No network is an island.
An outage at the Smart Systems for Health Agency's (SSHA) One network in January that left several hundred doctors in Ontario unable to access patient health records for several days has roused concerns about the risks of housing electronic health records (EHRs) in interdependent networks.
There has been insufficient attention paid to the potential problems, says Elaine Gibson, associate director of the Health Law Institute in Halifax. "The issue of liability is almost an untested field here."
Legal liability issues will likely come to the fore as more and more healthcare information is digitized and centralized in networks, says Gibson. About 10 per cent of patient records have been digitized in Canada at this point, but Canada Health Infoway's goal is to have EHRs for 50 per cent of Canadians by 2010.
SSHA's One Network connects over 7,000 healthcare sites across Ontario, explains CEO Bill Albino. "The optical core network goes across the province. On top is the distribution layer which connects hospitals and LHINs. There is also an off-core access layer which connects small- and mid-sized service agencies and physicians' offices."
The network glitch affected about 300 physicians who are still using older technology for their network connections. "We are getting rid of ADSL connections, which were put into some smaller offices about four years ago, but there are about 4 per cent we haven't gotten around to," he says, noting about 330 offices were affected by the glitch.
Patient safety was not an issue in this outage, he says. "Our hospitals have much more robust connections, as do areas where remote e-diagnostics are done. I don't know that physicians' offices deal with life and death cases over the network - they mostly use it to look up information or access portals."
Albino emphasizes that the problem did not originate in SSHA's network, but rather cascaded through from the service provider's network. "Bell Sympatico made changes in its residential service, which meant physicians using ADSL couldn't log into the clinical systems in their offices from their homes," he says.
Bell Canada has the right to make changes to its services, but it did communicate this one to customers, he says. "To this day, Bell has not advised us what changes they made in their settings."
It was a difficult problem to diagnose, since remote dial-in was not an issue in One Network's own settings, and also difficult to correct, as communications of software fixes to doctors' offices had to be done by phone and fax, he says. "It was a regrettable thing that some physicians' offices were down almost three days, but the number affected was not high."
A commentator suggested such a long outage would not have been tolerated in a financial network. But Albino says SSHA's network is designed to be up 99.5 per cent of the time, and its performance is on par with any managed private network used by a financial institution. And these nevertheless fail periodically too. "The Royal Bank's system was down for weeks, and the CRA's e-filing system went down in the middle of tax filing season," he says.
Bullet-proof, fail-safe networks don't exist, he says. "It's impossible to design a network that will never go down - no one ever has. Ours is engineered to the highest level of reliability that is affordable. Providing complete redundancy would cost unbelievable amounts of money, and no organization does that, not even banks."
It would cost 10 of millions to upgrade about 10,000 physicians' offices network connections to provide redundancy, he says. And even if the Ontario government were willing to foot the bill, it would still be impossible as there are many parts of the province where Bell Canada is the sole provider but a separate ISP is needed to provide back-up services.
Albino says the SSHA has set up a task force to look into less expensive technology to provide emergency back-up service. "We're looking at ways to improve our resiliency, as distinct from redundancy, which implies full emulation of service."
In addition to network outages that can prevent access to medical records, Gibson points out environmental experts are also predicting more power outages in the coming years as energy prices escalate.
"Even if it's not a medical emergency, there are still issues around lack of access to a patient's records, for example, in prescribing medication, "she says. "The solution is to set up a system of duplicate records, either paper or digital back-ups in the physician's office, but once you get into a system where you have more than one set of records, that raises other problems."
While the SSHA's outage was minor, there will likely be more serious problems as Canada increases the number of EHRs - and the lawsuits will come, she predicts.
There are so many players and interdependencies in developing and housing EHRs - software developers, healthcare institutions, ISPs, power companies - that affixing blame to any one entity would be difficult if some disastrous outage occurred.
But under tort law, liability is apportioned by percentage to all players - and the government is named in about a third of tort lawsuits, she says. "The more parties you have, the more likely courts will find liability in a tort case. And this is the prime reason the government is often named in these cases - there will be at least one party that is solvent and can't declare bankruptcy."
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