My fascination with the benefits of patient portals continues to grow as the technology continues to grow in popularity.
Given their resurgence in popularity over the course of the last three or four years, and with the latest push for patient engagement through stage 2, clearly they have a very strong future in the practice of healthcare for the foreseeable future; probably until a game-changing technology moves us beyond the era of EHRs.
Until quite recently, patient portals have been viewed as a novel concept, and, overwhelmingly, practice leaders and physicians kept coming back to how they were going to get patients to actually use the communication systems, and, likewise, what benefit would they deliver the practice if the patients used them.
It’s safe to say we’re now living in a different time than even just a few years ago. People are more mobile, landlines have been cut and actually using a phone to make a call is essentially going to the way of the tube television.
We’re in an always on society where access to information, regardless of the subject, must be had. As you’re well aware, portals don’t necessarily come automatically with your EHR; they’re not bolted on, in other words. They cost money in addition to what you pay for your practice management system and electronic health record. In some cases, they’re actually quite expensive, or have been known to be in a traditional sense.
And, if the case could be made to invest in the technology (practice portals that is), the most obvious question often went unanswered: How can a practice bill for the time spent by its physicians when administering it and when responding to communications from patients, for example.
I digress. This is all water under the bridge. Everyone knows this stuff. It’s been overworked and underpaid.
The feds now require portals to play a huge part in health IT through meaningful use. Insurance companies are now jumping on board and allowing physicians and practices to bill for the time they spend administering data collected through portals, and patients have become so engaged in their mobile lives that it’s only a short matter of time before portals are utilized as heavily as online banking and ATMs, let’s say.
When I began thinking about this post, I thought of grandiose ways in which I could depict the usability of the portal and speak to its ever-increasing importance to the world of heath IT, but I just don’t think I can sum up their benefits better than simply listing them, as they speak for themselves.
As we know, patient portals can increase patient engagement by providing secure access to medical information online. Additionally, they allow physicians to:
Send and receive messages to and from doctor’s office
Communicate with patients through secure messages
Post lab and imaging results
Send reminder notices to patients
Post patient consent forms
Make billing information available
Provide patient education materials
With patient portals, patients can:
View and enter medical history
View and update allergy and medication lists
Send messages to their doctor’s office
Complete registration forms
Update demographic information
Request appointments and prescription refills
Obtain patient education materials
View account statements and pay medical bills
Not a bad day’s work for a fascinating bit of technology that’s changing the face of healthcare IT.
Will meaningful use Stage 2 reach patient engagement?
Patient engagement now requires patient action. So says the Department of Health and Human Services in meaningful use stage 2.
As a patient, your physician is counting on you to engage with him or her. It’s up to you, folks, to bring it home. Your physician’s incentive, and ultimately his or her potential non-penalty for Medicare, is on your shoulders.
That’s an awful lot of weight to bear. Can’t you feel it? It’s overwhelming. I’m exhausted just thinking about it.
Seriously, though, I’m confused. Someone please set me straight; seriously.
Meaningful use is now up to the patient? Whether or not I choose to interact with my physician via electronic means determines his/her level of success as gauged by the government?
I’m sure I don’t need to recite the language from the ruling, but I’ll do so for good measure.
Five percent of more of patients must send secure messages to their physicians (yes, I said “must”)
Five percent or more of patients must access their health information online (yes, I said “must” again)
The language isn’t written in an inviting tone, but one that tries to demand respect. It doesn’t say “may’ or “can,” if says “must.”
Is this a Ray Kinsella moment and HHS’ field of dreams?
“If you build it, he (they) will come,” sounds the whispered voice across the sky.
Cue the sound of rustling corn fields blowing in the wind as each of us imagine memories of our happy places where dreams live on forever.
If this gets built, will we all come and play? How can this be a requirement of our physicians? How can their level of success, the quality of the care they provide, be gauged based on whether or not I choose to interact with them via the web? After all, I want healthcare, not a Facebook friend or a Twitter follower. (I’m using obvious over exaggeration to make a point.)
I am all for patient engagement and believe it will increase given time and effort behind it, but forcing me — as a patient — to do something makes me a little less likely to follow so easily along. I’m not a lemming, and I don’t intend to be.
Sure, five percent seems like a manageable number; not that big of a deal. Surely, it’s just a few people, right?
Until next time, when the number increases to 25 percent of the overall patient population then 50 percent then 75 percent and so on until it’s just mandatory.
What might be the most troubling, though, is how this affects physicians and practices. Engaging patients to receive incentives and keep from being penalized becomes a marketing function, not a care function.
I can see it now: Your doctor will start offering club-type discount cards and try to cajole you with attractive terms like, “Sign up today for the patient portal and after you send just one email to your physician, you’ll be receive a $5 credit to your account.”
Or, perhaps the whole thing will have physicians sounding like to cashiers at Target: “Sign up for your patient portal access today and you’ll not only receive a nifty tote bag for your things, but you’ll get 25 percent off of of your next purchase!”
Lastly, I’m reminded of the lines of credit card pushers lining the student union of every college in the U.S. trying to convince our young and inexperienced that credit is the same as cash, don’t you know.
As noted on HealthWorks Collective, meeting this portion of the stage 2 requirement will take everyone in the practice, not to mention the support of those outside it.
But portals can only facilitate access to patient’s information, but it can’t force the participation of people to do something they don’t want. Requiring physicians and their practices to encourage me to engage with my care providers is up to me, and no matter how useful or entertaining, whether I choose to engage is something I commit to on my own terms.
Just because “they” build (read as “require”) it doesn’t mean I’ll come.
Death by PowerPoint: Overly used templates filled with a variety of bland information that does little to emphasize the point of the presenter. In this scenario, slides are often filled with generic information that could have been excluded the presentation in the first place had the speaker actually taken the time to time the point he was trying to make.
Likewise, there’s “death by a thousand clicks.” Pretty close to the term “death by a thousands cuts.”
The oft used phrase is usually mentioned by physicians, practice leaders, members of the health IT community and nearly everyone to interact with a template-filled electronic health record. It’s derived from the seemingly endless clicking as a user navigates the encounter note in the respective system, or so the story goes.
Click after click after click of the same, repetitive information in case after case, even if two patients present with the exact same conditions on the same day. No matter, when using a template system, you’ll be forced to re-key every piece of detail and click the exact clicks as the previous encounter, no way around it.
All the clicking reminds me of a cartoon I saw recently. It goes something like this: a doctor goes to his doctor for an exam. “What seems to be the problem,” the presiding doctor says to his doctor patient. The doctor patient replies, “Well, doc, I think I’ve developed a case of carpal tunnel syndrome from too many clicks in my EHR.”
I recently met Dr. Bob. Those of you with a Praxis system know who I’m talking about. In actuality, Dr. Bob is nothing more than a mascot for Praxis, which is the maker of template-free EHRs.
After ridding his practice of paper, Dr. Bob celebrates because of his decision to implement some technology. However, he quickly finds himself boxed in by templates and non-customizable data fields populated by click after click. “The templates soon bogged him down. Everything was a drop down menu or pick list. His thoughts had to pick one of the options. There was no flexibility.”
Templates slowed Dr. Bob down. Dr. Bob felt more like he was becoming more like a data entry clerk than a physician.
I thought so.
The Praxis system is written by its users in free text. The more it’s used, the easier the system is to use, remembering data from an earlier note and it essentially begins to auto populate certain data that can then be customized and changed given the varying scenarios encountered during the visit.
The system allows you to enter a few minor details like condition or medication as you to build a case. The system remembers the details of each encounter and when you enter similar details again in the future, it helps you populate the field.
And the “thinking” the Praxis system does on behalf of the user is essentially the same as what you’d find when using Google to search the web. For every search conducted, Google remembers your past searches and auto populates what it thinks you are attempting to find. And, as you type, Google offers suggestions for what you might want to see.
From the demo, it’s clear the template-free system has its advantages and certainly would alleviate the some of the click, click, clicking. For some users, though, they may not enjoy the freedom the system seems to provide as it seems to provide the exact intuitiveness that so many EHR users seem to crave.
All in all, it’s intuitive, fast, and – in my opinion – pretty slick.
So, for those of you seeking more flexibility in your system and wanting to do away with the endless clicks and data administration, the Praxis system seems pretty cool.
And for the record, Praxis had nothing to do with this post; the company didn’t know I was writing it.
While the final 50 or so percent of ambulatory physicians decide whether to implement electronic health records and others re-evaluate their technology plans, which may include switching the systems they use, it seems like as good of a time as any to continue the series I started about the steps that need to be considered when selecting an EHR.
At this point in the process, you’ve obviously gained the understanding that it’s an arduous process and requires a great deal of planning. But, you know that. You’ve done the planning and you’re beyond examining how implementing the system will affect your practice’s workflows.
So, when you’re gearing up to finally take the plunge, or if you’ve decided to get out of the water and dive back in, the Office of the National Coordinator provides the following guidance for moving forward with these EHR implementation tips.
Here’s a concise breakdown:
Get to know as quickly as possible how vendor and its products will help you accomplish your goals. Test drive the product and never take the word of a salesperson without vetting it with other professionals using the product. You might also shy away from vendor-provided references as they tend to receive incentives from the vendors for giving them. And, according to ONC, “Provide the vendor with patient and office scenarios that they may use to customize their product demonstration.”
Clarify pricing of the entire implementation prior to signing the dotted line. You want complete pricing for all things including: hardware, software, maintenance fees and upgrade costs, interfaces for labs and pharmacies, cost to connect to health information exchange (HIE), customized quality reports, etc. If it’s offered, ask for the price and get it in writing. Every time the deal changes, get a new written quote.
Like pricing, define implementation: amount of time, schedule of completion, and availability of trainers and what’s included in the training.
Ask lots of questions about data migration and how much it’s going to cost. Ensure a structure for the data rather than simply allowing for a dump of information. “Clarify roles, responsibilities and costs for data migration strategy,” the ONC suggests. The amount of data you need to transfer, the more complex the process will be.
Know whether you’ll be better off with on-site server or a hosted, Saas solution.
Can the system be integrated with other systems easily? If so, ho much does it cost?
Privacy and security capabilities and back-up planning: are there any?
Is your proposed vendor stable? Will it be sold or divested? Does the vendor have a strong local presence? Are those practices leaders in the local market? Do you hear good things about said vendor?
Can the system connect to an HIE? How much does it cost?
Is the length of the initial contract much too long – like a five or seven year lock in – and does it potentially keep you from exploring alternative options should you need to make an earlier exit?
Finally, according to the ONC, though it may seem a little off topic, “Consider costs of using legal counsel for contract review verses open sources through medical associations.” Nevertheless, seek legal counsel before accepting the vendor’s agreement.
The best time to protect yourself from a poor decision involving the vetting and purchase and an EHR is during the shopping and review process. Take time at the beginning of the process to ensure you know what you’re getting, what you’re paying for and, ultimately, what type of vendor partner you’re going to get once the ink on the contract has dried.
EHR structured data begins to make a play for importance as health IT moves into Stage 2 and we begin to require useful and useable information. It’s not a new topic, but one, much like ICD-10 I suppose, that has had many a practice leader hoping to push off until later.
Unfortunately for many, the days of structured data are upon us. Hoping that the data you dumped into your system when you implemented won’t be a problem for you in the future may now begin to start causing you some nightmares.
For many practices, as they begin to look at their data and hope to find a treasure trove included, they may be surprised to find much of the information worthless, as least when trying to compare to health information as a whole.
Why? Well, according to Computerworld, there’s just not enough EHR structured data. For example, pieces of data like problem lists, medications and allergies are inconsistent between the varying EHRs and the codes are often different between the different products.
Perhaps most importantly, though, is during the initial set up of the EHR. Practices looking to get their systems up and running, they often simply dump data in and move on to the next step of the training process. This, according to Computerworld, means a lack of protocols, standards or proper charting of the data.
As we’re now finally beginning to see is that the data that goes into the EHR must come out in a standardized and useful way so that it can be reported through meaningful use and exchanged through HIEs and electronic health records.
From Computerworld, “EHR structured data is required to aggregate, report and transmit the collection of data at the point of care, it is often perceived by physicians to inhibit their ability to practice medicine and document in a fashion they feel is most effective.”
Again, the lack of proper protocols and creating a culture of success can sink a practice in the long term. Simply dumping the data and letting providers practice as they see fit is a lot like public companies with their eyes on short term, end of the quarter returns rather than trying to build a successful foundation to create a stronger organization even if it means a slower, more steady return on their investment.
In fact, a case might be made that suggests that the loss of productivity physicians face when first learning their EHRs could be related to their use of structured data. Creating a process for them to follow from the beginning will pay huge dividends in the long run. In the near term, though, there will be a minor fall off in productivity.
There are some solutions for streamlining your data structuring process:
Create a committee to police standards to maintain clinical information in your EHR and HIE
Educate physician on the importance of capturing structured data, but allow the some ability to customize how they capture notes, for example
Spread the workload for capturing structured data among your staff and allow physicians the ability to focus on providing care and maximizing their productivity
Prepare your technology solutions for extraction, and utilizing, structured data. An EHR along may not be the only solution you need to get the data you need. Plan ahead and remember that one size fits all rarely does.
Follow these, and perhaps few of your own, and the value of your data will be worth a whole lot more for your organization in the long term than any unstructured attempt you make.
Some of the most concise, yet useful, information about health information exchanges must come from Medicity. In a “primer” page (that might be written for the HIE novice) there’s quite a nice bit of information about the importance of the technology.
Obviously, Medicity is biased, as HIE is what it does, but I admit that after reading some of the points Medicity makes about the importance of HIEs, I’m sold (though I already was).
Let’s dig in.
As we know, health information exchanges help connect healthcare providers with information they likely would not have through paper records, and in many cases, not even with electronic health records as the EHRs are often fragmented or don’t depict the entire health scenario of a patient.
As noted by Medicity, HIEs help create efficiencies in the care setting in many ways, primarily by helping make information available across many platforms and even across many care locations.
Additionally, and I’m paraphrasing here: HIEs help reduce duplicate testing of patients; help create a more complete picture of a patients’ care and prior treatment protocols; and they help eliminate costs and fees associated with redundancies.
The best case I can make for an HIE (probably for an EHR, as well) is a story from a former colleague. Her mother was diagnosed with an aggressive form of cancer. At best, she was given months to live. However, after multiple specialist visits, redundant tests, labs and scans delivered the same information as the previous test, the woman died just a few weeks after initial diagnosis.
Moral of the story is this: according to my colleague, for every specialist she and her late mother visited, each one requested the same tests as the previous doc because the doc didn’t have an accurate, or complete, record. To make matters worse, the records were paper. My former colleague said the task of trying to assemble a complete care record was beyond arduous, not to mention difficult to construct given the red tape each practice had in place as the gate keeper of the records it kept.
If only the information had been in a single repository, perhaps her mother wouldn’t have wasted so much time on taking the same tests and she could have received the care she needed, my colleague said. I agree.
So does Medicity, which operates on the belief that HIEs change all of that. Simply and clearly put, HIEs “break down silos and make information available” to providers at virtually any location that’s connected to the HIE when the information is needed and required.
HIEs, like EHRs I suppose, can change and possibly save lives. Interestingly enough, at least to me, is that HIE’s lag in favor or in the very least have a history of not being able to generate the support they need to thrive (perhaps survive?).
As the government continues to place more importance on the availability of health information through exchanges and electronic records, the market will find a way to monetize HIEs (probably the biggest hurdle vendors face when considering whether to develop technologies to support them).
There are now, though, several vendors with their own HIE-like devices that can function within their EHRs the same way their patient portals work. They are able to trasmit data to other users of their company’s specific technology.
As these vendors continue to develop their own HIEs, and try to sell them, it will be interesting to see which technology – private or public – will be adopted by the healthcare community.
A special day here today; time to reflect on the direction of one’s life and its path. The past, its present and the future. It’s a hard process sometimes to think about where one has come from and, and most difficulty, where one is going; where one wants to go.
My time off the grid today was spent with those that matter most, because I could. Left it all behind and felt like I went back in time before technology placed me in the always on mentality. It felt nice taking the time to focus on other priorities and spending time disconnected.
Have to admit, the time away did make me think about life back on the ranch, though. Specifically, the promises told of health IT and how they make the lives of those who use the systems in their professional lives better, easier and efficient.
It might be a bit cliché by now, but during my time serving the health IT industry and its professional partners, I’ve told and been told countless times how systems like EHRs allow physicians to practice more effectively in a shorter amount of time and essentially lock up shop within minutes after the final patient has left.
In fact, I’ve seen testimonials by clients of one vendor say nearly this exact thing, and I understand from personal experience that this can be an actualized reality if a proper plan is put in place and a procedure is established for getting there.
And, just recently, in this forum, I featured Dr. David DeShan who is now able to follow his dream of heading up a medical mission in Russia while also maintaining his partnership at a practice in Texas, all because of his EHR.
So, despite all of the marketing speak and the canned comments, the question is: Do these healthcare technologies actually allow providers a better quality of life?
Are you able to hit the road a lot sooner now that you have a system in place or are you just a workaholic and despite the tools you have you’ll always find a way to work more than you should?
Does health IT make your lives easier? Are you able to spend more time with loved ones or more time on the links? Are you more flexible and able to live a richer more fulfilling life because of your technology or is it all wishful thinking as far of you are concerned?
Finally, have you been able to create more balance between work and personal life since you implemented your system and implemented equipment like tablet PCs or has access to work information while on the run been that more pressure on you to perform.
My situation is different, obviously. I simply turn off my computer and ignore my phone. I’m not in the business of saving lives; I just help people and companies tell their stories.
I’d love to know, once and for all, does it really matter or are these “potential” benefits just a bunch of marketing speak?
When I go to the doctor for a check up of another ailment, I understand that the record kept regarding my care is ultimately mine. Not because I’m told, not because I’ve asked (though I have on some occasions), but because the information collected comes from me. Without my providing it, my physician would not have it to keep it.
Maybe it’s my make up, but I pride myself on knowing what others often consider trite and trivial. For most, knowing who owns their health record is exactly that, trivial.
Interestingly, though, is that for every person with a health record, there are the same number of people with a care provider to tell them that the record is theirs. So why then doesn’t everyone know that their health record is theirs?
I don’t think the answer to this question lies in the patient apathy or the population’s potential indifference toward their health outcomes. Innately, I believe people do care.
The point I’m making here is that I think the ONC’s latest effort to market direct-to-consumer (DTC) information is well intentioned but perhaps the burden for doing so is misplaced.
Do we think physicians and their practice colleagues should be spending their time doting on the ownership of their patient’s health record? Is anything other than patient health and outcomes a priority they should be focused on? The ONC thinks so, and given meaningful use and the increased pressure providers face to record and provide results of meaningful health outcomes, physicians are being arm twisted to ensure this level of grassroots marketing provides the ends to the ONC’s means.
Certainly, we as consumers must continue to receive information and education to keep us informed about the world of health IT. It’s true that very few actually understand just how far back healthcare technology is from the mainstream in regard to use of technology. But, as I’ve said before in this very forum, should all of the responsibility for this lie on the providers’ shoulders?
Not so, in my opinion. Sure, physicians and care givers can be advocates to consumer enlightenment, but more of the responsibility really should go to the health IT vendors. After all, they are the ones selling the products to the physicians. It behooves them, and enriches them, the educate consumers to the value of the systems’ worth and how help improve health outcomes.
Sending this message to consumers, and helping to educate them of the benefits of these systems, will go a long way toward convincing them that their physicians need the systems. If consumers find value of these systems, they’ll let their wallets do the talking and give their business to physicians and practice that employ health IT.
And, if the physicians are truly going to be “the sales force for health IT,” perhaps it’s time the vendors started incentivizing these walking billboards the ONC wants them to be.
In speaking with a CEO of a major EHR/PM vendor recently, the conversation about the future of health IT kept coming back to money. Not necessarily the money saved by practices because of the implemented technology, but the money being flushed into the space by the government.
Though the money is flowing and the incentives are pouring into the economy and getting freely spent, there are obviously some still inside the vendor (and probably the practice) space that remain concerned about the viability of the government’s financial involvement in health IT in the long term.
The federal government’s money has created the structure of what we now know as health IT. Because of the push – the money, or the carrot and the stick, if you will – there’s now a deeper foundation set; there are studs and rafters in place, and even a few pieces of siding in some cases.
With roughly half (being generous) of the ambulatory market currently using some sort of an EHR, ground has obviously been gained in the market. It would have come eventually, the advancements, but the federal incentives no doubt hastened the proliferation of the technology. But, for the sake of argument, let’s say the federal money drives up or is re-appropriated. What happens then? Where does that leave the market, as my CEO colleague hypothesized?
I hadn’t exactly thought of it that way, especially now at this late stage in the program. But the man does pontificate an interesting point.
Given all of the money flowing into the health IT market, it’s one of the few booming economic segments, and given the number of parties staking claim to it hoping to make monumental returns on their investment, the scenario actually brings another very similar boom to mind.
From early 2004 though 2005, the profits were record breaking. Ad sales were way up, circulation was expanding into new markets and staffs were being bumped up to counter efforts made by the competition.
However, by late 2006, as a cautionary note, hiring slowed and expansion stopped. At the beginning of 2007, the layoffs began. Reporters, editors and production staff were cut. The newspaper chain I wrote for shuttered offices and cut more costs. Another round of employees was let go. Ad revenue hit the floor; newspapers stopped circulating, the market shrank and even more people were laid off. The business entered a tailspin that even now, five years later it hasn’t recovered from.
It never will.
The boom times went bust, and for newspapers, caught up in the seemingly never ending flow of cash from advertisers, who happened to be home builders and contractors, little planning for the future was done and any thoughts of a rainy day fund seemingly were little more than thoughts.
In Florida, at the time, you couldn’t spit or throw a stone without hitting a new housing development or condo conversion. There were housing starts everywhere. Houses, in all phases of development, were being erected. The building was constant. There was no end in sight. Contractors were hiring employees everyday, banks were lending, people were fighting, literally, over houses that were for sale.
When the boom was booming, everything even peripherally related to the market was booming. But when the housing market busted, well, I don’t need to tell you about how that affected each one of us.
So, my friend the CEO asks an interesting question. One that was probably asked thousands of times during the great housing bubble of the middle of the 21st century’s first decade: What happens if, God forbid, the money suddenly runs out of Health IT?
Come down to South Florida and see. I’m sure you could get yourself a pretty good deal on one of the thousands of properties sitting half built and empty.
Sure, they’ve got a good foundation, walls, rafters and, in some cases, a bit of siding, but they sure aren’t much to look at much less much better to live in.
In honor of the first ever National Health IT Week, here’s a gem of a story that seems to voraciously support the need for more integration of electronic health records, and technology in general, to find their way into more medical practices.
According to an article published by Referral MD, in a report issued by Health and Human Services (HHS), despite all of the attention surrounding the security of electronic health records, in actuality, between May 17 and June 17, there were 45 security breaches involving paper health records – 42 more than with EHRs.
I shouldn’t be surprised by this, but I guess I am. Perhaps I’m programmed to think about EHRs exclusively, but paper records are still the majority of records kept, at least in the smaller ambulatory practices where EHRs haven’t been implemented, so security breaches in environments like this are quite likely.
According to the report, the following fit the definition of a “breach,” including theft, unauthorized access, improper disposal and loss.
Some of these I understand, to a point. Loss. That’s easy. It’s one of the most common complaints about paper health records. They get shuffled about the office, from room to room. With the library of other records, it’s surprising that more don’t end up getting misplaced. Getting found is another story, though. If they’re found, what happens to them? Are they then stolen? Five-fingered discounted from the crevice in which they’ve been laid? And, truly, if practices are losing copious volumes of paper records – I’d think losing records would be somewhat of an ongoing problem because of internal procedures and record keeping – then I don’t want to patronize the practice.
Improper disposal. Well, that doesn’t take too much imagination, either. In fact, I once remember not too long ago that the state of Oregon disposed of thousands of Medicare patients’ records improperly by simply tossing them in a dumpster behind the state’s office building, in the same dumpster shared by the state’s capitol newspaper, The Statesman Journal.
If an organization as large the state of Oregon improperly destroys paper records, I’m sure countless others do so as well.
Unauthorized access. Okay, sure. Unwanted eyes get their mitts on the occasional (I assume it’s the occasional) record and potential danger ensues. I’m not sure how one goes about getting his mitts on someone else’s records since I’ve never thought of wanting to see someone else’s record, but I assume it has to do something with hurdling the records desk and making a mad dash for the shelves with the millions of cream-colored folders.
I jest. Obviously, info thieves aren’t jumping over counters. Perhaps one of you can set me straight, but I imagine it happens as a passerby passes someone’s record that’s sitting in the pocket outside the exam room door or something similar; just a passing glance at someone’s record as they scurry on by.
The hard one for to understand, though, is record theft. How are these records getting stolen? From a doctor’s car as he runs into the convenience store for a soda? Are they misplaced in some unfortunate public place? Are they scattered to the winds by disgruntled employees?
How on earth do they disappear?
And, perhaps more importantly, could any of these breaches been avoided with the use of an electronic health record?