Even worse, Tuskegee Study style, the risk is on the docs and patients, while the purveyors of the technology in question enjoy contractual freedom from liability and contractual protection from relevations of product risks and defects (see the remarkable article Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009;301(12):1276-1278).
Could this situation get any worse?
It's worse.
Here is a tale about the companies that medicine will be dependent upon for EHR's and other clinical IT - now by force of government (financial at first, but I would not at all rule out punitive licensure and other measures as a possibility in the future for "EHR noncompliers"):
Chi-Town Daily News
Billing glitch led to mental health closures
Alex Parker / Staff WriterApril 07, 2009
The Chicago Department of Public Health lost more than $1 million in state funding by failing to fix computer problems with its [Cerner-developed] billing system, public records show, sparking a funding crisis and the scheduled closure of four South Side mental health centers today.
City officials have previously blamed the closures in large part on state budget cutbacks.
But a trail of official paperwork, obtained by the Daily News through the Freedom of Information Act, shows that the department’s new computerized billing system was so flawed that patient bills weren’t submitted to the state for six months in 2008.
Where have I seen the name of that company before regarding HIT difficulty? While not about billing per se, I saw the name in the UK House of Commons Public Account Committee's Conclusions and recommendations of The National Programme for IT in the NHS: Progress since 2006 :
The termination of Fujitsu's contract has caused uncertainty among Trusts in the South and new deployments have stopped. One option being considered for new deployments is for Trusts to have a choice of either Lorenzo provided through CSC or the [Cerner] Millennium system provided through BT. There are, however, considerable problems with existing deployments of [Cerner] Millennium and serious concerns about the prospects for future deployments of Lorenzo. Before the new arrangements for the South are finalised, the Department should assess whether it would be wise for Trusts in the South to adopt these systems. Should either of the Local Service Providers take on additional commitments relating to the South, the Department should take particular care to assess the implications of the extra workload for the quality of services to Trusts in the Local Service Providers' existing areas of responsibility.
... The Programme is not providing value for money at present because there have been few successful deployments of the [Cerner] Millennium system and none of Lorenzo in any Acute Trust. Trusts cannot be expected to take on the burden of deploying care records systems that do not work effectively. Unless the position on care records system deployments improves appreciably in the very near future (i.e. within the next six months), the Department should assess the financial case for allowing Trusts to put forward applications for central funding for alternative systems compatible with the objectives of the Programme.
The problems with billing modules are not limited to one company. Yale had problems with another HIT billing vendor leading to a Justice Department investigation and a multimillion dollar fine, as did Drexel University with AllScripts and its subcontractor Medicomp, civil complaint in PDF here. I know about the former because I was there, I know about the latter only by circumstance even though I was there, reading about it at the HIT gossip site HisTalk.com from an anonymous commenter. Who knows how many other such situations exist, information flow censored by the aforementioned HIT vendor/purchaser nondisclosure clauses?
The Chicago article continues:
The city's current-year state payments are based on monthly reimbursements for service. When the state received no bills from the city for the last four months of the previous fiscal year, it amended the contract it had with the city to reflect the city's apparent lesser need for funds.
The city's public health chief, Terry Mason, declined to answer questions for this article. Carlo Govia, CDPH’s chief financial officer did not respond to a request to be interviewed. Nor did Cerner Corp., the Kansas City, Mo.-based company that developed the city's software.
The centers, which serve about 2,000 people, are scheduled to close today ... “These people are telling us in here that it don’t matter if we live or die,” says Helen Morley, a patient at the Beverly-Morgan Park facility.
Death by defective IT? It's not as if the problems were discovered suddenly:
The city first notified the Illinois Department of Human Services officials about the plan to switch from a state billing system to the Cerner system on Feb. 11, 2008 -- just over two weeks before the new system would be turned on. Shortly thereafter, the state warned that problems could arise if the city's system was unable to communicate with the state's computers.
“March 1st is right around the corner, and if the software is not programmed to work correctly with Springfield’s system, claims and service reporting will not be accepted,” says a Feb. 22 letter from Peggy Peterson, the chief DHS liaison to the city's public health department.
But the city began using the new system. [typical of asinine bureacratic edict - but could there also have been conflicts of interest, such as those with decision making authoirty being given financial stakes in this system's success? - ed.]
Problems ensued. On April 29, Peterson warned, “I can not stress enough the importance of continued and timely submission to DMH of all FY08 service reporting and billing via whatever software is functional.”
In the same email, she noted that the state began reducing monthly allocations based on billing in January, docking 10 percent of CDPH’s monthly service stipend, and would continue doing so if billing did not reach 100 percent. The city, she said, could risk more than $334,000 if it did not resolve its billing issues
In June, Peterson wrote that the state had received no billing since mid-March, shortly after the city began using the new system. A city official replied that the Department of Public Health and Cerner were working to fix the problems.
On June 9, Peterson again recommended that the city return to billing with the state system. She noted that the state had already docked the city $334,059 since February.
The next day, Mason wrote to DHS officials saying the transition to the Cerner system “to date, has been unsuccessful.” He said the city could not use the state system or manually submit bills because all of the city’s patient information resided in the new computer system.
... In August, the state wrote the city to say that it would withhold payment of $1.2 million that had been budgeted for Chicago mental health services. The funds were placed into a reserve fund, with no assurance the city would ever receive them.
A subsequent state letter advised the city that $99,000 of that cut was due to overall budget shortages affecting all mental health operators. The letter said $1,163,514 was due to the city's failure to submit bills to the state.
On Sept. 16, Peterson wrote a top city official to express “grave” concern about the city's inability to submit billing records since discontinuing its use of the state software in March.
Around the same time, records show that of the 14,261 claims submitted to the state, 95 percent were rejected for missing data.
Mason appealed the decision in late September, acknowledging in a letter to the state that billing had been a problem: "... Service reporting data and billing information has not been submitted for a period of six months."
He chalked the failure to file billing records up to the transition to the new computer system.
Mason's letter also said the state's decision to withhold money would "place the City of Chicago in an unfair position and result in the closure of multiple mental health facilities.”
Also in September, the city began using the state's billing system again. It was eventually able to submit records for about 90 percent of its outstanding bills from fiscal year 2008, but by that time the state had already decided not to allocate the money to the city.
On Oct. 31 the state wrote to say that the city's funding would not be restored.
DHS spokesman Tom Green says the decision to cut funding was based solely on the city's inability to provide billing data.
“The City did not provide adequate billing information to justify continuing to pay them the full amount," he says. "The Division of Mental Health chose not to allocate funding where it was not being spent effectively."
What a stunning and spectacular debacle. This, my friends, is the type of technology hospitals and physicians are now being pressured to adopt en masse by 2014.
Fortunately, in a surprise announcement, Chicago mayor Richard M. Daley said at a press conference that the plan to close four of Chicago’s city-run mental health clinics was put on hold for the moment, pending "investigation." All I can say is "amazing."
Can the dependence by physicians on HIT companies by government edict get any worse than this?
Indeed. It gets worse still:
Medical Economics
The problem with EHRs and coding
Apr 3, 2009
By: Deborah Grider, CPC, Robin Linker, CPC, Susan Thurston, CPC, Stephen Levinson, MD
... most physicians include among their highest priorities the goal of compliant evaluation and management (E/M) coding. Physicians believe they have a right to expect that these sophisticated and costly systems will ensure that they achieve compliant documentation and coding, thereby "making any E/M problems go away."
However, something has gone awry to create an environment that leaves well-intended physicians victimized when government audits reveal their software systems have allowed—even facilitated—submission of non-compliant and potentially fraudulent claims for E/M services. In the midst of increasing storm warnings of non-compliant designs, physicians are increasingly vulnerable to severe financial penalties.
This devastating storm has been developing for many years, often bolstered by an unintended lack of effective policies from several organizations that should have the best interests of physicians, patients, and the healthcare system at their core—organizations such as CMS, the Certification Commission for Healthcare Information Technology (CCHIT), and the U.S. Department of Health and Human Services (HHS), as well as EHR software vendors and physician training institutions (for more information).
With watchdogs like these, who needs enemies? Is this technology designed to help clinicians take care of their patients, or is this technology and its purveyors trying to kill people after driving clinicians to mental collapse - or to jail?
... Analyses of problems with EHR systems by physicians and their practice managers consistently reveal that the overwhelming preponderance of their challenges relate to the rarely discussed data-entry characteristics of the electronic history and physical (H&P), not to the heralded data-storage and retrieval features of their systems. One physician personally reported that "The software forces me to enter clinical information in a preloaded format; when I see a patient three weeks later, I cannot find any individualized details of the previous visit or understand why I did what I did."
Too often, these problems have proven insurmountable. At the Second HIT Summit in 2005, Mark McClellan, MD (then the administrator of CMS), reported "40 percent of attempted implementations fail." According to the April 1, 2006, issue of CIO Magazine, "The [Health and Human Services] department itself has acknowledged that the failure rate for EHR system implementation is 30 percent to 50 percent. Some healthcare network providers claim it is as high as 70 percent."
During the last several years, a significant number of articles have pointed out compliance problems intrinsic to the majority of current EHR systems. Chief among these relate to coding engines that fail to consider medical necessity, which CMS describes as "the overarching criterion for payment," and certain types of data-entry functionality that result in "cloned documentation," in which the records of every visit read almost word-for-word the same except for minor variations confined almost exclusively to the chief complaint.
The problem that physicians face is that most current EHR system designs have failed to incorporate protections to ensure the correct use of these shortcut tools. Without such "error proofing," it is not feasible for physicians, while concentrating on patient care, to differentiate the settings in which these various tools can be used compliantly from those circumstances in which their use could lead to pliant or even fraudulent documentation.
Guess who would be responsible for that?
("A computer is never put on trial.")
The Medical Economics authors are compliance experts who were called in to assist different physician groups during federal and state audits of those groups' EHRs, conducted either by individual Medicare Carriers, Recovery Audit Contractors (RACs), or the Office of the Inspector General of the HHS.
In each of the four cases, the audits revealed pliant E/M claims that were submitted as a consequence of physicians using their EHRs in accord with their particular designs for E/M documentation and coding. During audits the following was found:
- All of the systems had designs that failed to meet all of Current Procedural Terminology's and Documentation Guidelines for Evaluation and Management Services' published requirements for compliant documentation of medical history, physical examination, medical decision-making, and nature of the presenting problem(s) (which is the E/M system's measure of medical necessity)
- Each of the systems included three or more types of data-entry functionality that has been consistently identified as having the potential to promote non-compliant or even fraudulent documentation
- The E/M coding engines of all four systems failed to consider the three levels of risk in decision-making, failed to consider medical necessity in determining appropriate code levels, and failed to recognize the critical role of medical necessity in guiding medically indicated levels of care, documentation, and coding.
How, exactly, is such software supposed to help physicians?
This Medical Economics article concluded with a dire warning about a converging perfect storm, sounding similar to my own warnings at this blog. The article is worth reading in its entirety at this link. This all seems more like torture than the revolutionizing of healthcare via IT.
It seems physicians can be beaten over and over, not complain very much, and still come back for more. Being forced to use health IT may yet prove to be the most poster perfect example of physician learned helplessness and physician expected helplessness, ever.
Can it get worse than that?
Probably. See this post on government promoted, perhaps soon-to-be-government-mandated EHR computational alchemy, turning medical lead into gold, postmodern style.
-- SS
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