Sometimes the mere effort to access records leads to court. Last spring, Verma attempted to kick-start the sharing effort and later pledged a war on “information blocking,” threatening penalties for bad actors. Jennifer De Angelis, a Tulsa attorney, has frequently sparred with hospitals over releasing her clients’ records. Email KHNweb@kff.org for more information. Before long, “meaningful use” became pejorative shorthand to many for a burdensome government program — making doctors do things like check a box indicating a patient’s smoking status each and every visit. What the framers of that vision didn’t count on were the business incentives working against it. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. Using eye-tracking technology, Ratwani has demonstrated on video just how easy it is to make mistakes when performing basic tasks on the nation’s two leading EHR systems. EHR vendors often impose contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations — though some customers have taken to the courts to air their grievances. “The fact that we’re not able to broadcast that nationally and solve these issues immediately, and that another patient somewhere else may be harmed by the very same issue — that just can’t happen,” he said. The software would detect and warn users of dangerous drug interactions, but unbeknownst to physicians, the alerts stopped if the drug order was customized. A 2016 study by The Leapfrog Group, a patient-safety watchdog based in Washington, D.C., found that the medication-ordering function of hospital EHRs — a feature required by the government for certification but often configured differently in each system — failed to flag potentially harmful drug orders in 39 percent of cases in a test simulation. Said Verma, “We left that hospital and we still don’t have his information today.” That was nearly two years ago. That’s not an error that will harm a patient — though other medication mix-ups can and do. Allscripts said in an email that it cannot comment on an ongoing investigation, but that the civil investigations by the Department of Justice relate to businesses it acquired after the investigations were opened. KHN and Fortune examined more than two dozen medical negligence cases that have alleged that EHRs either contributed to injuries, had been improperly altered, or were withheld from patients to conceal substandard care. In a still-pending 2015 lawsuit, Chauvin alleges that Epic’s software failed to fire a critical medication warning; Chauvin suffered from conditions that heightened her risk for blood clots, and though that history was documented in her records, she was treated with drugs that restricted blood flow after a heart procedure at the hospital. But 10 years after President Barack Obama signed a law to accelerate the digitization of medical records — with the federal government, so far, sinking $36 billion into the effort — America has little to show for its investment. “It would be like if I was driving with the radio on and the windshield wipers going and when I hit the turn signal, the brakes suddenly didn’t work,” said Foster. Physicians complain about clumsy, unintuitive systems and the number of hours spent clicking, typing and trying to navigate them — which is more than the hours they spend with patients. In one sign of progress last summer, the dueling sharing initiatives of Epic and Cerner, the two largest players in the industry, began to share with each other — though the effort is fledgling. © 2021 Kaiser Family Foundation. A free exchange of information means that patients can be treated anywhere. But soon after he was hired, Delaney noticed scores of troubling problems with the system, which became the basis for his lawsuit. Ratwani spent his early career in the defense industry, studying things like the intuitiveness of information displays. We appreciate all forms of engagement from our readers and listeners, and welcome your support. Every time she prescribes the basic painkiller for a female patient, whether that patient is 9 or 68 years old, the prescription is blocked by a pop-up alert warning her that it may be dangerous to give the drug to a pregnant woman. In such cases, the suits typically settle prior to trial with strict confidentiality pledges, so it’s often not possible to determine the merits of the allegations. Listen: Reporter Describes Breakdowns In Electronic Medical Records “Physician burnout is real,” she told KHN and Fortune. So lawmakers devised a carrot-and-stick approach: Physicians would qualify for federal subsidies (a sum of up to nearly $64,000 over a period of years) only if they were “meaningful users” of a government-certified system. The need to stimulate the economy, which meant getting providers to adopt EHRs quickly, “presented a tremendous conundrum,” said Farzad Mostashari, who joined the ONC as deputy director in 2009 and became its leader in 2011: The ideal — creating a useful, interoperable, nationwide records system — was “utterly infeasible to get to in a short time frame.”, That didn’t stop the federal planners from pursuing their grand ambitions. Following the same playbook used by pharmaceutical companies, EHR sellers courted doctors at fancy dinners in ritzy hotels. In September 2012, following press reports suggesting that some doctors and hospitals were using the new technology to improperly boost their fees, a practice known as “upcoding,” then-Health and Human Services chief Kathleen Sebelius and Attorney General Eric Holder warned the industry not to try to “game the system.”. Foster began with Monachelli’s medical records, which offered a puzzle. The doctor is now typing away, making more eye contact with the computer screen, perhaps, than with the patient. So lawmakers devised a carrot-and-stick approach: Physicians would qualify for federal subsidies (a sum of up to nearly $64,000 over a period of years) only if they were “meaningful users” of a government-certified system. Allscripts offered a no-money-down purchase plan to help doctors “maximize the return on your EHR investment.” (An Athena­health spokesperson said the company’s “dinners were educational in nature and aimed at helping physicians navigate the government program.” Allscripts did not respond directly to questions about its marketing practices, but said it “is proud of the software and services [it provides] to hundreds of thousands of caregivers across the globe.”). “I can’t tell you how many times I’ve had to cancel an order because I was in the wrong chart.”. While the Food and Drug Administration doesn’t mandate reporting of EHR safety events — as it does for regulated medical devices — concerned posts have nonetheless proliferated in the FDA MAUDE database of adverse events, which now serves as an ad hoc bulletin board of warnings about the various systems. It’s important to note, not everything on khn.org is available for republishing. We now struggle with a lack of visual cues to know we’re writing and ordering on the correct patient.”, Dr. Joseph Schneider, a pediatrician at UT Southwestern Medical Center, compares the transition we’ve made, from paper records to electronic ones, to moving from horses to automobiles. A 2017 study by researchers at Yale found that of America’s 83 top-rated hospitals, only 53 percent offer forms that provide patients with the option to receive their entire medical record. TrakCare relies on two core capabilities included in the foundation products and automatically used wherever needed throughout the system: the Electronic Patient Record and the Master Patient Index. The baby began having seizures at 10 hours old and will “likely never walk, talk, eat, or otherwise live normally,” according to pleadings in the suit. A 2018 Merritt Hawkins survey found a staggering 78 percent of doctors suffered symptoms of burnout, and in January the Harvard School of Public Health and other institutions deemed it a “public health crisis.”, One of the co-authors of the Harvard study, Ashish Jha, pinned much of the blame on “the growth in poorly designed digital health records … that [have] required that physicians spend more and more time on tasks that don’t directly benefit patients.”. We put a big slug of money into trying to encourage everyone to digitalize, to catch up with the rest of the world … that’s been harder than we expected.”, Seema Verma, the current chief of the Centers for Medicare & Medicaid Services (CMS), which oversees the EHR effort today, shudders at the billions of dollars spent building software that doesn’t share data — an electronic bridge to nowhere. (In a response, Greenway Health did not address the charges or the settlement but said it was “committing itself to being the standard-bearer for quality, compliance, and transparency.”). In February, that company settled with the government for just over $57 million without denying or admitting wrongdoing. Ratwani is pushing for a central database to track such errors and adverse events. Ronisky, 34, who is fighting to rebuild his life, declined to comment. “Six years ago, I switched to PCC, who has, in my opinion, the premier pediatric practice management system. The baby began having seizures at 10 hours old and will “likely never walk, talk, eat, or otherwise live normally,” according to pleadings in the suit. — and made calls to his doctors in Indiana, scrambling to piece together his record, which should have been there in one piece. By one measure, certainly, the effort has achieved what it set out to do: Today, 96 percent of hospitals have adopted EHRs, up from just 9 percent in 2008. “Poor interface design and poor implementations can lead to errors and sometimes death, and that is just unbelievably bad as well as completely fixable,” he said. Few would deny that the swift digitization of America’s medical system has been transformative. Here’s what we ask: You must credit us as the original publisher, with a hyperlink to our khn.org site. “This company was not dishonest, but it was not effective four years ago,” he said.  … It was an absolute nightmare. Rather, it’s about a trouble-prone industry that intersects, in the most personal way, with every one of our lives. Electronic health records were supposed to do a lot: make medicine safer, bring higher-quality care, empower patients, and yes, even save money. Allscripts said in an email that it cannot comment on an ongoing investigation, but that the civil investigations by the Department of Justice relate to businesses it acquired after the investigations were opened. Earlier this year, MedStar’s human-factors center launched a website and public awareness campaign with the American Medical Association to draw attention to such rampant mistakes — they use the letters “EHR” as an initialism for “Errors Happen Regularly” — and to petition Congress for action. The two doses sent her into “complete respiratory distress” and resulted in a collapsed lung, according to a lawsuit filed by her mother. Although the order appeared on Epic’s screen, it was not sent to the lab. Vendors, for their part, had to develop systems that met the government’s requirements. In addition to the U.S. government’s $155 million False Claims Act settlement with eClinicalWorks noted above, the federal government has reached a second settlement over similar charges against another large vendor, Tampa-based Greenway Health. The pain radiated from the top of Annette Monachelli’s head, and it got worse when she changed positions. Doctor burnout: Many doctors say they spend half their day or more clicking pulldown menus and typing rather than interacting with patients. “Physician burnout is real,” she told KHN and Fortune. She visited doctors around the country, at big urban practices and tiny rural clinics, and from those front-line physicians she consistently heard one thing: They hated their electronic health records. She has promised to reduce the documentation burden on physicians and end the gag clauses that protect the EHR industry. But 10 years after President Barack Obama signed a law to accelerate the digitization of medical records — with the federal government, so far, sinking $36 billion into the effort — America has little to show for its investment. According to the institute of medicine which of the following core functions should be included in an EHR. Epic, among the nation’s largest manufacturers of computerized health records and the leading provider to most of America’s most elite medical centers, quietly paid $1 million to settle the suit in July 2018, according to court records. A Cerner-backed interoperability network called CommonWell formed in 2013, but some companies, including dominant Epic, didn’t join. He didn’t commit much money, but Bush did create an agency to do the job: the Office of the National Coordinator (ONC). Updates are not an option. Several of those who worked on the project admit the rollout was not as easy or seamless as they’d anticipated, but they contend that was never the point. Frantz tells KHN and Fortune that NextGen is cooperating with the investigation. Doctors failed to perform a cesarean section, and her baby was born brain-damaged as a result, she alleged in a lawsuit filed in 2017 against the U.S. government. Prescriptions, some 30,000 of them in 2010, lacked proper start and stop dates, introducing the opportunity for under- or overmedication. The case never got to a jury. EHRs were supposed to reduce health care costs, at least in part by preventing duplicative tests. Aneesh Chopra, appointed by Obama in 2009 as the nation’s first chief technology officer, called the spending a “down payment” on a vision to fundamentally change American medicine — creating a digital infrastructure to support new ways to pay for health services based on their quality and outcomes. Plaintiffs, moreover, say hospitals often fight to withhold records from injured patients or their families. The AMA assumes no liability for data contained or not contained herein. He added that forcing interoperability goals early on, when 90 percent of the nation’s providers still didn’t have systems or data to exchange, seemed unrealistic. Advocates bandied about a figure of $80 billion in cost savings even as congressional auditors were debunking it. Vendors, for their part, had to develop systems that met the government’s requirements. This is something the government mandated. “It was a big distraction. His results and diagnosis were delayed — by days, he claimed — during which time he suffered irreversible brain damage from herpes encephalitis. Beyond complicating the physician-patient relationship, EHRs have in some ways made practicing medicine harder, said Dr. Hal Baker, a physician and the chief information officer at WellSpan, a Pennsylvania hospital system. And perhaps none of these industries was more deserving of digital liberation than medicine, where life-measuring and potentially lifesaving data was locked away in paper crypts — stack upon stack of file folders at doctors’ offices across the country. Not everyone agreed, though, that they were the right ideas. Owen Foster, a newly hired assistant U.S. attorney with the District of Vermont, was assigned to defend the government. What worries the doctor most is the ease with which diligent, well-meaning physicians can make serious medical errors. The top-shelf vendors in 2009 crisscrossed the country on a “stimulus tour” like rock groups, gigging at some 30 cities, where they offered doctors who showed up to hear the pitch “a customized analysis” of how much money they could earn off the government incentives. With changes to the way eating disorders are categorized and the COVID-19 pandemic resulting in many changes to childrens’ eating habits, stress, and environments, it’s crucial for pediatricians to readdress their efforts, from reviewing the several forms of eating disorders, to connecting families to the resources they need for long term treatment. Moreover, the effort has handcuffed health providers to technology they mostly can’t stand and has enriched and empowered the $13-billion-a-year industry that sells it. MedStar’s Raj Ratwani (standing) studies eye-tracking with Dr. Zach Hettinger to see how doctors interact with EHRs.(T.J. The interviews reveal a tragic missed opportunity: Rather than an electronic ecosystem of information, the nation’s thousands of EHRs largely remain a sprawling, disconnected patchwork. Kirkpatrick for Fortune), In a study published last year in the journal Health Affairs, Ratwani and colleagues studied medication errors at three pediatric hospitals from 2012 to 2017. That’s not an error that will harm a patient — though other medication mix-ups can and do. The AMA does not directly or indirectly practice medicine or dispense medical services. The notion that one EHR should talk to another was a key part of the original vision for the HITECH Act, with the government calling for systems to be eventually interoperable. Epic, among the nation’s largest manufacturers of computerized health records and the leading provider to most of America’s most elite medical centers, quietly paid $1 million to settle the suit in July 2018, according to court records. The Joint Commission, which certifies hospitals, has sounded alarms about a number of issues, including false alarms — which account for between 85 and 99 percent of EHR and medical device alerts. And that data is passed as discrete data, not just a PDF or a screen shot, it takes the data and puts them into the right places in that EHR system.” Avizia The solution includes carts and tablets as well as proprietary software that enables remote consultations with patients using devices of their choosing. A Cerner-backed interoperability network called CommonWell formed in 2013, but some companies, including dominant Epic, didn’t join. Last spring, Verma attempted to kick-start the sharing effort and later pledged a war on “information blocking,” threatening penalties for bad actors. It’s not possible!”. Former House Speaker Newt Gingrich was fond of saying it was easier to track a FedEx package than one’s medical records. KHN and Fortune spoke with more than 100 physicians, patients, IT experts and administrators, health policy leaders, attorneys, top government officials and representatives at more than a half-dozen EHR vendors, including the CEOs of two of the companies. Ratwani is pushing for a central database to track such errors and adverse events. Patients don’t like that dynamic; for doctors, whose days increasingly begin and end with such fleeting encounters, the effect can be downright deadening. “It’s a disaster,” he said. The eCW system did not reliably track lab results, concluded Delaney, who tallied 1,884 tests for which they had never gotten outcomes. Though the software has reduced some types of clinical mistakes common in the era of handwritten notes, Raj Ratwani, a researcher at MedStar Health in Washington, D.C., has documented new patterns of medical errors tied to EHRs that he believes are both perilous and preventable. The idea had already been a fashionable one in Washington. Among the most outspoken is Ratwani, who directs MedStar Health’s National Center on Human Factors in Healthcare, a 30-­person institute focused on optimizing the safety and usability of medical technology. This is a poor tool issue.”, Many of the EHR makers acknowledge physician burnout is real and say they’re doing what they can to lessen the burden and enhance user experience. “You’re sitting in front of a patient, and there are so many things you have to do, and you only have so much time to do it in — seven to 11 minutes, probably — so when do you really listen?” asked John-Henry Pfifferling, a medical anthropologist who counsels physicians suffering from burnout. The wave of digitization had swept up virtually every industry, bringing both disruption and, in most cases, greater efficiency. “The interfaces are just so confusing and clunky,” she added. “We had an expression: They had to operate before they could interoperate,” he said. One hospital charged more than $500 to release them. When emergency room doctors went to order Tylenol, for example, they saw a drop-down menu listing 86 options, many of which were irrelevant for the specified patient. Foster began with Monachelli’s medical records, which offered a puzzle. NextGen responded that it disputed the claims made in the lawsuit and that the matter was resolved in 2015 “with no findings of fact by a court related to the allegations.” The hospital declined to comment. Five days later, an operation to repair the damage went awry, and he suffered permanent brain damage, apparently owing to an anesthesia problem. Prior work need not have been funded through the IUSE: EHR Program but should provide data and document expertise of the project team in support of project objectives. When he got to MedStar in 2012, he was stunned by “the types of [digital] interfaces being used” in health care, he said. Blumenthal acknowledged that he failed to grasp these perverse business dynamics and foresee what a challenge getting the systems to talk to one another would be. He added that forcing interoperability goals early on, when 90 percent of the nation’s providers still didn’t have systems or data to exchange, seemed unrealistic. In early December of that year, Obama, barely four weeks after his election, pitched an ambitious economic recovery plan. “The industry was moving along in a natural Darwinist way, and then along came the stimulus,” said Frantz, who blames the government’s ham-handed approach to regulation. As Biden would tell you, the original concept was a smart one. When Seema Verma’s husband was discharged from the hospital after his summer health scare, he was handed a few papers and a CD-ROM containing some medical images — but missing key tests and monitoring data. The patient medication lists weren’t reliable; prescribed drugs would not show up, while discontinued drugs would appear as current, according to the complaint. The software in question was an electronic health records system, or EHR, made by eClinicalWorks (eCW), one of the leading sellers of record-keeping software for physicians in America, currently used by 850,000 health professionals in the U.S. The Ohio hospital, which paid more than $1.5 million for its EHR system, claimed breach of contract. The EHR would sometimes display one patient’s medication profile accompanied by the physician’s note for a different patient, making it easy to misdiagnose or prescribe a drug to the wrong individual. “Physicians have to cognitively switch between focusing on the record and focusing on the patient,” he said. But lawsuits, like that filed by Fabian ­Ronisky, which do emerge from this veil, are quite telling. Physicians complain about clumsy, unintuitive systems and the number of hours spent clicking, typing and trying to navigate them — which is more than the hours they spend with patients. That’s right. The eCW spaghetti code was so buggy that when one glitch got fixed, another would develop, the government found. Click the button below to go to KFF’s donation page which will provide more information and FAQs. The eCW system did not reliably track lab results, concluded Delaney, who tallied 1,884 tests for which they had never gotten outcomes. By 2016, NextGen had more than 19,000 customers who had received federal subsidies. The doctors spoke of the difficulty in getting information from other systems and providers, and they complained about the government’s reporting requirements, which they perceived as burdensome and not meaningful. Aaron Zachary Hettinger, an emergency medicine physician with MedStar Health in Washington, D.C., said that when he and fellow clinicians need to share critical patient information, they write it on a whiteboard or on a paper towel and leave it on their colleagues’ computer keyboards. Duncan died a week later. “If you go into medicine because you care about interacting, and then you’re just a tool, it’s dehumanizing,” said Pfifferling, who has seen many physicians leave medicine over the shift to electronic records. A broad coalition of actors, from National Nurses United to the Texas Medical Association to leaders within the FDA, has long called for oversight on electronic-record safety issues. “That’s just the tiniest tip of the iceberg,” she said. @fredschulte, By Fred Schulte and Erika Fry, Fortune In response to the COVID-19 pandemic, the 2020 UDS included COVID-19 Healthcare Common Procedural Coding System (HCPCS), Current Procedural Terminology (CPT), and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to enable the collection of COVID-19 testing and treatment data at health centers. 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