Medical Records During a typical trip to the doctor, you will see shelves full of folders and papers

devoted to the storage of medical records. Every time you visit, your records are created or modified, and often duplicate copies are generated throughout the course of a visit to the doctor or a hospital. The majority of medical records are currently paper-based, making effective communication and access to the records difficult. Americans made well over a billion visits to doctors and hospitals over the past year, with each American making approximately four visits on average. As a result, there are millions of paper medical records lining the corridors of thousands of local medical practices, and for the most part, they cannot be systematically examined, and they are difficult to share. Though the challenge of updating this antiquated system is enormous, companies such as Google appear to be taking up the task. In March 2008, Google announced an application that it hopes will alleviate the inefficiency of the current medical record storage system: Google Health. Google Health will allow consumers to enter their basic medical data into an online repository and invite doctors to send relevant information to Google electronically. The service is free to users. Features will include a 'health profile' for medications, conditions, and allergies, reminder messages for prescription refills or doctor visits, directories for nearby doctors, and personalized health advice. The application will also be able to accept information from many different recordkeeping technologies currently in use by hospitals and other institutions. The intent of the system is to make patients' records easily accessible and more complete and to streamline recordkeeping. Google's mission is "to organize the world's information and make it universally accessible and useful." It's hard to disagree with the worthiness of this goal, and as the undisputed leader in Web search, Google has proven that it is very good at what it does. But what if Google were seeking personal information about you? You might not feel as good about Google's quest to organize the world's information when you consider that some of that information is information that you'd prefer remain private. Google's development of its Google Health application illustrates the conflict between its selfavowed mission and the individual's right to privacy. As with similar cases such as government surveillance and data aggregation, the question is whether or not the privacy risks posed by information systems are significant enough to abandon or curtail the collection of useful information. If information gathering should be curtailed-but not eliminated-how will this be decided and who should decide? Google is no stranger to this conflict of values; this is merely one

example of many where Google has clashed with privacy advocates regarding its information collection practices and handling of that information. With the launch of Google Health, Google aims to be the catalyst for the process of digitizing and standardizing the nation's medical records in an easy-to-use format. Currently only a small fraction, under 15 %, of American medical practices keep their medical records online, making it difficult for patients and other doctors to quickly and easily access them. When a patient changes doctors, begins seeing a new doctor, or moves, the absence of online medical records can be a source of needless hassle and effort on the part of both patient and practice. Sometimes, access to medical records can even be a life or death matter in the rare cases when power failure prevents access to local data storage systems. But the added convenience of easily accessible medical records is just one potential benefit of going electronic. As the healthcare industry continues to face budget pressures from Medicare cutbacks and reductions in managed-care fees, digitizing patient records has become increasingly attractive as a cost-cutting measure. Although many practices consider the costs of implementing new software to be prohibitive, the potential benefits for the industry as a whole are significant. One survey found that 26 percent of healthcare technology professionals cited lack of financial support as the most important factor preventing them from digitizing their recordkeeping. But once practices make the initial investment in new technology, the increase in efficiency is likely to reduce future costs by an estimated $80 to $240 billion dollars, more than enough to make the switch worthwhile. Google Health and other efforts to convert to electronic health records stand to provide much needed organization and efficiency to the healthcare industry, the single largest segment of America's gross domestic product (GDP). But concerned individuals and privacy advocates argue that electronic health records will be stored in such a way that increases the likelihood of privacy invasions. Some potential users of the system are concerned that Google will make their medical information accessible to advertisers in a manner similar to the targeted advertisements Gmail users currently see based on the content of their e-mail. These privacy concerns are far from unfounded. HIPAA-the Health insurance portability and Accountability Act of 1996-provides very limited protections for personal medical records. (lt primarily covers information flowing between healthcare providers, health insurers, and clearinghouses for payment processing.) There are currently no federal privacy protections for patients who set up personal health records online. Even hospitals and practices that currently use electronic storage formats report a high incidence of security breaches, fifth a quarter of healthcare technology professionals exporting at least one security breach in the past year. According to a 2006 Federal Trade Commission study, about 249,000 Americans had their personal information misused for the purpose of obtaining medical

treatment, supplies, or services. But breaches and other forms of medical identity theft are not the biggest concern surrounding electronic health records. . Most people are more worried that sensitive information legitimately accessible via electronic health records might lead to their losing health insurance or job opportunities. For instance, if employers knew that you had a chronic heart condition, would they want to hire you? Though the healthcare industry argues that these privacy concerns are for the most part misplaced, there is evidence that these fears are justified. Horror stories like those of Patricia Galvin reinforce the worries many people have about the privacy of their medical records. Galvin's attempts to acquire disability benefits for her chronic back pain were turned down on the basis of her psychologist's notes, which were supposed to be confidential. The number of monthly medical privacy complaints received by the Department of Health and Human Services has been steadily approaching 750 per month over the past several years, up from 150 in 2003. People fear that a switch to electronic medical records could be even more vulnerable to security breaches and privacy violations. Proponents of electronic health records argue that computer technology, once fully implemented, would enhance security rather than threaten it. They also believe that it is more important to first get the system up and running than to worry about privacy matters. Congressional Representative Joe Barton of Texas, an advocate of legislation that would speed the development of such records, said that "privacy is an important issue, but more important is that we get a health information system in place." Lawmakers like Barton feel that the benefits of systems like Google Health outweigh the privacy risks, and that further legislation to impose privacy control s can be added after the fact. Some experts disagree with that stance, saying that unless an electronic system has sufficient privacy controls from the outset, it is less likely to become universally used. Even if the system's security controls are sufficient, it is important that consumers are aware of those controls and confident that they can use the system without fear of their records being accessed by unauthorized parties. Creating an electronic health system without the proper security controls would not only be an unacceptable privacy risk, but would be doomed to failure because potential users would be unwilling to cooperate with the information requirements of the system. Google has tried to reassure the public that its security is iron-tight and that businesses and individuals should have confidence in its ability to store and protect their data. According to Google senior security manager Eran Feigenbaum, "We've taken an in-depth approach to security, with lots of different layers that build on each other." However, Google has not provided much detail about its security practices- where its computer centers are located, how many people it employs in its security department, and how it protects its army of servers against attack-for fear of opening itself up to attacks.

"Businesses are hoping Google will pick the right tools to secure the infrastructure, but they have no assurances and no say in what it will pick," notes Randall Gamby, security analyst for Burton Group, a Midvale, Utah, research and advisory firm. Feigenbaum adds that Google relies on its own security system and applications for its day-to-day business operations, and that should be proof that its security works. Google is not the only company to set its sights on online medical records. Microsoft and Revolution Health Group LLC, founded by AOL co-founder Steve Case, among others, are also launching similar sites where users can maintain online health profiles. As of yet it is too early to tell whether any of these ventures will be successful in the long term, but Revolution Health Group was forced to fire a quarter of its employees in the face of lower-thanexpected earnings in 2007. Microsoft's venture, Health Vault, is still in its infancy along with Google Health. The federal office in charge of creating a national network of electronic health records, the Office of the Coordinator of Health Information Technology, announced in March of 2008 that it plans to integrate its system with both Google and Microsoft's healthcare databases, among others. The office did not provide details or a timetable on how the integration would occur. Privacy concerns are not likely to halt the shift towards digitizing our records entirely, but will continue to be arguably the most significant obstacle for these ventures as they work towards creating a standardized, digital system for medical recordkeeping.

CASE STUDY QUESTIONS 1. What concepts are illustrated in this case? Who are the stakeholders in this case? 2. What are the problems with America's current medical recordkeeping system? How would electronic medical records alleviate these problems? 3. What management, organization, and technology factors are most critical to the creation and development of electronic medical records? 4. What are the pros and cons of electronic patient records? Do you think the concerns over digitizing our medical records are valid? Why or why not? 5. Should people entrust Google with their electronic medical records? Why or why not? 6. If you were in charge of designing an electronic medical recordkeeping system, what are some features you would include? What are features you would avoid?