Hospitals are spending billions of dollars to achieve meaningful use of electronic medical records, but if patients don't use the new technology,  hospitals may not reap the federal stimulus payments that await.

That's the conclusion of a report -- Putting Patients into Meaningful Use – from  PwC's Health Research Institute, which found that 14% of 1,000 consumers surveyed last fall said they get their medical records electronically from their physicians, and 30% of patients said they didn't know why they would need to.

Bruce Henderson, director and national leader of the EHR-HIE Practice at PwC says  hospitals need to build in patient input earlier in the process to comply with Stage 2 of meaningful use requirements.

"Successful use of electronic health information will ultimately be measured in better patient outcomes, higher quality and reduced costs," Henderson said. "Health systems need to have both patients and physicians actively using the health information to make care decisions, and they aren't there yet."

Henderson said providers must first understand what healthcare consumers want before they can be sold on the benefits of EMR. "Then, they need to build new, technology-enabled healthcare delivery processes around patient preferences and convenience, which means changing how clinicians work," he said.

• Half of patients said they call their physician's office or hospital for a paper record, and 11% said they don't know how to get their health record.
•  Of those who access their medical record electronically, 34% share the information with primary care physicians and specialists.
• While basic information about prescriptions and appointments are readily available to consumers who have electronic access to medical records, 55% can't access lab results or physician visit notes.
• Only 13% of consumers said they'd been asked by providers what they think about EMRs, even though 56% said they'd be willing to talk about what they'd like in an EMR and how they'd like to use it.
•  When asked how they would like EMR to be used, 66% of consumers said for physicians to follow-up on their condition, 59% said for scheduling follow-up appointments, and 53% said to learn about treatment options.
•  35% of consumers said they would like their physician to use the information to monitor treatment compliance, and 34% said they would like their physician to monitor their health condition, such as blood pressure, remotely via a device that automatically sends information.
• Approximately one-quarter of respondents would like to share electronic health information with family members to better understand family medical history.

Comparatively, data from the Healthleaders Media Industry Survey 2011, shows that:

• 13% of health leaders have an interactive patient portal in place, while
• 66% have a physician portal in place

HHS' Stage 2 proposed standards for meaningful use may require hospitals to offer 80% of patients with the ability to access to view and download their health information via a Web-based portal within 36 hours of discharge. Doctors and other providers must have at least 20% of their patient populations electronically accessing their health information, including access to diagnostic test results. Providers must meet these minimum requirements by October 2012 to qualify for additional stimulus money.

While 90% of more than 300 provider executives surveyed by PwC in the spring of 2010 said they expected to achieve meaningful use standards before the penalties kick in, their confidence is waning slightly as new realities set in and health organizations rethink their work plans to devote more attention on engaging external stakeholders. By the fall of 2010, 82% of the executives said they will meet the timetable.

Henderson said there are significant social, educational, and access barriers that providers are trying to overcome – including a gap in expectations between what patients and physicians want, and conflicting views about turnaround time. PwC's cited one hospital's internal research that found that physicians thought 45 days was a reasonable timeframe for making test results available electronically, while patients expected this information within 30 minutes.

"A patient's medical record and the health information within it should not be a history lesson. Those days are over," Henderson said. "To be meaningful, health information needs to be relevant, actionable, integrated into care and treatment decisions and available in real-time."

PwC's survey also found progress. Nearly one-third of health systems said they are now adding patient input into their meaningful use initiatives, up from 19% last spring. Approximately 50% of health systems are providing assistance to physicians who need support tools for using EMR in their clinical work.

Maryland-based Cignet Health has been slapped with a $4.3 million fine for its refusal to provide patients with copies of their health records, and for willfully failing to cooperate with the federal government's attempts to resolve the complaint, the Department of Health and Human Services announced Tuesday.  

HHS's Office for Civil Rights said the fine is the first such "civil money penalty" imposed for violations of the Privacy Rule of the Health Insurance Portability and Accountability Act.

Calls to Mitchellville, MD-based Cignet on Tuesday afternoon were not immediately returned.

HHS's Office of Civil Rights said Cignet violated 41 patients' rights by denying them access to their medical records when requested between September 2008 and October 2009. The patients complained to OCR alleging that Cignet was violating the HIPAA rule that requires "covered entities" to provide patients with copies of their medical records within 30 days -- and no later than 60 days -- of the request, HHS said.

During the investigations, however, Cignet allegedly ignored OCR's demands to produce the records. A federal court issued a default judgment against Cignet on March 30, 2010. On April 7, 2010, Cignet gave the medical records to OCR, allegedly with no efforts to resolve the complaints through "informal means." OCR alleged that Cignet also failed to cooperate with the investigation from March 17, 2009, to April 7, 2010, indicating "Cignet's willful neglect to comply with the Privacy Rule." The failure to cooperate with OCR added $3 million to the civil money payment, HHS said.

"Covered entities and business associates must uphold their responsibility to provide patients with access to their medical records, and adhere closely to all of HIPAA's requirements," said OCR Director Georgina Verdugo. "The U.S. Department of Health and Human Services will continue to investigate and take action against those organizations that knowingly disregard their obligations under these rules."

The civil money penalty is based on the violation categories and increased penalty amounts authorized by Section 13410(d) of the Health Information Technology for Economic and Clinical Health (HITECH) Act.

Most U.S. healthcare providers would never photograph patients and post the pictures on the Internet. Doing so, they understand, would violate patient confidentiality, and would merit substantial fines for breaching the federal Health Insurance Portability and Accountability Act. 

Yet, some U.S. physicians, nurses, medical students, and other providers who volunteer their medical skills in developing nations have posted pictures of their patients on Facebook and other social media Web sites. That doesn't violate HIPAA because it's beyond U.S. borders, but it is a breach of ethics, University of College of Medicine researchers write in a Journal of Medical Internet Research study. The researchers want providers to respect privacy rights for all patients, regardless of where they're treated and where they live. 

"A medical student would not take a picture of a patient in clinic here and post it on Facebook," said Erik Black, an assistant professor of pediatrics with the UF College of Medicine and a lead author of the paper. "But there is a disconnect on these trips. We are not respecting these people as individuals. If we are not going to respect them in the same way we respect patients in the United States, why are we even going?" 

UF researchers examined the Facebook profile pages of 1,023 medical students and residents, finding no breaches of patients' privacy in the United States. However, they found 12 photos of patient care in developing countries.

Every year, students from all health fields work in clinics in medically underserved nations, such as the Dominican Republic, Haiti, and Ecuador. It's a chance to get hands-on experience in a patient-care setting and help people who sometimes travel days for care. 

HIPAA doesn't apply to patients outside of the United States, says Lindsay Thompson, MD, an assistant professor of pediatrics in the College of Medicine, and a lead author of the report. If a nation has privacy laws in place, doctors must follow them when practicing there.  

In addition, Thompson says, doctors are ethically bound to follow the laws of the state or country where they practice. "We in the medical profession have to be held to a different standard. Our actions, however altruistic they are, could have some unintended consequences," Thompson said. 

Ruben Ayala, MD, a primary care physician and medical officer with Operation Smile, which provides corrective facial and oral surgery for children in developing nations, said his organization has strict guidelines for using pictures of its patients. 

"Anything we put on the Web site or anything we put out in mailings or videos, all of that done only after we double- and triple-check that we have permission from the patients or their parents to do so. Not everybody is eager to tell their story," Ayala says. 

"A few years ago we modified our informed consent. In a lot of these countries there isn't a culture of informed consent. These patients, we realized, there is always a chance that because they are poor or don't have access they would think that if they don't say 'yes,' they won't get the surgery. We have to make sure they understand that if they say 'yes' to any pictures that will not increase the changes of their child having surgery, and if they say 'no' that does not decrease the chances of their child having surgery," Ayala says.

Physicians and other medical professionals from the United States who volunteer for Operation Smile must sign a code of conduct that forbids posting pictures of patients. Ayala says that on the rare occasion when they learn that a picture has been posted inappropriate, Operation Smile contacts the healthcare provider and asks them to remove the post. "Most times the reaction will be 'Oh I'm sorry. I didn't realize,'" he says. "I don't know where the disconnect comes from because these are practitioners who would never do this in the United States." 

In many cases, medical students and doctors may not realize the differing patient privacy laws in other countries or that that these laws could be even stricter than those in the U.S. 

"A lot of people consider this an ethical gray area," said Reed Van Deusen, MD, an assistant professor of internal medicine and pediatrics at the University of Pittsburgh, who was not involved with the study. "It is pretty complicated, but I agree with their basic tenet that trainees, and physicians in general, should not be posting pictures of patients, whether they are in this country or not. I think it is going to take a bit of a culture change to get everyone else on the same page." 

Terry Kind, MD, a director of pediatric medical student education at the Children's National Medical Center at George Washington University, in Washington, DC, said medical school faculty must teach students about issues like these, namely by modeling professional behavior themselves. 

"(Social media) is here and not going away," Kind said. "There are opportunities for use, but there is risk. The nature of the widespread dissemination is people forget to have that internal check on professionalism."

U.S. patients who agree to be photographed sign consent forms. Black says even getting consent from patients in developing countries poses an ethical challenge, because patients may feel they have to sign the form to receive medical care. Also, because the Internet is borderless, posting pictures to social networking sites could have repercussions for some patients, particularly if the images were taken in countries where being treated by an American doctor is frowned upon. 

Even posting photos to a "private" page is not really ensuring patient privacy because, in some cases, the person posting the photo could be sharing it with 1,000 "friends," Black said. 

"We are not telling people not to do anything," Black said. "We are telling them to think about it. Use your moral and ethical compass. What if this was your child?"

The College of Healthcare Information Management Executives (CHIME) has recommended that the federal government push back the deadline for Stage 2 implementation of meaningful use until the impact of Stage 1 on hospitals can be more accurately evaluated.

"Absent such as assessment, we greatly fear that the (Health Information Technology Policy Committee's) proposals for Stage 2 may be unduly ambitious, even unattainable, for many eligible hospitals and eligible professionals," CHIME President/CEO Richard A. Correll and Lynn Vogel, MD, chair of the CHIME board, said in the Feb. 18 letter to Joshua Seidman at Health and Human Services' Office of the National Coordinator for Health Information Technology.

The CHIME leaders said that seeking public comment about Stage 2 implementation before a proper assessment of Stage 1 "is a big like putting the cart before the horse."

CHIME recommended not moving to Stage 2 until about 30% of eligible hospitals and providers have been able to demonstrate competency with stage 1 meaningful use.

"We believe this approach would strike a reasonable balance between the desire to push EHR adoption and MU as quickly as possible and the recognition that unreasonable expectations could end up discouraging EHR adoption if providers conclude that it will be essentially impossible for them to qualify for incentives," CHIME wrote.

CHIME also suggested that Medicare allow hospitals and providers to "skip a year" if they are not fully prepared to move to the next stage. "CHIME sees no value to imposing some artificial deadline on the movement to stage 2 and urges ONC and CMS to take all the time needed to produce clear and understandable policies. We consider this better than rushing the rulemaking process only to have to repeatedly issue frequently asked questions (and answers) and other policy clarifications and explanations to address provider and EHR vendor confusion and uncertainty," CHIME said in the letter.

To read the CHIME letter, click here.