people find out, capture of your crew by the police will be inevitable. the latter is also risky because you're going to make a lot of noise assembling said crew, and one of them is going to snitch on you. in contrast, if all the records were centralized in one online database, all you'd have to do is have a small team of experienced hackers hack it from a the safety of a country with no extradition treaty. low risk of one of them snitching on you AND low risk of capture. >I'm not so sure it's going to be easier to compromise super-guarded database compared to a lot of paper records, would like some hard numbers, but those are going to be hard to get. I'm sure on an individual level, it's definitely easier to burgle a doctor's office than a super secure government database. but see last paragraph about scaleability.
sbov 8y ago
You forgot one: * cancer doctor doesn't know about infection, runs chemo treatment, infection spreads and ultimately kills patient. Happened to a relative of mine.

Avamander 8y ago

* A single point of attack Totally the same with your data in that one primary doctor's office or whatever * No way to assure people it is ultimately secure, because it can never be Totally same with your paper records, someone could walk in and steal your data, imagine that. * Creeping requirements mean that a few years later, the government might change what they can use it for. Just like paper records, you can't say what they will use them for in the future.

TheSpiceIsLife 8y ago
I believe you’ve misunderstood the concept of single point of attack. This means single point of attsck for everyone with an ehealth record. With paper records, or in-house digital records, a hacker / thief, or malicious government, or what have you, has to compromise many systems. The same applies to your paper record comment.
- Avamander 8y ago
  > I believe you’ve misunderstood the concept of single point of attack. Single point in who's perspective though, OP worded it more like (s)he cares about his/her data not everyone else's (e.g. "I visit another doctor when on holiday - they don't have my records"). But yes, you are right about it being in general a higher risk endeavour. The question now is though, when other commenters here describe how their life and career could get in danger when someone steals their data, which do you think is going to be much harder to breach, your local doctor's office or a central database that's guarded by armed guards and experts?
  - TheSpiceIsLife 8y ago
    > which do you think is going to be much harder to breach, your local doctor's office or a central database that's guarded by armed guards and experts? Who’s going to break in to a doctors office, then scan and upload your medical records? I don’t think thieves in Australia would even bother with doctors offices because no drugs or cash. Rather, it seems certain that this database will be breached and the data sold on the black market, and / or some future government using it outside its intended scope.
tgb 8y ago
Electronic records have a single point of attack for the entire country's data versus a breach at your local hospital. Makes beaches much worse while also greatly incentivizing the breach.
- Avamander 8y ago
  What about greatly incentivizing protecting that data compared to individual actors who won't bother? What about increased redundancy? What about improved medical care? I don't think this is all this black and white as you paint it to be.
pjc50 8y ago
This is true "on paper", but in practice our whole industry is built on the fact that electronic records behave qualitively differently from paper records because they're so much easier to handle. You can't steal everyone's paper records all at once in the way you can with electronic records, for example.
- Avamander 8y ago
  > You can't steal everyone's paper records all at once in the way you can with electronic records, for example. You're assuming you can steal the entire database at once which most certainly will also be noticed and stopped swiftly.
  - j16sdiz 8y ago
    Maybe. But how about those already stolen? Photocopying paper records are slow. If you can get the original copy back quickly, you can be quite confident they are not copied. Not so for e-records.
    - Avamander 8y ago
      > But how about those already stolen? Digital records can most likely be duplicated much more easily.
  - pjc50 8y ago
    History is full of massive data breaches which were only noticed when the dump turned up being sold. Few places have decent exfiltration detection on their IDS. Or there's the classic "health records left on train" incident: http://news.bbc.co.uk/1/hi/uk/7449927.stm http://news.bbc.co.uk/1/hi/uk/7449927.stm
  - justinclift 8y ago
    > ... most certainly will also be noticed and stopped swiftly. That's not necessarily the case. It very much depends on how it's "stolen", the cluefulness of the attackers, etc. For example, if the data is pulled out of the live system via (say) some kind of SQL exploit, then intrusion detection gear has a possibility of noticing and reacting in a reasonable time frame. However, if (again, for example) the data is copied directly from backup tape when the tapes are transported to secondary storage, or are (in)correctly disposed of. That's extremely unlikely to be detected. Ever. There are just so many attack vectors. :/
Spooky23 8y ago
Paper records have a better scope. It isn’t economically justifiable to steal paper. Electronic records are easier to steal and cheap to sell, mine or otherwise utilize.
- Avamander 8y ago
  > Electronic records are easier to steal How are they easier to steal? I would really like to know.
  - Spooky23 8y ago
    It’s easy to bypass whatever security mechanisms are in place by a hospital, physicians office, insurance company, subrogation contractor, pharmacy, billing contractor, branch office of a sprawling health network. The sheer volume scope of custodians is big, and every one of them is a risk, some more than others. Even without a breach, custodians are able to monetize “anonymized” data to third parties, who can often reconstruct it. In olden times, all of our records were in a paper folder. Breaches were more often related to office staff losing said folder. Incidents where a bunch of guys with a truck stole shelves of folders were rare if they ever happened. IMO, with the exception of inpatient orders, prescriptions and referral automation, most of the impact of EMR has been a net negative to the patient. The fact that all of my providers don't trust the system and ask me the same 5-15 questions every time I see them belies that.
gruez 8y ago
>Totally the same with your data in that one primary doctor's office or whatever still, it's a huge target compared to thousands of doctor's offices >Totally same with your paper records, someone could walk in and steal your data, imagine that. nowhere near as scaleable compared to hacking a site with everyone's records
- Avamander 8y ago
  So what you're saying is that someone is going to steal the entire medical database of everyone and that's somehow going to be more "scalable" than stealing paper records? If that database contained everyone's medical data it will not fit on anything that anyone non-state/non-corporate actor can aquire, and if you have state actor or corporate level of budget one could easily scale stealing paper medical records. I'm not so sure it's going to be easier to compromise super-guarded database compared to a lot of paper records, would like some hard numbers, but those are going to be hard to get.
  - gruez 8y ago
    >If that database contained everyone's medical data it will not fit on anything that anyone non-state/non-corporate actor can aquire source? that might be the case if you're including all the high resolution imagery, but I'd imagine all the text records can't be that big. >and if you have state actor or corporate level of budget one could easily scale stealing paper medical records that would either require an operation lasting weeks/months to hit all the doctors offices (with a small crew), or hitting all tho doctors offices at the same time (huge crew). the former increases risk of detection exponentially, as someone is going to notice eventually, and once people find out, capture of your crew by the police will be inevitable. the latter is also risky because you're going to make a lot of noise assembling said crew, and one of them is going to snitch on you. in contrast, if all the records were centralized in one online database, all you'd have to do is have a small team of experienced hackers hack it from a the safety of a country with no extradition treaty. low risk of one of them snitching on you AND low risk of capture. >I'm not so sure it's going to be easier to compromise super-guarded database compared to a lot of paper records, would like some hard numbers, but those are going to be hard to get. I'm sure on an individual level, it's definitely easier to burgle a doctor's office than a super secure government database. but see last paragraph about scaleability.

sbov 8y ago

You forgot one: * cancer doctor doesn't know about infection, runs chemo treatment, infection spreads and ultimately kills patient. Happened to a relative of mine.