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posted by chromas on Wednesday March 27 2019, @10:22PM   Printer-friendly
from the frmForm1 dept.

Submitted via IRC for Bytram

Death by a Thousand Clicks: Where Electronic Health Records Went Wrong

The pain radiated from the top of Annette Monachelli’s head, and it got worse when she changed positions. It didn’t feel like her usual migraine. The 47-year-old Vermont attorney turned innkeeper visited her local doctor at the Stowe Family Practice twice about the problem in late November 2012, but got little relief.

Two months later, Monachelli was dead of a brain aneurysm, a condition that, despite the symptoms and the appointments, had never been tested for or diagnosed until she turned up in the emergency room days before her death.

Monachelli’s husband sued Stowe, the federally qualified health center the physician worked for. Owen Foster, a newly hired assistant U.S. attorney with the District of Vermont, was assigned to defend the government. Though it looked to be a standard medical malpractice case, Foster was on the cusp of discovering something much bigger—what his boss, U.S. Attorney Christina Nolan, calls the “frontier of health care fraud”—and prosecuting a first-of-its-kind case that landed the largest-ever financial recovery in Vermont’s history.

Foster began with Monachelli’s medical records, which offered a puzzle. Her doctor had considered the possibility of an aneurysm and, to rule it out, had ordered a head scan through the clinic’s software system, the government alleged in court filings. The test, in theory, would have caught the bleeding in Monachelli’s brain. But the order never made it to the lab; it had never been transmitted.

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. It didn’t take long for Foster to assemble a dossier of troubling reports—Better Business Bureau complaints, issues flagged on an eCW user board, and legal cases filed around the country—suggesting the company’s technology didn’t work quite like it said it did.

Until this point, Foster, like most Americans, knew next to nothing about electronic medical records, but he was quickly amassing clues that eCW’s software had major problems—some of which put patients, like Annette Monachelli, at risk.

Damning evidence came from a whistleblower claim filed in 2011 against the company. Brendan Delaney, a British cop turned EHR expert, was hired in 2010 by New York City to work on the eCW implementation at Rikers Island, a jail complex that then had more than 100,000 inmates. But soon after he was hired, Delaney noticed scores of troubling problems with the system, which became the basis for his lawsuit. 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 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. Prescriptions, some 30,000 of them in 2010, lacked proper start and stop dates, introducing the opportunity for under- or overmedication. The eCW system did not reliably track lab results, concluded Delaney, who tallied 1,884 tests for which they had never gotten outcomes.

The District of Vermont launched an official federal investigation in 2015.

eCW’s spaghetti code was so buggy that when one glitch got fixed, another would develop, the government found. The user interface offered a few ways to order a lab test or diagnostic image, for example, but not all of them seemed to function. The software would detect and warn users of dangerous drug interactions, but unbeknownst to physicians, the alerts stopped if the drug order was customized. “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,” says Foster.

The eCW system also failed to use the standard drug codes, and in some instances, lab and diagnosis codes as well, the government alleged.

The case never got to a jury. In May 2017, eCW paid a $155 million settlement to the government over alleged “false claims” and kickbacks—one physician made tens of thousands of dollars—to clients who promoted its product. Despite the record settlement, the company denied wrongdoing; eCW did not respond to numerous requests for comment.

If there is a kicker to this tale, it is this: The U.S. government bankrolled the adoption of this software—and continues to pay for it. Or we should say: You do.

Which brings us to the strange, sad, and aggravating story that unfolds below. It is not about one lawsuit or a piece of sloppy technology. Rather, it’s about a trouble-prone industry that intersects, in the most personal way, with every one of our lives. It’s about a $3.7-trillion-dollar health care system idling at the crossroads of progress. And it’s about a slew of unintended consequences—the surprising casualties of a big idea whose time had seemingly come.

[Click through to read a whole lot more.]


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  • (Score: 2) by JoeMerchant on Thursday March 28 2019, @04:37PM (1 child)

    by JoeMerchant (3937) on Thursday March 28 2019, @04:37PM (#821394)

    If one is not absolutely dying this minute then the ER is not necessarily the location one should be in

    Case(s) in point: last two family visits to the E.R. - one was for suspected blood poisioning infection (could lead to loss of limb if not treated promptly), first noticed at 4:30pm on a Sunday, the E.R. was the only treatment facility available within 100 miles that was open before the following morning. Wait time: until 11:30pm

    Cut foot @ 10pm, approximately 10oz of blood lost, 8 stitches required. Again, E.R. was the only option before morning. Checked in @ 10:10pm, stitches applied to wound @ 5:30am.

    As to less pressing medical needs: most of the uninsured can't afford other care, so they go untreated until their needs are appropriately
    addressed in the E.R. - which is almost never the most cost effective or highest quality of life course of action.

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  • (Score: 2) by All Your Lawn Are Belong To Us on Thursday March 28 2019, @06:25PM

    by All Your Lawn Are Belong To Us (6553) on Thursday March 28 2019, @06:25PM (#821435) Journal

    I agree with you that prompt care facilities should be held to something similar to EMTALA - show up and you must be treated - and you have a point. IANAL nor an expert in that area, only read this [youtube.com] just now where hospital-connected urgent cares may also have EMTALA liability. (For any not in the know Emergency Medical Treatment and Labor Act of 1986 is the law that says an ER must stabilize a patient regardless of anything else. The "don't let a patient die on the hospital steps" law.)

    10 ounces of blood loss in an adult (most importantly Bleed Controlled) is something that can wait to be stitched. Fun? Hell, no. But, uncomplicated, not a life threatening emergency though it is on the borderline of hypovolemic symptoms depending on total patient blood volume. Treatable in ER? Yep! Of course it will be stitched (or stapled or glued but stitches are probably best in a foot). Life-threatening emergency? Not if the bleed is controlled. If the bleed is uncontrolled then watch how the system swings into action to make lifesaving care happen - and there may be a delay between bleed control and stitching even then. (In fact, a doc might want to push a little bit of fluids to re-perfuse the tissues if that can be done without reopening the bleed before stitching either way. Stabilize before closure. Dunno.)

    Blood poisoning infection: IS an emergency of ER grade quality. Will the patient die in 7 hours? Well, if the patient was sweaty and shocky you'd see a sepsis code and watch how the system swings into action to make lifesaving care happen. Again: The point of an ER is to stabilize the patient, not cure the infection.

    And in both the cases above the staff should be keeping an eye on the patients in sufficient frequency to recognize a downswing and be ready to treat accordingly. But the key is: Stable patients can wait. Unstable patients can't. And they don't stick themselves in situations where the care of stable patients means an unstable one doesn't get immediate treatment.

    Another thing most people don't realize: ER must diagnose and stabilize. Actual treatment of a non-emergent condition beyond stabilization is legally regarded as billing fraud. Unnecessary care in the emergency room setting is an unnecessary service and therefore not paid, I kid you not. Is that insane? In its way, yes. But ER's do not want to be the dumping ground for nonemergent conditions since other care modes are available. Especially when that care would be free because insurances would reject - see Billing Fraud, again.

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