Circle The Wagons

September’s terrorist attacks in New York and Washington shook every facet of America’s being. And yet five nights later, as I attended a performance of Stephen Sondheim’s Merrily We Roll Along in a small suburban theater, I was reminded of the vital role the arts play in helping us to understand our lives, our culture, and the increasingly hostile world in which we live. Now enjoying cult status, it’s interesting to recall how this 1981 musical -- which paired the creative talents of director Harold Prince and composer/lyricist Stephen Sondheim for the last time -- bombed on Broadway. Critics and audiences alike wondered how the boy geniuses of musical theater could have hit so far from the mark. Why was this show so bitter? What went wrong? How could this have happened?

Hindsight is a remarkable phenomenon. The ability to look back and re-examine choices made – and how they affected people’s lives – can be cause for rejoicing as well as for remorse. Based on the original play by George S. Kaufman and Moss Hart, Merrily We Roll Along boasts a unique theatrical gimmick. Instead of following the usual chronological direction, the clock ticks backward, allowing the three protagonists to regress through twenty years of their adult lives back to the moment when they were starry-eyed idealists standing on a Manhattan rooftop as they tried to see the Sputnik satellite speed across the nighttime sky.

The ability to pick apart a professional career – as well as the personal choices one makes in life – and peel away the layers of events that led to one’s loss of innocence is like having your life flash before you. In this case, three hours of exposition starts from the bitter end until the audience witnesses the core of good: the idealistic youths who, as they grew older, found themselves traveling down increasingly compromised and cynical paths.

As Americans try to understand what kinds of events or insults could have led to a world in which people are filled with such hatred, the arts frequently open a window into human nature which we may have ignored. Those still struggling to find out where terrorists get such horrible ideas need only look to such movies as The Manchurian Candidate, Independence Day, Arlington Road, Bulworth, American History X, and last but certainly not least, Fight Club, for images which might have inspired September’s tragic events.

Alas, terrorist events are no longer limited to hijackings, bombs, and mass murder. They can just as easily involve the unauthorized use of a patient’s medical record. A recent HIPAA advisory tells the tragic story of an Illinois woman whose photo and medical records were posted to the Internet by anti-abortion activists after she underwent an abortion. According to the St. Louis Post-Dispatch, anti-abortion activist Daniel Michael testified that he and his wife, Angela, had received the medical records in the mail from ‘an unknown source.’ They then sent the records and photo, previously taken by Daniel Michael, to a Mr. Wetzel in Nebraska. Daniel Michael said that the couple forwarded the materials because they were “frustrated that local news outlets had declined to write about the woman's abortion complications.” He further noted that they had intended for the material to be used for informational purposes, instead of being posted to an Internet website.

In reviewing some of the columns I have written for this magazine that warn about the inherent risks of outsourcing medical transcription to entrepreneurs in Third World nations, I was saddened to encounter many of the same issues which are now making headlines. In articles entitled Of Cows and Confidentiality, Fools Rush In, Thanks But No Thanks and How Much Are Your Secrets Worth? I had tried to make people understand that technology cannot always transcend a clash of cultures. And that people in other lands -- even though they may use the same types of computers and word processing programs that Americans have access to -- do not always share our loyalties.

Such cultural differences cannot and should not be ignored for, despite the very best of intentions, they have already led to negative outcomes. It is ironic that, in his September 9th newsletter, Maj (Dr.) Amit Chatterjee, SM (the strategist and founder of MT India) was forced to explain why his website could no longer be free to everyone. “There is a latest group we have identified -- and this group really uses our services!!” he wrote. “Using our free service they blatantly and openly sell pirated software, photocopies of books and course materials, confidential patient dictation and carry out all sorts of fraudulent activity that you can *NOT* imagine!! I do regret that most of our time and energy and much bandwidth is being wasted in catering to and trying to police their nefarious activities.”

In that same newsletter, Chatterjee reported another form of cyber crime involving medical transcription: “According to reports, IGSP Technology Centre India Pvt Limited, a sister concern of IGSP Incorporation, 3550Lexington Avenue, North Suite 100, Shoreview, Minnesota, 55126 USA, signed anagreement for MT work on subcontract with TNIL, a local MT company, on July 4,2000. The agreement bears the sign of Anupama Nangia, director TNIL and OP Bharadwaj, MD, IGSP India Pvt Ltd. The complainant alleged that their Principals in USA stopped work at about 6.30 p.m. on August 21, 2001 by cancelling the access password given to TNIL. But TNIL made repeated attempts to log into the FTP Server in USA. After making several hundred such attempts they managed to log on and downloaded confidential information from their FTP site, the complainant alleged. We have registered a case and confiscated two servers, two monitors, five hubs, one router, one VPM device, an ASM rod and nine connecting cables from the premises of TNIL.”

Make no mistake about the issue at hand. What this scenario tells us is that if an American firm reneges on a subcontracting agreement, it may be vulnerable to computer sabotage from disgruntled subcontractors -- or being held hostage as a result of the theft of confidential medical information. If this kind of computer theft occurs in the United States,there are laws which hold the criminals responsible for their acts. If arrests are made, the perpetrators of such acts pass through a system of law enforcement designed to hold them accountable for their crimes. Unfortunately, the laws of Congress do not apply and are unenforceable in Third World nations. The same goes for our neighbors, Canada and Mexico.

In the three years that American hospitals and MTSOs have been deluged with solicitations from medical transcription firms in India, Pakistan, Bangladesh, and other nations, a dedicated group of American MTs has tried to educate the medical establishment about the risk they keep taking with regard to patient confidentiality.

In many cases, our warnings fell on deaf ears (the same way the findings of the commission on terrorism headed by Gary Hart and Warren Rudman was ignored by politicians in the Bush administration). But we are now at a turning point in America’shistory. As we adjust to an environment in which America’slaw enforcement officials must carefully revisit such issues as security, intelligence, and terrorist acts, the time has come for risk managers, hospital administrators, and everyone else involved in the health information management industry to wake up and smell the coffee.

As children we learned how all the king’s horses and all the king’s men couldn’t put Humpty Dumpty back together again. As adults, we recently learned that all of our intelligence forces and all of our airport security checks couldn’t prevent the tragic events which took place on September 11, 2001. As health information management professionals, we need to understand that all of our encryption programs and all of our HIPAA regulations aren’t worth the code or legalese they’re written in if an angry person in another country decides to “think outside the box.”

What does this mean?

• If its blind dependence on technology didn’t allow the most powerful nation in the world to prevent four simultaneous hijackings, how can we be so sure that speech recognition software can meet the challenges raised by physicians with compromised language skills?

• If all the pipe dreams we’ve been sold about cheap overseas labor cutting transcription costs in half have failed to come true (even Medquist’s leadership admits that offshore transcription has not yet proven to be cost effective or of sufficiently high quality), then maybe it’s time to cut our losses and cancel the experiment.

• With political tensions heating up globally (and passions against the United States running especially high in Third World countries), tighter security means making sure that steps are taken to minimize the vulnerability of American patients to any unnecessary threat.

• If the American economy is truly headed into a recession, then as part of our effort to rebuild we should be giving serious thought to training more Americans as medical transcriptionists. Without meaning to sound overly jingoistic, by keeping American MTs employed we can help our nation by directing their earnings back into America’s economy instead of sending that money overseas.
  
  Nearly every security expert has pointed to the issue of airport security guards (who receive minimum training and are often paid a minimum wage) as being one of the weak points that allowed terrorists to wreak such havoc on our nation. If the medical records community can salvage one valuable lesson from this horrific chapter in history, it is that you get what you pay for. And that the lowest price per line does not necessarily give the best value or strongest assurance of patient confidentiality.