Our Short-Sighted and Divided Country Looks for an ACA Replacement

We have short attention spans and shorter memories. That serves politicians well but it makes bad policy.

Say, for example, you decided to run for President of the United States but you pulled a really stupid college-style prank, like plagiarizing someone else’s work, that makes you ethically ineligible for the presidency when the story gets out.  If you’re lucky, voters and even journalists who investigate the backgrounds of candidates might well forget your indiscretion a few decades later and you could end up, say, in the  White House a heartbeat away from the Oval Office.  You just never know in politics. Yesterday’s bum steer could end up today’s political sacred cow.

Take Obamacare. Please.

Way back in 2010, the public furor over the passage of the Affordable Care Act meant that some legislators were afraid to go home on break. Representatives’ offices were picketed, windows  broken, personal safety threatened. Citizens were very unhappy with the ACA’s mandatory coverage and legislated benefits packages that didn’t suit their needs and cost more than their current policies that allowed them to keep their plans and their doctors.

How unhappy were they?

As the October 2013 rollout approached, one health insurance company required training for their call center employees to teach them how to calm down member subscribers. The insurer ordered the training because it knew that it would be sending out letters terminating current policies and replacing them with more expensive, government-mandated ones. They anticipated the tears and anger, and put call center employees through sensitivity training to handle distraught customers.  That company knew well before the ACA launched that people could not keep their plans or their doctors, and that their rates would skyrocket to make up for it. The people who wrote the law, promoted it and voted for it probably knew, too. If they didn’t, they should have been fired.

Oh, wait! They were.

And here we are, in the land of Repeal and Replace.

In an administration where each new regulation requires that two are de-commissioned, we can expect a flurry of confusion from an industry that operates on auto-respond to commands from DC. While healthcare doesn’t like having to zig and zag to expensive orders from DC, providers, insurers, patients, drug and device manufacturers and even IT companies are used to reacting to dicta from federal regulatory agencies.

The most widely, publicly discussed aspects of the ACA pertain to patient coverage. The public is concerned, and understandably so, about the fate of mandatory coverage for pre-existing conditions and the 26-year-old dependent coverage clause. Everyone is required to have coverage so those who flat-out can’t afford it get subsidized. Those who flat-out can’t afford it and don’t meet the income thresholds for a subsidy pay a penalty.  Part of Repeal-and-Replace is figuring out how to address the grievances of those who haven’t fared as well under ObamaCare as they did under their former policies, and assuage those who have benefitted. It’s a job fit for a politician. Other normal humans would not want to find themselves between that particular rock and hard place.

On to the other aspects of Repeal and Replace, those aspects that affect the way the healthcare industry operates and gets paid. What happens to an industry when the regulatory bonds are loosed?

Under the ACA and other related legislation that support various facets the healthcare industry overhaul, doctors face new reimbursement models starting this year based on certain performance targets with rules so arcane that most did not even know late last year that they were subject to the new payment system called MACRA. Other laws resulted in providers and hospitals installing electronic record systems trying to catch the Meaningful Use stagecoach to reach reimbursement targets. Meanwhile, many doctors complained those same mandated electronic records systems were detracting from patient care.

On other fronts, providers are wondering what will happen to accountable care organizations, a concept best achieved with great data capture and analytics that rely on the integrity of the aforementioned electronic health record. Speculation abounds about the fate of other ACA spawn, such as bundled care payments, care coordination and value-based payment models that attempt to support population health in an effort to control costs.  

Finally, when President Trump told a joint session of Congress this week that he wants to loosen the reins on the FDA approval process, you could almost hear a little cheer go up from the pharmaceutical industry. But in the next breath, when he mentioned cutting price deals with drug companies, you got murmuring from the same quarter.

Certainly, many ACA and ACA-spawn initiatives have philosophical merit, as well as their defenders and detractors. The question before the healthcare industry now asks whether an affordable healthcare system can best be reached with less government over-reach?

The answer lies in whether initiatives that are rolled out naturally as a consequence of their merit will lower costs, improve outcomes and increase access, and can do so without adding a regulatory timeline or requiring an outlay of billions of dollars on the part of the government or the health systems that have to dance to the piper’s tune.

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The President’s Day Edition of Health Wonk Review on Your Virtual Newsstand Now

politicsDavid E. Williams is on top of the President’s Day Edition of Health Wonk Review. Click here to go to David’s Health Business Group blog for this special edition on your virtual newsstand today.

I also want to add my mea culpa that I have not been a good corporate HWR citizen and contributed lately. Writer’s Block? Actually, it’s been Writer’s Overwhelm…there is just so much I am still figuring out where to start. In the meantime, let’s all be thankful that the HWR crew remains faithfully on the job.

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Posted in biotechnology, consumer health apps, electronic patient records, health economics, health insurance, health IT, health policy, health reform, healthcare marketing, pharmaceutical marketing | Leave a comment

Fresh Prints: An All-New, Alt-Fax Edition of Health Wonk Review

2017-02-09-alternative-facts-edition-1

Health Wonk Review for February 9, 2017

#alternative_facts Edition

Honesty is such a lonely word. Everyone is so untrue.

– Billy Joel

The title of Billy Joel’s hit song wouldn’t have been nearly as appealing – and probably harder to pair with a melody if he had called it #Alternative_Facts.

Steve Anderson outdid himself again with this latest edition of the HWR. You will want to read the rest of this edition here.

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Health Wonk Review’s Inaugural Edition: Read It Here!

For our Health Wonk Review afficianados, here is this week’s blog aggregation in toto. Enjoy all Joe Paduda’s hard work, and those of the other contributors.

Health Wonk Review’s Inauguration Edition

by Joe Paduda of Health Care Matters

Through election after election, HealthWonkReview has been your go-to source for the real impact on healthcare, health policy, access, coverage, and the rest of the story about the industry that accounts for one-sixth of our nation’s economy.

In preparing this edition, I was struck by how much better these blog posts were than pretty much any articles in the mass media (with a couple notable exceptions.).

The depth, understanding of core issues, knowledge of how various parts of ACA interact, and ability of the authors to explain all this in words everyone can understand is impressive indeed.

Louise Norris, Roy Poses, Andrew Sprung, David Harlow, David Williams – these are the folks you need to be following.

Repeal…

Andrew Sprung’s contribution is a welcome list of 7 ways the GOP could blow up ACA gains.  Or maybe not.

Andrew describes various paths to repeal and replace, dissects the problems, perils and promise of each, and handicaps the odds.  It’s a very, very insightful read.

Tick, tock…Louise Norris just keeps getting better and better; as a small-business insurance broker she is on the front lines AND understands the core issues affecting ACA and health policy.  Her entry this month discusses the Republicans’ plan to have legislation ready tomorrow – yes, January 27 – to begin the repeal process. 

A bit of background on the trump Executive Order that required the January 27 legislation comes from the estimable David Harlow.  A quick read, and a valuable one.

Friend and colleague Bob Laszewski’s wondering if the trump administration is prepping for it’s own “if you like your insurance you can keep it” fiasco.  In a great companion piece to the Norris and Harlow reportage, Bob asks a question the current administration likely didn’t:

if you take this new executive order to its logical conclusion, doing things like killing or easing the individual mandate or allowing for cheaper medically underwritten plans can’t have any effect other than making an already fragile Obamacare risk pool worse. Making the pool worse can only lead to fewer consumer choices, or no choices, or higher rates and bigger out-of-pocket expenses for those who remain in the Obamacare risk pool.

My entry this month compares the Republican position on repeal and replace to Wile E Coyote’s headlong charge off the cliff.  Beyond repeal and into replace, things could get pretty interesting – as Mr Coyote learns every episode, it’s not the fall that hurts, it’s the reality of the landing.

As I see it there are two main issues:

  1. Repeal without replacement is a budgetary and political minefield.
  2. Congressional Republicans aren’t even close to agreeing on what a replacement bill would look like

One of the big changes might be block grants for Medicaid – where the Feds just give each state a chunk of money and the state gets more flexibility in how they spend it.  There’s a LOT of detail around this, but at least in Massachusetts, it may not be much of an issue.  David Williams posits that MA is in a pretty different place than most states, one where a full-on total repeal of ACA wouldn’t be a big deal.  That’s because Mass has been in the forefront of these changes, and things are working pretty well.

Federal changes…

OSHA is going to be a different animal altogether in the new administration; perhaps more akin to a cuddly panda than a persistent bloodhound. Julie Ferguson details how the agency is already shifting to a more “employer-friendly” mode.

Julie’s post also digs into the administration’s claim of a “dramatic expansion of the federal workforce in recent years.” and resulting hiring freeze and consequences thereof; quoting a source that finds there has been no federal workforce expansion and that “employment by the federal government as share of all US employment is relatively low compared to most of the last 70 years.”

That’s a fact, not an “alternative fact”, or what we would call a “lie”.

Peter Thiel is the focus of Roy Poses’ ire this month, and that ire is well-placed.  The trump advisor supported one “Jim O’Neill, one of Mr Theil’s business associates, for this position [of head of the FDA], despite Mr O’Neill’s apparent complete lack of experience or training in medicine, health care, public health, or biomedical research, and Mr O’Neill’s obvious conflicts of interest.”

Other news of note

Brad Flansbaum’s penned a piece on healthcare CFO and CEO ratings at The Hospital Leader. Interesting take on how administrators – who currently are not being “rated” – perhaps should be. Brad provides his views on a few evaluation standards; good to see the proverbial shoe being placed on another foot!

And the ever-wonderful Hank Stern informs us that healthcare inflation is not limited to this side of either pond; costs are going up in other countries too – driven there by a demand for private care.

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Healthcare’s Future? Population Health and Information Technology

Many people are wondering if we are living in a post-ACA world. The uncertainty has pundits posturing all over the political map. No matter how the economy or politics turn, there are a few constants where people can have some control.

We live in a technology-driven world so no matter how we feel about it, that train has left the station. The potential of technology will continue to improve our ability to monitor our own health and for providers to cure disease. Admittedly, some of it is expensive but much of it, such as personal wearables, are inexpensive and allow patients to self-monitor. We all have friends and family who track the number of steps they take every day.

The wellness movement is another trend that is making a difference in the cost and effectiveness of the care we provide. This week I saw an interview with a leading light in the wellness movement, Dr. Mark Hyman, who is the founder of the Cleveland Clinic’s Center for Functional Medicine in which he discussed the fact that people’s health status is most heavily influenced by the health status of their friends. He talked about the implication of this finding for population health.

Dr. Hyman’s main message is that the food we eat is the key driver to our health. He is behind movements to change the way people eat and focuses on implementing the social supports around their habits. On the one hand, his message is not new or revolutionary. On the other, as our country faces a way to pay the health bill for an aging and chronically ill population, perhaps these messages will begin to make serious inroads in the public consciousness.

As we look at a possible post-ACA world, perhaps the discussion can revolve around health and health care, and move away from health insurance. When we squarely face the unsupportable cost of our healthcare system,  that may be the trigger for us to reframe what we actually seek – health or a way to pay for healthcare products and services that we may not need in such great amounts if we change the way we live.

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Puppies and Kittens Edition of Health Wonk Review

Hank Stern’s roundup of wonkery and punditry as the Health Wonk Review group looks at where things are going under a new administration in DC in this Puppies and Kittens edition of our beloved HWR.

Here come da fuzz.

2IeTff-V

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Healthcare Industry in an Age of Uncertainty

Havana-CentroUncertainty.  The markets hate it. Established, successful businesses hate it.

The markets are priced using certain assumptions, and successful businesses usually got that way under the current rules. So any disruption is a cause to pause. During that pause, some panic. Others, who are looking for opportunity or aren’t faring as well under current conditions, might see uncertainty as a place where gaps appear and a little light shines in, presenting opportunity to improve their lot.

In the healthcare industry, we are in the pause. Depending on whom you ask, either the sun will come up Tomorrow or we are on the Eve of Destruction. (Those are both song lyrics, so fire them up on your computer for a little background music while you read the rest of this post. This is a long and winding personal reflection, you might want a sound track.)

Whether you think the sun will come up or we’re teetering on social destruction, all players in the industry are in a period of reassessment.

People who need to make decisions for hospitals, for manufacturers, for insurers, and patients themselves are all looking for clues about direction, and the answers are dribbling in. There is a lot still left for speculation, but for now, here are a few personal thoughts on considerations while we live out Healthcare in an Age of Uncertainty.

Administrative Relief for Providers

We are learning something about direction from the choice of Tom Price for HHS Secretary.  He backed the 90-day reporting period for MACRA and electronic health record reporting to ease the administrative burden on providers.  If past performance is any indication of future performance, we can expect more administrative relief for doctors and hospitals. Even under the rosiest ACA scenario, we knew that the majority of physicians did not even know what MACRA was let alone how to report under it starting in January 2017 – one month from today- and MACRA was the basis of the new physician payment system. Yes, with Tom Price we also get efforts to remove public funding for abortion. One of my daughter’s medical school colleagues wears a coat-hanger necklace to remind people about the alternative to legalized abortion.

Drug Pricing

Having spent most of my career in and around the pharmaceutical industry, I was most interested in the suggestion that Medicare may want to start to negotiate prices to get a better deal. Having done a lot of work interpreting Part D when it was first passed, one of the concessions (promises) made to strike the deal with pharma specifically spelled out that the government would not be able to establish fixed pricing for the Part D program because it is such a big piece of the industry’s business. Deals are made to be broken, or so I’ve heard.

What Does Fidel Castro Have To Do With It?

Several years ago I did a project on the global vaccine market, and the viability of getting vaccines to the elderly in emerging nations in places where the infrastructure does not support special delivery of refrigerated products. I interviewed a few dozen physicians who work in the field and are associated with vaccine efforts. One doctor said he has worked in about 70 countries. As one of those last “oh-by-the-way” questions, I asked him where he saw the best healthcare system in the world. He said, “Cuba.” Follow-up question, “Why?” Answer (paraphrased): They have a free clinic in every neighborhood and the ratio is roughly one clinic to every 500 people. Everybody goes to the doctor when they get sick.

I haven’t been to Cuba, and if any readers have first-hand knowledge of the healthcare system there, I’d love to hear from you.

That doctor’s answer has been on my mind lately for a couple of reasons.

First, I wrote my honors thesis in journalism on the coverage of the Cuban Revolution and the difference between how it was covered in the Miami Herald versus how it was covered in El Diario in Havana. I have always been fascinated by Cuba, particularly the stories of pre-revolutionary Havana because my first college roommate’s family were refugees during the revolution, and they had been a wealthy family who had to leave everything behind. Castro’s death last week catapulted that doctor’s response to the front of my mind. (My thesis has stoked my lifelong interest in ferreting out bias in reporting – how words are used and images are chosen to influence public perception.)

Second, the new administration has been asked how they will care for indigent people if they lose their subsidized healthcare. I am reminded of some of the clinics we currently have operational such as Federally Qualified Health Centers and I wonder if that system can be expanded to serve indigent populations at less cost and less administrative burden than using an insurance model.

Third, yesterday I saw this article and I thought of all those free Cuban clinics, and the doctors who serve there:

Be entertained and click on Cuba: Where Taxi Drivers Earn More than Doctors.

El pueblo, unido, jamas sera vencido.  (The people, united, will never be defeated.)

I learned this phrase in my total immersion Spanish course in college from a Columbian revolutionary hired by my university to teach Spanish to American university students. To his amusement, he taught  us to yell this phrase while raising our fists.

U.S. Medicine and Lessons from the Rest of the World

We alternately hear that the United States has the best healthcare system in the world, the most expensive, we get the least for our buck, we have the worst infant mortality statistics in the “developed” or “first” world, and other pearls of common wisdom. Some say the solution to getting care to the indigent sick when they need it is to move toward a system more like the UK’s National Health System. The UK is a place where everybody gets care, but we have also heard the lines are long and the care is rationed. Something we don’t hear as often is how little the providers of that care are paid. This article from the Business Wire, dateline London, shows us the effect of the UK medical system on the providers themselves.

Data Analysis of over 160,000 Fresh Loan Applications Reveals That over 35,000 NHS Nurses Forced to Rely on Payday Loans

LONDON–(BUSINESS WIRE)–Cashfloat.co.uk, a moral payday loan company based in London, has revealed shocking statistics about the financial hardships of NHS nurses. Over 35,000 NHS nurses forced to rely on payday loans – almost double 2013’s number.

“It is deeply worrying that so many nurses and other caregivers would require our services. We hope that by releasing this data it will draw attention to the hardships being faced by these undervalued and yet essential caregivers in our communities.”
Western Circle Ltd, a short-term lending company trading as Cashfloat, analysed the data from over 160,000 payday loan applications. They discovered that those employed in the health and social care sectors are most likely to apply for payday loans. Within this section, 19% were nurses, 18% carers, and 11% were health care assistants.

The disproportionately large use of payday loans in the nursing sector is a clear sign that something is seriously wrong. The Cashfloat team pride themselves on truly caring for their customers. This prompted them to take action and publish these results, aiming to draw attention to the plight of NHS nurses. These nurses are an essential part of society, often going above and beyond to help the public. If nurses are earning so little that any unexpected expense requires a payday loan to cover it, something must be done about it.
The NHS pay rise cap had many critics when it was first introduced, and it seems that as a result, NHS nurses are struggling financially now more than ever before. Jeremy Lloyd, director at Cashfloat, says, “It is deeply worrying that so many nurses and other caregivers would require our services. We hope that by releasing this data it will draw attention to the hardships being faced by these undervalued and yet essential caregivers in our communities.”

As a responsible payday lender, Cashfloat is in a unique position to gather information and statistics about the financial state of the different sectors of society.

[From International Health Care Business Strategies/MCOL Global, November 29, 2016.]

Playing the Hand You’re Dealt

In the fine American tradition of sparring civilly in the public arena, special interests are lining up to preserve what they’ve gained, to hold hard-won ground and to recover ground they may have lost under the ACA and other healthcare laws.

There is a lot to consider as we decide how to move toward getting people care when they are sick, and fairly paying providers in the bargain. Legislation has consequences. Decisions must be paid for by somebody.

Shift happens. It is a good time to find your opportunity and leverage the shift.

 

 

 

 

 

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A Post-Election Report from Pennsylvania: The ACA Factor?

The federal government promised health insurance companies that they’d be made whole by the feds if they had shortfalls while participating in ACA marketplaces. Many insurance companies have since found out all their money is not promptly forthcoming and their participation isn’t viable. And that is just one of the reasons why ACA premiums in Pennsylvania are up an average of 52% this year and only two health plans remain in the commonwealth’s health insurance exchange. In many ways and diverse places, the promise of the ACA hasn’t been delivered.

I had dinner with a self-employed friend a few weeks ago about the time he was looking at health insurance plans and prices during the enrollment period. He was upset that the cost of his coverage had skyrocketed while his choices shrunk. He said he was considering an affordable faith-based insurance model that allowed him to avoid paying the ACA fine for not having coverage at all. I sent him Hank Stern’s Health Wonk Review article posted a few weeks ago that lent some support to his decision.

Pennsylvania has been a Democratic stronghold for decades and was expected to be a shoe-in for Hillary Clinton. The pundits will be analyzing the data for a while trying to make sense of the outcome of this election. At this point, I can’t say that the ACA cost the Democrats the Keystone State, but when every single vote counts it didn’t help, either.

The repeal-and-replace message resonated with a lot of people who feel the sting of the ACA in their pocketbooks and in their choice of providers and plans.

For those who live in the echo chamber that is Washington D.C. and academia, they don’t hear, see or feel what impacts many of those who live outside the Beltway but have to live by its laws, fines and penalties. When the ACA was passed, not one Republican cast a vote for it. The electorate was so angry that those who had voted for it were afraid to return to their home districts for holiday. Those voters just had their day.

Now What?

No matter who won on Tuesday, it doesn’t change the fact that our country is facing hard times and difficult choices. People who pulled the lever for “anyone else but” registered frustration at the state of our country and our world. In fact, one could argue that the winner would actually be “The Biggest Loser.” One of the many daunting challenges facing our 45th president will be to create an affordable healthcare system that works. Repeal-and-replace is a skeleton plan that lacks substance and detail. Over the next few months, as the new administration takes shape, I expect President-elect Donald Trump to assemble a council of expert advisors who can provide that substance and detail. He is a businessman, and he has been successful, which leads me to believe perhaps he is open to wise counsel.

A great outcome would preserve the best of innovation and technology, and throw overboard reams of regulations that hamstring doctors and require payers, providers and patients to jump through hoops that don’t improve care or add anything to the wellbeing of patients.

I have long been an advocate of the promise of healthcare technology. Going forward, any government efforts should preserve our progress toward interoperable electronic patient records and robust data capture that can continue to inform research and patient care. We should throw overboard regulations that require providers to show they are meeting arbitrary targets that interfere with their ability to provide patient care and threaten them with reduction of reimbursement if they don’t participate.

Biotech stocks reacted favorably to the election results, and I expect companies offering cost-effective, technology-enabled solutions will do well going forward notwithstanding the overall direction of the stock market or general economy. Beyond that, the people who have the ear of the Trump administration’s transition team will provide clues about what the meat on the bones of the repeal-and-replace skeleton will look like.

As for those who voted thinking that it can’t get any worse, let’s hope they are right.

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Posted in biotechnology, electronic patient records, health economics, health insurance, health IT, health policy, health reform | 1 Comment

The Baseball Lover’s Presidential Politics Edition of Health Wonk Review

cubs

In this week’s health policy roundup, Brad Wright posts Health Wonk Review: The Game 7 of Politics Edition  at Wright on Health. His post skillfully ties two of America’s favorite and most contentious pastimes together: sports and politics. Something here for everyone.

 

And next Tuesday, don’t forget to “Play Ball!”  

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Healthcare Devices and the Internet of Things – Promise, Peril and Distributed-Denial-of-Service Attacks

Last Friday, widely used websites like PayPal, Netflix and Twitter were unavailable due to a distributed denial of service (DDOS) attack . Hackers got into those systems through technical holes in hundreds of thousands of personal wifi-enabled devices like baby monitors and personal devices to bring down a website host, Dyn. For people in healthcare who are concerned about security, it brought a system vulnerability into sharp relief.

I am not a computer expert (disclaimer), but as I understand it, many of the consumer and even medical personal devices that we use to monitor our health and deliver data to the electronic patient record are pre-set with default passwords. Users don’t usually reset them to a private password so most of these IoT devices remain set with the factory default. Apparently, any hacker can guess the default passwords, hijack the devices and get them to log into a web host system like Dyn all at once which overloads the system with requests and causes it to fail.

Vulnerabilities to Healthcare Organizations and Individual Patients

These kinds of vulnerabilities pose risks to individual patients and healthcare systems.

Healthcare organizations have already sustained several debilitating attacks that have occurred in this way. In 2014, Boston Children’s Hospital was offline for several days after a DDOS attack by the group Anonymous that was protesting its treatment of a patient; other hospitals have sustained similar attacks. Computer experts say there are measures that hospitals and health systems can institute to prevent such attacks. This article broadly describes some of those precautions.

Concerns regarding the safety of individual patient devices such as heart monitors and insulin pumps fall into two broad categories 1) diverting data thus compromising patient privacy and 2) resetting dosing parameters thus endangering patient lives. The FDA, which regulates medical devices, is interested in the issue and has studied it, but so far has decided not to regulate the IoT of medical devices for several reasons. It is technically difficult to do, technology and security advance more quickly than threats, and the threat to individual patient health and safety is more theoretical than actual. A hacker could hack into an individual patient’s medical device to reset it, but that is very unlikely. It doesn’t mean that patients with consumer or medical devices cannot or should not take steps to protect themselves. Patients can reset default passwords. This article from TechTarget describes the pros and cons of patient access to device passwords in more detail.

Due Diligence

The attack last week wasn’t a state-sponsored attack from Russia as originally postulated, but came from non-state-sponsored vulnerabilities out of China .DDOS No matter where it came from, last week’s incident reminds everyone, including those in healthcare, that a damaging hack attack is not that hard to do. In fact, attacks like this occur all the time, all over the globe. For a little fun – or for a wake-up call – check out this website where you can watch cyberattacks in real time. There is usually a lot of activity into and out of the U.S., Russia and China.

The challenge for IT specialists in health care is to make sure these attacks aren’t perpetrated on your patients or your organization. This article from Modern Healthcare  describes Athenahealth and Allscripts outages that occurred during the DDOS attack last week. A Medical Group Management Association health information expert reminded individual physicians’ offices that their data, too, can be taken offline during an attack and he recommends backup plans that involve having a technician on speed dial.

An article out of the 2014 Black Hat hackers conference  explains that all attacks –even those not directly targeted at healthcare – should be of concern to health IT professionals.

All hacks and cyberattacks can expose your patients and organizations. The Dyn DDOS attack is a reminder to do your due diligence.

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Posted in consumer health apps, electronic patient records, health IT, health IT training | 1 Comment