Tagged Cost and Quality

Must-Reads Of The Week (Some Flying Below The Radar)

Your wonderfully entertaining compiler of “The Friday Breeze,” Brianna Labuskes, is off today, so I’m jumping in to keep you abreast of this week’s vital health care news. Here’s what I found most fascinating, some of it far away from the headlines.

Let’s dive into my “Department of Health Studies,” where I found several worthy of your time.

First, the scourge of fentanyl drug overdoses is rising most sharply among African-Americans. The CDC’s National Center for Health Statistics, which did the study, said the synthetic opioid is also a factor in the rise of death rates across other demographic groups.

The Washington Post: Fentanyl Drug Overdose Deaths Rising Most Sharply Among African Americans

A group of academics studying anti-vaccination posts on Facebook found that it’s not just the unfounded fear of autism driving the sentiment. While 86 percent of the posters were women, their motivation varied from conspiracy — as in poliovirus does not exist and pesticides caused the clinical symptoms of polio — to a belief in alternative medicine — eating yogurt cures human papillomavirus.

Science Direct: It’s Not All About Autism: The Emerging Landscape of Anti-Vaccination Sentiment on Facebook

Many news outlets reported on a study on the Apple Watch and its heavily promoted ability to detect an irregular heartbeat. The Apple-funded study, which has not been published or peer-reviewed, concluded the watch works.

CNN: Apple Watch App Could Detect Life-Threatening Irregular Heartbeat, Study Says


Moving on to data, the Robert Wood Johnson Foundation issued its county health rankings this week. It’s a user-friendly display of a matrix of health indicators that lets you spot the country’s trouble spots. This year’s report, the foundation explains, tried to get at the relationship of the cost of housing to health. “The research reveals that in the most segregated counties nearly one in four black households spends more than half their income on housing, compared with one in 10 white households.”

Robert Wood Johnson Foundation: How Healthy Is Your Community?

Doctors will like this one: a study comparing hospital CEO salaries — nonprofit hospital CEOs, mind you — with physician salaries. CEO salaries are five times higher than surgeons’ salaries, up from a ratio of 3-to-1 only 10 years earlier.

Healthcare Dive: CEO Salaries at Nonprofit Hospitals Up 93% Since 2005


Drug prices remain the hot topic this week in health care news. The BBC looked at the high drug prices in the U.S. compared with the prices in Great Britain and chortled a bit.

BBC News: The Human Cost of Insulin in America

Elisabeth Rosenthal, the editor-in-chief of KHN, wrote an analysis in The New York Times of Eli Lilly’s baffling public relations move to cut insulin prices in the U.S. with an “authorized generic.” She writes, “It is, perhaps, a sign of how desperate Americans are for something — anything — to counteract the escalating price of drugs that Lilly’s move was greeted with praise rather than a collective ‘Huh?’”

The New York Times: Why Should Americans Be Grateful for $137 Insulin? Germans Get It for $55


While we are on the topic of the high cost of health care, the federal government’s General Accountability Office issued a report on air ambulances and the sky-high bills the companies send patients. (KHN featured the problem in its “Bill of the Month” series and the St. Louis Post-Dispatch did some excellent pieces on the problem last year.) Bob Herman of Axios noted that the report found that the median price of medical helicopter transport in 2017 was $36,400.

Government Accountability Office: Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial Risk


I’d be remiss if I didn’t mention a fabulous article by another KHN staffer, Fred Schulte, who with Erika Fry of Fortune magazine wrote about the mess that electronic health records have become. It’s long, but so good at illuminating a problem that is largely invisible to patients.

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

The Baltimore Sun produced a great graphic, a live map of sewage pollution in the city. The accompanying article says: “More than 14 million gallons of sewage-tainted water has washed into Baltimore streams over the past two months, but city officials haven’t alerted the public of the contamination.”

The Baltimore Sun: Baltimore Launches Live Map of Sewage Pollution — and Temporarily Stops Alerting the Public to Contamination

Enjoy the weekend with this selection of things to read.

Even With Insurance, She Faced $227K In Medical Bills. What It Took To Get Answers.

The first surprise was the massive heart attack, which struck as Debbie Moehnke waited in a Vancouver, Wash., medical clinic last summer.

“She had an appointment because her feet were swollen real bad,” said Larry Moehnke, her husband. “But she got in there and it was like, ‘I can’t breathe, I can’t breathe!’”

Her life suddenly at risk, the 59-year-old was rushed by ambulance, first to a local hospital, where she was stabilized, and then, the next day, to Oregon Health & Science University across the river in Portland for urgent cardiac care.

That meant heart bypass surgery, replacement of one valve and repair of another. Just as she recovered from that, Debbie Moehnke developed a raging infection that required powerful IV antibiotics to treat. She spent a month in the hospital, some of it in intensive care, before she was discharged home.

That’s when she got the next surprise: Bills totaling more than $454,000 for the medical miracle that saved her life. Of that stunning amount, officials said, she owed nearly $227,000 after her health insurance paid its part.

“I wish I would have known. I would have said ‘no’ to life support,” said Debbie Moehnke, a former cocktail waitress who suffers from signs of early-onset dementia. “We’ll lose everything.”

Large “surprise bills” like the Moehnkes received have become a national epidemic outraging patients and politicians alike. Solutions have been elusive to date, even in a progressive state like Washington.

Lawmakers in Olympia this year are trying for the fourth time to pass legislation banning the practice that leaves consumers with huge out-of-pocket costs.

“Everybody agrees we’ve got to get the consumer out of being stuck in between,” said Mike Kreidler, the state insurance commissioner who has repeatedly backed the proposals.

While the protection would be beneficial to patients, there has been formidable and effective pushback from insurers, hospitals and doctors.

The central issue is money. Such surprise bills, or “balance bills,” typically occur when a patient’s insurer and a hospital or doctor not in its network don’t agree on what treatment is worth. The insurer — LifeWise Health Plan of Washington, in this case — pays what it judges to be fair. Providers then bill patients for the balance, which can easily tally tens if not hundreds of thousands of dollars.

As of December, 25 states had laws providing protection against balance bills, according to the Commonwealth Fund. Those laws take consumers out of the middle in billing disputes and force providers and insurers to negotiate directly for payment.

When an insurer and a provider disagree about how much a service is worth, who decides the legitimate charge? The proposed bills in Washington state use a “commercially reasonable” rate as the standard. But what does that mean in a country where medical prices are so variable?

“We need to make sure that any law that is enacted doesn’t tilt the scale toward one side or another,” said Chelene Whiteaker, senior vice president of government affairs for the Washington State Hospital Association.

The Washington state legislation borrows from a 2015 New York law that sends insurers and providers to baseball-style binding arbitration if they can’t come to an agreement about costs. Both parties remain cautious.

“I hope they will give up the idea that this is a chance to stick it to doctors,” said Dr. Nathan Schlicher of the Washington State Medical Association.

Leonard Sorrin, vice president of congressional and legislative affairs for Premera Blue Cross, which operates LifeWise, said in a statement that his organization is working for legislation that prevents balance billing, but also “maintains a contracting balance that allows health plans to build networks for members and pays the provider a fair rate.”

While patients can generally avoid balance billing by staying in-network, a life-or-death emergency such as Debbie Moehnke’s can make that impossible. Also, many in-network hospitals often use out-of-network doctors, leaving patients vulnerable to surprise charges.

So much money is at stake that, even when they exist, laws are filled with loopholes and offer only patchwork protection. For example, hospitals are not prohibited from sending balance bills; patients have to know they’re protected by law and go to considerable effort to contest them.

And about 60 percent of employer-based plans are governed by federal rather than state law. There is currently no federal prohibition against balance billing, although a bipartisan bill to end the practice was proposed last year.

Oregon, where Debbie Moehnke was treated, does have a law banning surprise bills, which took effect last year. But it applies only to out-of-network charges sent to a patient who received care at an in-network provider. And it covers only insurers regulated in the state, which excludes the Moehnkes’ plan, according to state insurance officials.

The proposed Washington legislation would ban balance billing for most of the state’s nearly 6 million insured consumers under age 65. But it could skip about 2 million people who get coverage through employers with self-funded plans. Those plans are regulated by a federal law, called ERISA, shorthand for the Employee Retirement Income Security Act of 1974, which doesn’t prohibit balance billing.

Self-insured employers would be allowed, but not required, to participate in provisions of the new law, if approved.

So far, however, change has come too slowly for families like the Moehnkes, who found themselves facing crushing bills, despite buying a well-subsidized plan on the state’s insurance exchange. In Debbie Moehnke’s case, the full bill from OHSU and affiliated providers was $454,550.54. Her insurance paid $227,959.19.

That left the Moehnkes with bills totaling $226,591.35.

“What do you think you’re going to do, squeeze blood out of a turnip?” said Larry Moehnke, 70, a big-rig truck driver.

Married 32 years, the Moehnkes and their two dogs, Coco and Belle, live in a 47-year-old mobile home in rural southwestern Washington. Larry Moehnke hasn’t been able to work since health problems of his own developed after his wife’s heart attack. They’re getting by on his Social Security income of $1,884 a month.

Charges for Debbie Moehnke’s emergency care totaled more than $454,000. Her health insurance plan agreed to pay about half the costs, leaving the couple responsible for the rest. With help from a patient advocate, the bill was eventually erased.(Michael Hanson for KHN)

LifeWise spokesman Bo Jungmayer said the insurer paid for her emergency care to the extent required under the Affordable Care Act.

Debbie Moehnke was hospitalized at OHSU from Aug. 14 to Sept. 12, 2018. She was initially admitted for her emergency heart treatment. While there, she developed an unidentified infection that required two additional weeks of care.

Only later did the couple learn that she could have been transferred to an in-network hospital, potentially saving tens of thousands of dollars.

“They never said anything about not being ‘in network’ or anything,” Larry Moehnke said.

Debra Tomsen, OHSU’s director of hospital billing and coding, said LifeWise officials should have notified the Moehnkes after receiving bills for nearly $250,000 halfway through her stay.

“Insurance should tell them they’re incurring out-of-pocket costs,” she said.

Jungmayer, of LifeWise, said it was up to OHSU to let Debbie Moehnke know about the high bills — and about the option to transfer to another hospital.

“Typically we allow that conversation between the provider and the patient while they’re there,” he said. “I don’t know why OHSU didn’t ask them.”

Early this month, after repeated inquiries about Debbie Moehnke’s care — first from a reporter, then from a patient advocate alerted by the Washington state insurance commission — the couple’s outstanding bills were resolved.

With the help of Jared Walker, who runs Dollar for Portland, a nonprofit group, the couple applied for a medical charity care waiver, in itself a complicated process. OHSU officials granted the waiver, erasing the sky-high debt.

“Their balance is now zero,” OHSU spokeswoman Tamara Hargens-Bradley confirmed in an email.

The Moehnkes are relieved, but they said they resent that they endured the stress of mounting bills and collection calls for six months when there was a solution available.

“Nobody ever said anything about charity care,” said Larry Moehnke.

That’s not how the process should work, said Kreidler.

“It shouldn’t be one where the squeaky wheel gets help,” he said. “There should be fairness and equality in the system. You shouldn’t have to file a complaint. This should be ingrained into the system so that when you have a problem and you’re due relief, you get it.”

FDA Chief Calls For Stricter Scrutiny Of Electronic Health Records

Food and Drug Administration Commissioner Scott Gottlieb on Wednesday called for tighter scrutiny of electronic health records systems, which have prompted thousands of reports of patient injuries and other safety problems over the past decade.

“What we really need is a much more tailored approach, so that we have appropriate oversight of EHRs when they’re doing things that could create risk for patients,” Gottlieb said in an interview with Kaiser Health News.

Gottlieb was responding to “Botched Operation,” a report published this week by KHN and Fortune magazine. The investigation found that the federal government has spent more than $36 billion over the past 10 years to switch doctors and hospitals from paper to digital records systems. In that time, thousands of reports of deaths, injuries and near misses linked to EHRs have piled up in databases — including at least one run by the FDA.

Gottlieb said Congress would need to enact legislation to define when an electronic health record would require government oversight. He said that the digital records systems, which store a patient’s medical history, don’t fit neatly under the agency’s existing mandate to regulate items such as drugs and medical devices.

Gottlieb said the best approach might be to say that an EHR that has a certain capability becomes a medical device. He called EHRs a “unique tool,” noting that the risks posed by their use aren’t the same as for a traditional medical device implanted in a patient. “You need a much different regulatory scheme,” he said.

The 21st Century Cures Act of 2016 excludes the FDA from having oversight over electronic health records as a medical device.

Gottlieb said that health IT companies could add new functions that would improve EHRs, but they have been reluctant to do so because they didn’t want their products to fall under FDA jurisdiction. He added that he was “not calling” for FDA to take over such a duty, however, and suggested that any new approach could be years away. Proponents have long argued that widespread use of EHRs can make medicine safer by alerting doctors to potential medical errors, though critics counter that software glitches and user errors may cause new varieties of medical mistakes.

How closely the FDA should watch over the digital medical record revolution has been controversial for years. The agency’s interest in the issue perked up after Congress decided in February 2009 to spend billions of dollars on digital medical records as part of an economic stimulus program.

At the time, many industry groups argued that FDA regulation would “stifle innovation” and stall the national drive to bring medicine into the modern era. Federal officials responsible for doling out billions in subsidies to doctors and hospitals generally sympathized with that view and were skeptical of allowing the FDA to play a role.

The debate became public in February 2010, when Jeffrey Shuren, an FDA official, testified at a public hearing that the agency had tied six deaths and more than 200 injuries to health information technology. In all, the FDA said, it had logged 260 reports in the previous two years of “malfunctions with the potential for patient harm.”

The agency said the findings were based largely on reports voluntarily submitted to the FDA and suggested “significant clinical implications and public safety issues.” In one case cited, lab tests done in a hospital emergency room were sent to the wrong patient’s file. Since then, several government and private repositories have associated thousands of injuries, near misses and deaths to EHR technology.

Shuren said in 2010 that the agency recognized that health information technology had great potential to improve patient care, but also needed oversight to “assure patient safety.”

While some safety proponents agree that EHRs offer tremendous benefits, they also see a greater opportunities to improve their safety.

Dean Sittig, a professor of bioinformatics and bioengineering at the University of Texas Health Science Center, said EHRs have improved safety within the health care system, but they have not eliminated errors to the extent that he would have expected. Federal officials were initially pushing for rapid adoption and “there wasn’t a lot of interest in talking about things that could go wrong,” Sittig told KHN and Fortune.

Earlier this month, Gottlieb announced his resignation from the FDA. His last day is scheduled to be April 5.

KHN correspondents Sarah Jane Tribble, Sydney Lupkin and Julie Rovner contributed to this report.

Podcast: KHN’s ‘What The Health’ Surprise! Fixing Surprise Medical Bills Is Harder Than it Looks

Surprise medical bills — when patients receive an unexpected bill from a health provider not in their insurance network — are among the few problems in health care just about everyone wants to solve. But it turns out that no one in the health industry wants to take responsibility for paying those bills. That could complicate efforts toward a legislative fix, despite bipartisan support.

And the 2020 presidential campaign is already in full swing, with candidates staking out some surprisingly diverse positions on how to expand access to health care.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Alice Miranda Ollstein of Politico.

Also, Rovner interviews Scott Gottlieb, the commissioner of the Food and Drug Administration, who is stepping down in early April.

Among the takeaways from this week’s podcast:

  • State and federal lawmakers of both parties and industry groups say they want to find a way to protect patients from getting surprise bills from out-of-network doctors and hospitals after treatment. But they can’t find agreement on a way to fix the system.
  • Efforts to end surprise bills generally fall into two categories: setting rates for out-of-network services (which might be based on some percentage of Medicare rates) or requiring patients and providers to go through an arbitration process (a technique some states are using).
  • Among Democratic candidates for president, the push for switching to a “Medicare-for-all” system appears to be moderating a bit as more centrists call for less sweeping changes in the health care system, hoping to avoid blowback from people who like their current insurance and a united opposition from industry groups.
  • The Trump administration’s budget proposal would put money behind the effort to stop the spread of HIV. But while medical advances have made HIV eradication possible, obstacles remain, including the difficulty of reaching many of the communities that need the support.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Fortune’s “Death by a Thousand Clicks: Where Electronic Health Records Went Wrong,” by Erika Fry and KHN’s Fred Schulte

Joanne Kenen: NBC’s “Surprise Medical Bills Lead to Liens on Homes and Crippling Debt,” by Lindsey Bomnin and Stephanie Gosk

Anna Edney: Stat News’ “The Astounding 19-Year Journey to a Sea Change for Heart Patients,” by Matthew Herper

Alice Miranda Ollstein: The New York Times’ “States Seek Financial Relief for Family Caregivers,” by KHN’s Samantha Young

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

University Of Illinois At Chicago Acknowledged Failure To Catch Warnings Signs Over Child Psychiatrist Who Violated Research Protocols

According to new documents, the University of Illinois at Chicago Institutional Review Board, the committee responsible for protecting research subjects, improperly fast-tracked approval of Dr. Mani Pavuluri’s clinical trial, didn’t catch serious omissions from the consent forms parents had to sign and allowed children to enroll in the study even though they weren’t eligible. Still, UIC officials have continued to blame only Pavuluri, and have downplayed the institution’s role in the research.

University Of Illinois At Chicago Acknowledged Failure To Catch Warnings Signs Over Child Psychiatrist Who Violated Research Protocols

According to new documents, the University of Illinois at Chicago Institutional Review Board, the committee responsible for protecting research subjects, improperly fast-tracked approval of Dr. Mani Pavuluri’s clinical trial, didn’t catch serious omissions from the consent forms parents had to sign and allowed children to enroll in the study even though they weren’t eligible. Still, UIC officials have continued to blame only Pavuluri, and have downplayed the institution’s role in the research.

State Highlights: Baltimore Mayor Leaves Hospital Board After Profit-Making Concerns Raised; ‘Dehumanizing’ Medical Care At N.Y. Jail Haunts Physician

Media outlets report on news from Maryland, New York, Texas, Kansas, Connecticut, California, Florida, Wisconsin, Minnesota, Arizona, Oregon, Massachusetts, Rhode Island and Louisiana.

When Drug Costs Get Too High, Patients Are Skipping Doses Or Just Not Taking Medication

Experts are worried this behavior could be extremely dangerous for the patients. “We have lots of treatments where if you don’t take them exactly as prescribed, you might be doing more harm than good,” said Stacie Dusetzina, a health policy researcher at Vanderbilt University. Other ways patients are trying to control costs are by asking for cheaper drugs from doctors or seeking out alternative therapies. Meanwhile, Ohio’s attorney general is suing UnitedHealth’s OptumRx unit alleging it overcharged the state for prescription drugs.

New Ads Accuse Trump Of Wanting To ‘Slash Our Health Care To The Bone’ With Proposed Medicaid, Medicare Cuts

The ad is the latest example of Democratic attacks on the Trump administration’s budget proposal for fiscal year 2020. Democrats saw health care as a winning issue in the midterms, and are hoping to repeat that success in upcoming elections. Other Medicaid news comes out of Tennessee, Ohio, Georgia and Idaho.

Death By A Thousand Clicks

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 the way 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.

The eCW 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,” said 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 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.

The Virtual Magic Bullet

Electronic health records were supposed to do a lot: make medicine safer, bring higher-quality care, empower patients, and yes, even save money. Boosters heralded an age when researchers could harness the big data within to reveal the most effective treatments for disease and sharply reduce medical errors. Patients, in turn, would have truly portable health records, being able to share their medical histories in a flash with doctors and hospitals anywhere in the country — essential when life-and-death decisions are being made in the ER.

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. 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. 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. 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.

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. But on most other counts, the newly installed technology has fallen well short. 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. Unlike, say, with the global network of ATMs, the proprietary EHR systems made by more than 700 vendors routinely don’t talk to one another, meaning that doctors still resort to transferring medical data via fax and CD-ROM. ­Patients, meanwhile, still struggle to access their own records — and, sometimes, just plain can’t.

(Nicolas Rapp/Fortune)

Instead of reducing costs, many say, EHRs, which were originally optimized for billing rather than for patient care, have instead made it easier to engage in “upcoding” or bill inflation (though some say the systems also make such fraud easier to catch).

More gravely still, a months-long joint investigation by KHN and Fortune has found that instead of streamlining medicine, the government’s EHR initiative has created a host of largely unacknowledged patient safety risks. Our investigation found that alarming reports of patient deaths, serious injuries and near misses — thousands of them — tied to software glitches, user errors or other flaws have piled up, largely unseen, in various government-funded and private repositories.

Compounding the problem are entrenched secrecy policies that continue to keep software failures out of public view. 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. Plaintiffs, moreover, say hospitals often fight to withhold records from injured patients or their families. Indeed, two doctors who spoke candidly about the problems they faced with EHRs later asked that their names not be used, adding that they were forbidden by their health care organizations to talk. Says Assistant U.S. Attorney Foster, the EHR vendors “are protected by a shield of silence.”

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 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.

David Blumenthal, who, as Obama’s national coordinator for health information technology, was one of the architects of the EHR initiative, acknowledged to KHN and Fortune that electronic health records “have not fulfilled their potential. I think few would argue they have.”

The former president has likewise singled out the effort as one of his most disappointing, bemoaning in a January 2017 interview with Vox “the fact that there are still just mountains of paperwork … and the doctors still have to input stuff, and the nurses are spending all their time on all this administrative work. 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. “Providers developed their own systems that may or may not even have worked well for them,” she told KHN and Fortune in an interview last month, “but we didn’t think about how all these systems connect with one another. That was the real missing piece.”

Perhaps none of the initiative’s former boosters is quite as frustrated as former Vice President Joe Biden. At a 2017 meeting with health care leaders in Washington, he railed against the infuriating challenge of getting his son Beau’s medical records from one hospital to another. “I was stunned when my son for a year was battling stage 4 glioblastoma,” said Biden. “I couldn’t get his records. I’m the vice president of the United States of America.  … It was an absolute nightmare. It was ridiculous, absolutely ridiculous, that we’re in that circumstance.”

A Bridge To Nowhere

As Biden would tell you, the original concept was a smart one. The wave of digitization had swept up virtually every industry, bringing both disruption and, in most cases, greater efficiency. 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.

Stowed in steel cabinets, the records were next to useless. Nobody — particularly at the dawn of the age of the iPhone — thought it was a good idea to leave them that way. The problem, say critics, was in the way that policy­makers set about to transform them.

“Every single idea was well-meaning and potentially of societal benefit, but the combined burden of all of them hitting clinicians simultaneously made office practice basically impossible,” said John Halamka, chief information officer at Beth Israel Deaconess Medical Center, who served on the EHR standards committees under both George W. Bush and Barack Obama. “In America, we have 11 minutes to see a patient, and, you know, you’re going to be empathetic, make eye contact, enter about 100 pieces of data, and never commit malpractice. It’s not possible!”

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 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. EHR vendors also frequently have contract stipulations, known as “hold harmless clauses,” that protect them from liability if hospitals are later sued for medical errors — even if they relate to an issue with the technology.

But lawsuits, like that filed by Fabian ­Ronisky, which do emerge from this veil, are quite telling.

Ronisky, according to his complaint, arrived by ambulance at Providence Saint John’s Health Center in Santa Monica on the afternoon of March 2, 2015. For two days, the young lawyer had been suffering from severe headaches while a disorienting fever left him struggling to tell the 911 operator his address.

Suspecting meningitis, a doctor at the hospital performed a spinal tap, and the next day an infectious disease specialist typed in an order for a critical lab test — a check of the spinal fluid for viruses, including herpes simplex — into the hospital’s EHR.

The multimillion-dollar system, manufactured by Epic Systems Corp. and considered by some to be the Cadillac of medical software, had been installed at the hospital about four months earlier. Although the order appeared on Epic’s screen, it was not sent to the lab. It turned out, Epic’s software didn’t fully “interface” with the lab’s software, according to a lawsuit Ronisky filed in February 2017 in Los Angeles County Superior Court. His results and diagnosis were delayed — by days, he claimed — during which time he suffered irreversible brain damage from herpes encephalitis. The suit alleged the mishap delayed doctors from giving Ronisky a drug called acyclovir that might have minimized damage to his brain.

Epic denied any liability or defects in its software; the company said the doctor failed to push the right button to send the order and that the hospital, not Epic, had configured the interface with the lab. 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 hospital and two doctors paid a total of $7.5 million, and a case against a third doctor is pending trial. Ronisky, 34, who is fighting to rebuild his life, declined to comment.

Incidents like that which happened to Ronisky — or to Annette Monachelli, for that matter — are surprisingly common, data show. And the back-and-forth about where the fault lies in such cases is actually part of the problem: The systems are often so confusing (and training on them seldom sufficient) that errors frequently fall into a nether zone of responsibility. It can be hard to tell where human error begins and the technological short­comings end.

EHRs promised to put all of a patient’s records in one place, but often that’s the problem. Critical or time-sensitive information routinely gets buried in an endless scroll of data, where in the rush of medical decision-making — and amid the maze of pulldown menus — it can be missed.

Thirteen-year-old Brooke Dilliplaine, who was severely allergic to dairy, was given a probiotic containing milk. The two doses sent her into “complete respiratory distress” and resulted in a collapsed lung, according to a lawsuit filed by her mother. Rory Staunton, 12, scraped his arm in gym class and then died of sepsis after ER doctors discharged the boy on the basis of lab results in the EHR that weren’t complete. And then there’s the case of Thomas Eric Duncan. The 42-year-old man was sent home in 2014 from a Dallas hospital infected with Ebola virus. Though a nurse had entered in the EHR his recent travel to Liberia, where an Ebola epidemic was then in full swing, the doctor never saw it. Duncan died a week later.

Bobby and Tara Dilliplaine hold a photo of daughter Brooke, who suffered complications when she was given medication she was allergic to. (She later died of causes unrelated to the EHR issue.)(Heidi de Marco/KHN)

Many such cases end up in court. Typically, doctors and nurses blame faulty technology in the medical-records systems. The EHR vendors blame human error. And meanwhile, the cases mount.

Quantros, a private health care analytics firm, said it has logged 18,000 EHR-related safety events from 2007 through 2018, 3 percent of which resulted in patient harm, including seven deaths — a figure that a Quantros director said is “drastically underreported.”

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. In 13 percent of those cases, the mistake could have been fatal.

The Pew Charitable Trusts has, for the past few years, run an EHR safety project, taking aim at issues like usability and patient matching — the process of linking the correct medical record to the correct patient — a seemingly basic task at which the systems, even when made by the same EHR vendor, often fail. At some institutions, according to Pew, such matching was accurate only 50 percent of the time. Patients have discovered mistakes as well: A January survey by the Kaiser Family Foundation found that 1 in 5 patients spotted an error in their electronic medical records. (Kaiser Health News is an editorially independent program of the foundation.)

(Nicolas Rapp/Fortune)

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. (One study by researchers at Oregon Health & Science University estimated that the average clinician working in the intensive care unit may be exposed to up to 7,000 passive alerts per day.) Such over-warning can be dangerous. From 2014 to 2018, the commission tallied 170 mostly voluntary reports of patient harm related to alarm management and alert fatigue — the phenomenon in which health workers, so overloaded with unnecessary warnings, ignore the occasional meaningful one. Of those 170 incidents, 101 resulted in patient deaths.

The Pennsylvania Patient Safety Authority, an independent state agency that collects information about adverse events and incidents, counted 775 “laboratory-test problems” related to health IT from January 2016 to December 2017.

To be sure, medical errors happened en masse in the age of paper medicine, when hospital staffers misinterpreted a physician’s scrawl or read the wrong chart to deadly consequence, for instance. But what is perhaps telling is how many doctors today opt for manual workarounds to their EHRs. 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.

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.

Further complicating the picture is that health providers nearly always tailor their one-size-fits-all EHR systems to their own specifications. Such customization makes every one unique and often hard to compare with others — which, in turn, makes the source of mistakes difficult to determine.

(Nicolas Rapp/Fortune)

Dr. Martin Makary, a surgical oncologist at Johns Hopkins and the co-author of a much-cited 2016 study that identified medical errors as the third-leading cause of death in America, credits EHRs for some safety improvements — including recent changes that have helped put electronic brakes on the opioid epidemic. But, he said, “we’ve swapped one set of problems for another. We used to struggle with handwriting and missing information. 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. But in this analogy, he added, “our cars have advanced to about the 1960s. They still don’t have seat belts or air bags.”

Schneider recalled one episode when his colleagues couldn’t understand why chunks of their notes would inexplicably disappear. They figured out the problem weeks later after intense study: Physicians had been inputting squiggly brackets — {} — the use of which, unbeknownst to even vendor representatives, deleted the text between them. (The EHR maker initially blamed the doctors, said Schneider.)

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. 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. Ratwani spent his early career in the defense industry, studying things like the intuitiveness of information displays. When he got to MedStar in 2012, he was stunned by “the types of [digital] interfaces being used” in health care, he said.

MedStar’s Raj Ratwani (standing) studies eye-tracking with Dr. Zach Hettinger to see how doctors interact with EHRs.(T.J. 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. They discovered that 3,243 of them were owing in part to EHR “usability issues.” Roughly 1 in 5 of these could have resulted in patient harm, the researchers found. “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. “We should not have patients harmed this way.”

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. 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. They had to read the list carefully, so as not to click the wrong dosage or form — though many do that too: In roughly 1 out of 1,000 orders, physicians accidentally select the suppository (designated “PR”) rather than the tablet dose (“OR”), according to one estimate. That’s not an error that will harm a patient — though other medication mix-ups can and do.

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. Ratwani is pushing for a central database to track such errors and adverse events.

Others have turned to social media to vent. Dr. Mark Friedberg, a health-policy researcher with the Rand Corp. who is also a practicing primary care physician, champions the Twitter hashtag ­#EHRbuglist to encourage fellow health care workers to air their pain points. And last month, a scathing Epic parody account cropped up on Twitter, earning more than 8,000 followers in its first five days. Its maiden tweet, written in the mock voice of an Epic overlord, read: “I once saw a doctor make eye contact with a patient. This horror must stop.”

As much as EHR systems are blamed for sins of commission, it is often the sins of omission that trip up users even more.

Consider the case of Lynne Chauvin, who worked as a medical assistant at Ochsner Health System, in Louisiana. 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. She developed gangrene, which led to the amputation of her lower legs and forearm. (Ochsner Health System said that while it cannot comment on ongoing litigation, it “remains committed to patient safety which we strongly believe is optimized through the use of electronic health record technology.” Epic declined to comment.)

Echoing the complaints of many doctors, the suit argues that Epic software “is extremely complicated to view and understand,” owing to “significant repetition of data.” Chauvin said that her medical bills have topped $1 million and that she is permanently disabled. Her husband, Richard, has become her primary caregiver and had to retire early from his job with the city of Kenner to care for his wife, according to the suit. Each party declined to comment.

An Epidemic Of Burnout

The numbing repetition, the box-ticking and the endless searching on pulldown menus are all part of what Ratwani called the “cognitive burden” that’s wearing out today’s physicians and driving increasing numbers into early retirement.

In recent years, “physician burnout” has skyrocketed to the top of the agenda in medicine. 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.”

Few would deny that the swift digitization of America’s medical system has been transformative. With EHRs now nearly universal, the face and feel of medicine has changed. The doctor is now typing away, making more eye contact with the computer screen, perhaps, than with the patient. Patients don’t like that dynamic; for doctors, whose days increasingly begin and end with such fleeting encounters, the effect can be downright deadening.

“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. “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. “It’s a disaster,” he said.

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. “Physicians have to cognitively switch between focusing on the record and focusing on the patient,” he said. He points out how unusual — and potentially dangerous — this is: “Texting while you’re driving is not a good idea. And I have yet to see the CEO who, while running a board meeting, takes minutes, and certainly I’ve never heard of a judge who, during the trial, would also be the court stenographer. But in medicine … we’ve asked the physician to move from writing in pen to [entering a computer] record, and it’s a pretty complicated interface.”

Even if docs may be at the keyboard during visits, they report having to spend hours more outside that time — at lunch, late at night — in order to finish notes and keep up with electronic paperwork (sending referrals, corresponding with patients, resolving coding issues). That’s right. EHRs didn’t take away paperwork; the systems just moved it online. And there’s a lot of it: 44 percent of the roughly six hours a physician spends on the EHR each day is focused on clerical and administrative tasks, like billing and coding, according to a 2017 Annals of Family Medicine study.

For all that so-called pajama time — the average physician logs 1.4 hours per day on the EHR after work — they don’t get a cent.

Many doctors do recognize the value in the technology: 60 percent of participants in Stanford Medicine’s 2018 National Physician Poll said EHRs had led to improved patient care. At the same time, about as many (59 percent) said EHRs needed a “complete overhaul” and that the systems had detracted from their professional satisfaction (54 percent) as well as from their clinical effectiveness (49 percent).

In preliminary studies, Ratwani has found that doctors have a typical physiological reaction to using an EHR: stress. When he and his team shadow clinicians on the job, they use a range of sensors to monitor the doctors’ heart rate and other vital signs over the course of their shift. The physicians’ heart rates will spike — as high as 160 beats per minute — on two sorts of occasions: when they are interacting with patients and when they’re using the EHR.

“Everything is so cumbersome,” said Dr. Karla Dick, a family medicine physician in Arlington, Texas. “It’s slow compared to a paper chart. You’re having to click and zoom in and zoom out to look for stuff.” With all the zooming in and out, she explained, it’s easy to end up in the wrong record. “I can’t tell you how many times I’ve had to cancel an order because I was in the wrong chart.”

Among the daily frustrations for one emergency room physician in Rhode Island is ordering ibuprofen, a seemingly simple task that now requires many rounds of mouse clicking. 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. The physician, whose institution does not allow her to comment on the systems, must then override the warning with yet more clicks. “That’s just the tiniest tip of the iceberg,” she said.

What worries the doctor most is the ease with which diligent, well-meaning physicians can make serious medical errors. She noted that the average ER doc will make 4,000 mouse clicks over the course of a shift, and that the odds of doing anything 4,000 times without an error is small. “The interfaces are just so confusing and clunky,” she added. “They invite error … it’s not a negligence issue. 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. Dr. Sam Butler, a pulmonary critical care specialist who started working at Epic in 2001, leads those efforts at the Wisconsin-based company. When doctors get more than 100 messages per week in their in-basket (akin to an email inbox), there’s a higher likelihood of burnout. Butler’s team has also analyzed doctors’ electronic notes — they’re twice as long as they were nine years ago, and three to four times as long as notes in the rest of the world. He said Epic uses such insights to improve the client experience. But coming up with fixes is difficult because doctors “have different viewpoints on everything,” he said. (KHN and Fortune made multiple requests to interview Epic CEO Judy Faulkner, but the company declined to make her available. In a trade interview in February, however, Faulkner said that EHRs were unfairly blamed for physician burnout and cited a study suggesting that there’s little correlation between burnout and EHR satisfaction. Executives at other vendors noted that they’re aware of usability issues and that they’re working on addressing them.)

“It’s not that we’re a bunch of Luddites who don’t know how to use technology,” said the Rhode Island ER doctor. “I have an iPhone and a computer and they work the way they’re supposed to work, and then we’re given these incredibly cumbersome and error-prone tools. This is something the government mandated. There really wasn’t the time to let the cream rise to the top; everyone had to jump in and pick something that worked and spend tens of millions of dollars on a system that is slowly killing us.”

$36 Billion And Change

The effort to digitize America’s health records got its biggest push in a very low moment: the financial crisis of 2008. In early December of that year, Obama, barely four weeks after his election, pitched an ambitious economic recovery plan. “We will make sure that every doctor’s office and hospital in this country is using cutting-edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes and help save billions of dollars each year,” he said in a radio address.

The idea had already been a fashionable one in Washington. Former House Speaker Newt Gingrich was fond of saying it was easier to track a FedEx package than one’s medical records. Obama’s predecessor, President George W. Bush, had also pursued the idea of wiring up the country’s health system. He didn’t commit much money, but Bush did create an agency to do the job: the Office of the National Coordinator (ONC).

In the depths of recession, the EHR conceit looked like a shovel-ready project that only the paper lobby could hate. In February 2009, legislators passed the HITECH Act, which carved out a hefty chunk of the massive stimulus package for health information technology. The goal was not just to get hospitals and doctors to buy EHRs, but rather to get them using them in a way that would drive better care. 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. Vendors, for their part, had to develop systems that met the government’s requirements.

Vice President Joe Biden watches President Barack Obama sign the American Recovery and Reinvestment Act in February 2009, which included a stimulus for electronic health records.(Jim Watson/AFP/Getty Images)

They didn’t have much time, though. 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. Everyone had big ideas for the EHRs. The FDA wanted the systems to track unique device identifiers for medical implants, the Centers for Disease Control and Prevention wanted them to support disease surveillance, CMS wanted them to include quality metrics and so on. “We had all the right ideas that were discussed and hashed out by the committee,” said Mostashari, “but they were all of the right ideas.”

Not everyone agreed, though, that they were the right ideas. 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.

The EHR vendor community, then a scrappy $2 billion industry, griped at the litany of requirements but stood to gain so much from the government’s $36 billion injection that it jumped in line. As Rusty Frantz, CEO of EHR vendor NextGen Healthcare, put it: “The industry was like, ‘I’ve got this check dangling in front of me, and I have to check these boxes to get there, and so I’m going to do that.’”

Halamka, who was an enthusiastic backer of the initiative in both the Bush and Obama administrations, blames the pressure for a speedy launch as much as the excessive wish list. “To go from a regulation to a highly usable product that is in the hands of doctors in 18 months, that’s too fast,” he said. “It’s like asking nine women to have a baby in a month.”

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. 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.

Dr. Bob Kocher, a physician and star investor with venture capital firm Venrock, who served in the Obama administration from 2009 to 2011 as a health and economic policy adviser, not only defends the rollout then but also disputes the notion that the government initiative has been a failure at all. “EHRs have totally lived up to the hype and expectations,” he said, emphasizing that they also serve as a technology foundation to support innovation on everything from patients accessing their medical records on a smartphone to AI-driven medical sleuthing. Others note the systems’ value in aggregating medical data in ways that were never possible with paper — helping, for example, to figure out that contaminated water was poisoning children in Flint, Mich.

But Rusty Frantz heard a far different message about EHRs — and, more important, it was coming from his own customers.

The Stanford-trained engineer, who in 2015 became CEO of NextGen, a $500-million-a-year EHR heavyweight in the physician-office market, learned the hard way about how his product was being viewed. As he stood at the podium at his first meeting with thousands of NextGen customers at Las Vegas’ Mandalay Bay Resort, just four months after getting the job, he told KHN and Fortune, “People were lining up at the microphones to yell at us: ‘We weren’t delivering stable software! The executive team was inaccessible! The service experience was terrible!’ ” (He now refers to the event as “Festivus: the airing of the grievances.”)

Frantz had bounced around the health care industry for much of his career, and from the nearby perch of a medical device company, he watched the EHR incentive bonanza with a mix of envy and slack-jawed awe. “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. “The software got slammed in, and the software wasn’t implemented in a way that supported care,” he said. “It was installed in a way that supported stimulus. This company, we were complicit in it, too.”

Even that may be a generous description. KHN and Fortune found a trail of lawsuits against the company, stretching from White Sulphur Springs, Mont., to Neillsville, Wis. Mary Rutan Hospital in Bellefontaine, Ohio, sued NextGen (formerly called Quality Systems) in federal court in 2013, arguing that it experienced hundreds of problems with the “materially defective” software the company had installed in 2011.

A consultant hired by the hospital to evaluate the NextGen system, whose 60-page report was submitted to the court, identified “many functional defects” that he said rendered the software “unfit for its intended purpose.” Some patient information was not accurately recorded, which had the potential, the consultant wrote, “to create major patient care risk which could lead to, at a minimum, inconvenience, and at worst, malpractice or even death.” Glitches at Mary Rutan included incidents in which the software would apparently change a patient’s gender at random or lose a doctor’s observations after an exam, the consultant reported. The company, he found, sometimes took months to address issues: One IT ticket, which related to a physician’s notes inexplicably deleting themselves, reportedly took 10 months to resolve. (The consultant also noted that similar problems appeared to be occurring at as many as a dozen other hospitals that had installed NextGen software.)

The Ohio hospital, which paid more than $1.5 million for its EHR system, claimed breach of contract. 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.

At the time, as it has been since then, NextGen’s software was certified by the government as meeting the requirements of the stimulus program. By 2016, NextGen had more than 19,000 customers who had received federal subsidies.

(Nicolas Rapp/Fortune)

NextGen was subpoenaed by the Department of Justice in December 2017, months after becoming the subject of a federal investigation led by the District of Vermont. Frantz tells KHN and Fortune that NextGen is cooperating with the investigation. “This company was not dishonest, but it was not effective four years ago,” he said. Frantz also emphasized that NextGen has “rapidly evolved” during his tenure, earning five industry awards since 2017, and that customers have “responded very positively.”

Glen Tullman, who until 2012 led Allscripts, another leading EHR vendor that benefited royally from the stimulus and that has been sued by numerous unhappy customers, admitted that the industry’s race to market took priority over all else.

“It was a big distraction. That was an unintended consequence of that,” Tullman said. “All the companies were saying, This is a one-time opportunity to expand our share, focus everything there, and then we’ll go back and fix it.” The Justice Department has opened a civil investigation into the company, Securities and Exchange Commission filings show. 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.

Much of the marketing mayhem occurred because federal officials imposed few controls over firms scrambling to cash in on the stimulus. It was a gold rush — and any system, it seemed, could be marketed as “federally approved.” Doctors could shop for bargain-price software packages at Costco and Walmart’s Sam’s Club — where eClinicalWorks sold a “turnkey” system for $11,925 — and cash in on the government’s adoption incentives.

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. Following the same playbook used by pharmaceutical companies, EHR sellers courted doctors at fancy dinners in ritzy hotels. One enterprising software firm advertised a “cash for clunkers” deal that paid $3,000 to doctors willing to trade in their current records system for a new one. Athenahealth held “invitation only” dinners at luxury hotels to advise doctors, among other things, how to use the stimulus to get paid more and capture available incentives. 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.”)

EHRs were supposed to reduce health care costs, at least in part by preventing duplicative tests. But as the federal government opened the stimulus tap, many raised doubts about the promised savings. Advocates bandied about a figure of $80 billion in cost savings even as congressional auditors were debunking it. While the jury’s still out, there’s growing suspicion the digital revolution may potentially raise health care costs by encouraging overbilling and new strains of fraud and abuse.

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.”

There’s also growing evidence that some doctors and health systems may have overstated their use of the new technology to secure stimulus funds, a potentially enormous fraud against Medicare and Medicaid that likely will take many years to unravel. In June 2017, the HHS inspector general estimated that Medicare officials made more than $729 million in subsidy payments to hospitals and doctors that didn’t deserve them.

Individual states, which administer the Medicaid portion of the program, haven’t fared much better. Audits have uncovered overpayments in 14 of 17 state programs reviewed, totaling more than $66 million, according to inspector general reports.

Last month, Sen. Chuck Grassley, an Iowa Republican who chairs the Senate Finance Committee, sharply criticized CMS for recovering only a tiny fraction of these bogus payments, or what he termed a “spit in the ocean.”

EHR vendors have also been accused of egregious and patient-endangering acts of fraud as they raced to cash in on the stimulus money grab. 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. In February, that company settled with the government for just over $57 million without denying or admitting wrongdoing. “These are cases of corporate greed, companies that prioritized profits over everything else,” said Christina Nolan, the U.S. attorney for the District of Vermont, whose office led the cases. (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.”)

Tower Of Babel

In early 2017, Seema Verma, then the country’s newly appointed CMS administrator, went on a listening tour. 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. “Physician burnout is real,” she told KHN and Fortune. 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.

What she heard then became suddenly personal one summer day in 2017, when her husband, himself a physician, collapsed in the airport on his way home to Indianapolis after a family vacation. For a frantic few hours, the CMS administrator fielded phone calls from first responders and physicians — Did she know his medical history? Did she have information that could save his life? — and made calls to his doctors in Indiana, scrambling to piece together his record, which should have been there in one piece. Her husband survived the episode, but it laid bare the dysfunction and danger inherent in the existing health information ecosystem.

Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, is taking on health “information blockers,” gag clauses and more.(T.J. Kirkpatrick for Fortune)

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.

What the framers of that vision didn’t count on were the business incentives working against it. A free exchange of information means that patients can be treated anywhere. And though they may not admit it, many health providers are loath to lose their patients to a competing doctor’s office or hospital. There’s a term for that lost revenue: “leakage.” And keeping a tight hold on patients’ medical records is one way to prevent it.

There’s a ton of proprietary value in that data, said Blumenthal, who now heads the Commonwealth Fund, a philanthropy that does health research. Asking hospitals to give it up is “like asking Amazon to share their data with Walmart,” 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. “We had an expression: They had to operate before they could interoperate,” he said.

In the absence of true incentives for systems to communicate, the industry limped along; some providers wired up directly to other select providers or through regional exchanges, but the efforts were spotty. A Cerner-backed interoperability network called CommonWell formed in 2013, but some companies, including dominant Epic, didn’t join. (“Initially, Epic was neither invited nor allowed to join,” said Sumit Rana, senior vice president of R&D at Epic. Jitin Asnaani, executive director of CommonWell countered, “We made repeated invitations to every major EHR … and numerous public and private invitations to Epic.”)

Epic then supported a separate effort to do much the same.

Last spring, Verma attempted to kick-start the sharing effort and later pledged a war on “information blocking,” threatening penalties for bad actors. She has promised to reduce the documentation burden on physicians and end the gag clauses that protect the EHR industry. Regarding the first effort at least, “there was consensus that this needed to happen and that it would take the government to push this forward,” she said. 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.

When it comes to patients, though, the real sharing too often stops. Despite federal requirements that providers give patients their medical records in a timely fashion, in their chosen format and at low cost (the government recommends a flat fee of $6.50 or less), patients struggle mightily to get them. 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. Fewer than half would share records via email. One hospital charged more than $500 to release them.

Sometimes the mere effort to access records leads to court. Jennifer De Angelis, a Tulsa attorney, has frequently sparred with hospitals over releasing her clients’ records. She said they either attempt to charge huge sums for them or force her to obtain a court order before releasing them. De Angelis added that she sometimes suspects the records have been overwritten to cover up medical mistakes.

Consider the case of 5-year-old Uriah R. Roach, who fractured and cut his finger on Oct. 2, 2014, when it was accidentally slammed in a door at school. Five days later, an operation to repair the damage went awry, and he suffered permanent brain damage, apparently owing to an anesthesia problem. The Epic electronic medical file had been accessed more than 76,000 times during the 22 days the boy was in the hospital, and a lawsuit brought by his parents contended that numerous entries had been “corrected, altered, modified and possibly deleted after an unexpected outcome during the induction of anesthesia.” The hospital denied wrongdoing. The case settled in November 2016, and the terms are confidential.

More than a dozen other attorneys interviewed cited similar problems, especially with gaining access to computerized “audit trails.” In several cases, court records show, government lawyers resisted turning over electronic files from federally run hospitals. That happened to Russell Uselton, an Oklahoma lawyer who represented a pregnant teen admitted to the Choctaw Nation Health Care Center in Talihina, Okla. Shelby Carshall, 18, was more than 40 weeks pregnant at the time. 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. 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. Though the federal government requires hospitals to produce electronic health records to patients and their families, Uselton had to obtain a court order to get the baby’s complete medical files. Government lawyers denied any negligence in the case, which is pending.

“They try to hide anything from you that they can hide from you,” said Uselton. “They make it extremely difficult to get records, so expensive and hard that most lawyers can’t take it on,” he said.

Nor, it seems, can high-ranking federal officials. 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. Said Verma, “We left that hospital and we still don’t have his information today.” That was nearly two years ago.

Death By A Thousand Clicks

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 the way 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.

The eCW 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,” said 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 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.

The Virtual Magic Bullet

Electronic health records were supposed to do a lot: make medicine safer, bring higher-quality care, empower patients, and yes, even save money. Boosters heralded an age when researchers could harness the big data within to reveal the most effective treatments for disease and sharply reduce medical errors. Patients, in turn, would have truly portable health records, being able to share their medical histories in a flash with doctors and hospitals anywhere in the country — essential when life-and-death decisions are being made in the ER.

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. 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. 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. 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.

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. But on most other counts, the newly installed technology has fallen well short. 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. Unlike, say, with the global network of ATMs, the proprietary EHR systems made by more than 700 vendors routinely don’t talk to one another, meaning that doctors still resort to transferring medical data via fax and CD-ROM. ­Patients, meanwhile, still struggle to access their own records — and, sometimes, just plain can’t.

(Nicolas Rapp/Fortune)

Instead of reducing costs, many say, EHRs, which were originally optimized for billing rather than for patient care, have instead made it easier to engage in “upcoding” or bill inflation (though some say the systems also make such fraud easier to catch).

More gravely still, a months-long joint investigation by KHN and Fortune has found that instead of streamlining medicine, the government’s EHR initiative has created a host of largely unacknowledged patient safety risks. Our investigation found that alarming reports of patient deaths, serious injuries and near misses — thousands of them — tied to software glitches, user errors or other flaws have piled up, largely unseen, in various government-funded and private repositories.

Compounding the problem are entrenched secrecy policies that continue to keep software failures out of public view. 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. Plaintiffs, moreover, say hospitals often fight to withhold records from injured patients or their families. Indeed, two doctors who spoke candidly about the problems they faced with EHRs later asked that their names not be used, adding that they were forbidden by their health care organizations to talk. Says Assistant U.S. Attorney Foster, the EHR vendors “are protected by a shield of silence.”

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 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.

David Blumenthal, who, as Obama’s national coordinator for health information technology, was one of the architects of the EHR initiative, acknowledged to KHN and Fortune that electronic health records “have not fulfilled their potential. I think few would argue they have.”

The former president has likewise singled out the effort as one of his most disappointing, bemoaning in a January 2017 interview with Vox “the fact that there are still just mountains of paperwork … and the doctors still have to input stuff, and the nurses are spending all their time on all this administrative work. 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. “Providers developed their own systems that may or may not even have worked well for them,” she told KHN and Fortune in an interview last month, “but we didn’t think about how all these systems connect with one another. That was the real missing piece.”

Perhaps none of the initiative’s former boosters is quite as frustrated as former Vice President Joe Biden. At a 2017 meeting with health care leaders in Washington, he railed against the infuriating challenge of getting his son Beau’s medical records from one hospital to another. “I was stunned when my son for a year was battling stage 4 glioblastoma,” said Biden. “I couldn’t get his records. I’m the vice president of the United States of America.  … It was an absolute nightmare. It was ridiculous, absolutely ridiculous, that we’re in that circumstance.”

A Bridge To Nowhere

As Biden would tell you, the original concept was a smart one. The wave of digitization had swept up virtually every industry, bringing both disruption and, in most cases, greater efficiency. 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.

Stowed in steel cabinets, the records were next to useless. Nobody — particularly at the dawn of the age of the iPhone — thought it was a good idea to leave them that way. The problem, say critics, was in the way that policy­makers set about to transform them.

“Every single idea was well-meaning and potentially of societal benefit, but the combined burden of all of them hitting clinicians simultaneously made office practice basically impossible,” said John Halamka, chief information officer at Beth Israel Deaconess Medical Center, who served on the EHR standards committees under both George W. Bush and Barack Obama. “In America, we have 11 minutes to see a patient, and, you know, you’re going to be empathetic, make eye contact, enter about 100 pieces of data, and never commit malpractice. It’s not possible!”

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 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. EHR vendors also frequently have contract stipulations, known as “hold harmless clauses,” that protect them from liability if hospitals are later sued for medical errors — even if they relate to an issue with the technology.

But lawsuits, like that filed by Fabian ­Ronisky, which do emerge from this veil, are quite telling.

Ronisky, according to his complaint, arrived by ambulance at Providence Saint John’s Health Center in Santa Monica on the afternoon of March 2, 2015. For two days, the young lawyer had been suffering from severe headaches while a disorienting fever left him struggling to tell the 911 operator his address.

Suspecting meningitis, a doctor at the hospital performed a spinal tap, and the next day an infectious disease specialist typed in an order for a critical lab test — a check of the spinal fluid for viruses, including herpes simplex — into the hospital’s EHR.

The multimillion-dollar system, manufactured by Epic Systems Corp. and considered by some to be the Cadillac of medical software, had been installed at the hospital about four months earlier. Although the order appeared on Epic’s screen, it was not sent to the lab. It turned out, Epic’s software didn’t fully “interface” with the lab’s software, according to a lawsuit Ronisky filed in February 2017 in Los Angeles County Superior Court. His results and diagnosis were delayed — by days, he claimed — during which time he suffered irreversible brain damage from herpes encephalitis. The suit alleged the mishap delayed doctors from giving Ronisky a drug called acyclovir that might have minimized damage to his brain.

Epic denied any liability or defects in its software; the company said the doctor failed to push the right button to send the order and that the hospital, not Epic, had configured the interface with the lab. 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 hospital and two doctors paid a total of $7.5 million, and a case against a third doctor is pending trial. Ronisky, 34, who is fighting to rebuild his life, declined to comment.

Incidents like that which happened to Ronisky — or to Annette Monachelli, for that matter — are surprisingly common, data show. And the back-and-forth about where the fault lies in such cases is actually part of the problem: The systems are often so confusing (and training on them seldom sufficient) that errors frequently fall into a nether zone of responsibility. It can be hard to tell where human error begins and the technological short­comings end.

EHRs promised to put all of a patient’s records in one place, but often that’s the problem. Critical or time-sensitive information routinely gets buried in an endless scroll of data, where in the rush of medical decision-making — and amid the maze of pulldown menus — it can be missed.

Thirteen-year-old Brooke Dilliplaine, who was severely allergic to dairy, was given a probiotic containing milk. The two doses sent her into “complete respiratory distress” and resulted in a collapsed lung, according to a lawsuit filed by her mother. Rory Staunton, 12, scraped his arm in gym class and then died of sepsis after ER doctors discharged the boy on the basis of lab results in the EHR that weren’t complete. And then there’s the case of Thomas Eric Duncan. The 42-year-old man was sent home in 2014 from a Dallas hospital infected with Ebola virus. Though a nurse had entered in the EHR his recent travel to Liberia, where an Ebola epidemic was then in full swing, the doctor never saw it. Duncan died a week later.

Bobby and Tara Dilliplaine hold a photo of daughter Brooke, who suffered complications when she was given medication she was allergic to. (She later died of causes unrelated to the EHR issue.)(Heidi de Marco/KHN)

Many such cases end up in court. Typically, doctors and nurses blame faulty technology in the medical-records systems. The EHR vendors blame human error. And meanwhile, the cases mount.

Quantros, a private health care analytics firm, said it has logged 18,000 EHR-related safety events from 2007 through 2018, 3 percent of which resulted in patient harm, including seven deaths — a figure that a Quantros director said is “drastically underreported.”

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. In 13 percent of those cases, the mistake could have been fatal.

The Pew Charitable Trusts has, for the past few years, run an EHR safety project, taking aim at issues like usability and patient matching — the process of linking the correct medical record to the correct patient — a seemingly basic task at which the systems, even when made by the same EHR vendor, often fail. At some institutions, according to Pew, such matching was accurate only 50 percent of the time. Patients have discovered mistakes as well: A January survey by the Kaiser Family Foundation found that 1 in 5 patients spotted an error in their electronic medical records. (Kaiser Health News is an editorially independent program of the foundation.)

(Nicolas Rapp/Fortune)

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. (One study by researchers at Oregon Health & Science University estimated that the average clinician working in the intensive care unit may be exposed to up to 7,000 passive alerts per day.) Such over-warning can be dangerous. From 2014 to 2018, the commission tallied 170 mostly voluntary reports of patient harm related to alarm management and alert fatigue — the phenomenon in which health workers, so overloaded with unnecessary warnings, ignore the occasional meaningful one. Of those 170 incidents, 101 resulted in patient deaths.

The Pennsylvania Patient Safety Authority, an independent state agency that collects information about adverse events and incidents, counted 775 “laboratory-test problems” related to health IT from January 2016 to December 2017.

To be sure, medical errors happened en masse in the age of paper medicine, when hospital staffers misinterpreted a physician’s scrawl or read the wrong chart to deadly consequence, for instance. But what is perhaps telling is how many doctors today opt for manual workarounds to their EHRs. 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.

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.

Further complicating the picture is that health providers nearly always tailor their one-size-fits-all EHR systems to their own specifications. Such customization makes every one unique and often hard to compare with others — which, in turn, makes the source of mistakes difficult to determine.

(Nicolas Rapp/Fortune)

Dr. Martin Makary, a surgical oncologist at Johns Hopkins and the co-author of a much-cited 2016 study that identified medical errors as the third-leading cause of death in America, credits EHRs for some safety improvements — including recent changes that have helped put electronic brakes on the opioid epidemic. But, he said, “we’ve swapped one set of problems for another. We used to struggle with handwriting and missing information. 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. But in this analogy, he added, “our cars have advanced to about the 1960s. They still don’t have seat belts or air bags.”

Schneider recalled one episode when his colleagues couldn’t understand why chunks of their notes would inexplicably disappear. They figured out the problem weeks later after intense study: Physicians had been inputting squiggly brackets — {} — the use of which, unbeknownst to even vendor representatives, deleted the text between them. (The EHR maker initially blamed the doctors, said Schneider.)

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. 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. Ratwani spent his early career in the defense industry, studying things like the intuitiveness of information displays. When he got to MedStar in 2012, he was stunned by “the types of [digital] interfaces being used” in health care, he said.

MedStar’s Raj Ratwani (standing) studies eye-tracking with Dr. Zach Hettinger to see how doctors interact with EHRs.(T.J. 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. They discovered that 3,243 of them were owing in part to EHR “usability issues.” Roughly 1 in 5 of these could have resulted in patient harm, the researchers found. “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. “We should not have patients harmed this way.”

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. 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. They had to read the list carefully, so as not to click the wrong dosage or form — though many do that too: In roughly 1 out of 1,000 orders, physicians accidentally select the suppository (designated “PR”) rather than the tablet dose (“OR”), according to one estimate. That’s not an error that will harm a patient — though other medication mix-ups can and do.

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. Ratwani is pushing for a central database to track such errors and adverse events.

Others have turned to social media to vent. Dr. Mark Friedberg, a health-policy researcher with the Rand Corp. who is also a practicing primary care physician, champions the Twitter hashtag ­#EHRbuglist to encourage fellow health care workers to air their pain points. And last month, a scathing Epic parody account cropped up on Twitter, earning more than 8,000 followers in its first five days. Its maiden tweet, written in the mock voice of an Epic overlord, read: “I once saw a doctor make eye contact with a patient. This horror must stop.”

As much as EHR systems are blamed for sins of commission, it is often the sins of omission that trip up users even more.

Consider the case of Lynne Chauvin, who worked as a medical assistant at Ochsner Health System, in Louisiana. 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. She developed gangrene, which led to the amputation of her lower legs and forearm. (Ochsner Health System said that while it cannot comment on ongoing litigation, it “remains committed to patient safety which we strongly believe is optimized through the use of electronic health record technology.” Epic declined to comment.)

Echoing the complaints of many doctors, the suit argues that Epic software “is extremely complicated to view and understand,” owing to “significant repetition of data.” Chauvin said that her medical bills have topped $1 million and that she is permanently disabled. Her husband, Richard, has become her primary caregiver and had to retire early from his job with the city of Kenner to care for his wife, according to the suit. Each party declined to comment.

An Epidemic Of Burnout

The numbing repetition, the box-ticking and the endless searching on pulldown menus are all part of what Ratwani called the “cognitive burden” that’s wearing out today’s physicians and driving increasing numbers into early retirement.

In recent years, “physician burnout” has skyrocketed to the top of the agenda in medicine. 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.”

Few would deny that the swift digitization of America’s medical system has been transformative. With EHRs now nearly universal, the face and feel of medicine has changed. The doctor is now typing away, making more eye contact with the computer screen, perhaps, than with the patient. Patients don’t like that dynamic; for doctors, whose days increasingly begin and end with such fleeting encounters, the effect can be downright deadening.

“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. “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. “It’s a disaster,” he said.

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. “Physicians have to cognitively switch between focusing on the record and focusing on the patient,” he said. He points out how unusual — and potentially dangerous — this is: “Texting while you’re driving is not a good idea. And I have yet to see the CEO who, while running a board meeting, takes minutes, and certainly I’ve never heard of a judge who, during the trial, would also be the court stenographer. But in medicine … we’ve asked the physician to move from writing in pen to [entering a computer] record, and it’s a pretty complicated interface.”

Even if docs may be at the keyboard during visits, they report having to spend hours more outside that time — at lunch, late at night — in order to finish notes and keep up with electronic paperwork (sending referrals, corresponding with patients, resolving coding issues). That’s right. EHRs didn’t take away paperwork; the systems just moved it online. And there’s a lot of it: 44 percent of the roughly six hours a physician spends on the EHR each day is focused on clerical and administrative tasks, like billing and coding, according to a 2017 Annals of Family Medicine study.

For all that so-called pajama time — the average physician logs 1.4 hours per day on the EHR after work — they don’t get a cent.

Many doctors do recognize the value in the technology: 60 percent of participants in Stanford Medicine’s 2018 National Physician Poll said EHRs had led to improved patient care. At the same time, about as many (59 percent) said EHRs needed a “complete overhaul” and that the systems had detracted from their professional satisfaction (54 percent) as well as from their clinical effectiveness (49 percent).

In preliminary studies, Ratwani has found that doctors have a typical physiological reaction to using an EHR: stress. When he and his team shadow clinicians on the job, they use a range of sensors to monitor the doctors’ heart rate and other vital signs over the course of their shift. The physicians’ heart rates will spike — as high as 160 beats per minute — on two sorts of occasions: when they are interacting with patients and when they’re using the EHR.

“Everything is so cumbersome,” said Dr. Karla Dick, a family medicine physician in Arlington, Texas. “It’s slow compared to a paper chart. You’re having to click and zoom in and zoom out to look for stuff.” With all the zooming in and out, she explained, it’s easy to end up in the wrong record. “I can’t tell you how many times I’ve had to cancel an order because I was in the wrong chart.”

Among the daily frustrations for one emergency room physician in Rhode Island is ordering ibuprofen, a seemingly simple task that now requires many rounds of mouse clicking. 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. The physician, whose institution does not allow her to comment on the systems, must then override the warning with yet more clicks. “That’s just the tiniest tip of the iceberg,” she said.

What worries the doctor most is the ease with which diligent, well-meaning physicians can make serious medical errors. She noted that the average ER doc will make 4,000 mouse clicks over the course of a shift, and that the odds of doing anything 4,000 times without an error is small. “The interfaces are just so confusing and clunky,” she added. “They invite error … it’s not a negligence issue. 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. Dr. Sam Butler, a pulmonary critical care specialist who started working at Epic in 2001, leads those efforts at the Wisconsin-based company. When doctors get more than 100 messages per week in their in-basket (akin to an email inbox), there’s a higher likelihood of burnout. Butler’s team has also analyzed doctors’ electronic notes — they’re twice as long as they were nine years ago, and three to four times as long as notes in the rest of the world. He said Epic uses such insights to improve the client experience. But coming up with fixes is difficult because doctors “have different viewpoints on everything,” he said. (KHN and Fortune made multiple requests to interview Epic CEO Judy Faulkner, but the company declined to make her available. In a trade interview in February, however, Faulkner said that EHRs were unfairly blamed for physician burnout and cited a study suggesting that there’s little correlation between burnout and EHR satisfaction. Executives at other vendors noted that they’re aware of usability issues and that they’re working on addressing them.)

“It’s not that we’re a bunch of Luddites who don’t know how to use technology,” said the Rhode Island ER doctor. “I have an iPhone and a computer and they work the way they’re supposed to work, and then we’re given these incredibly cumbersome and error-prone tools. This is something the government mandated. There really wasn’t the time to let the cream rise to the top; everyone had to jump in and pick something that worked and spend tens of millions of dollars on a system that is slowly killing us.”

$36 Billion And Change

The effort to digitize America’s health records got its biggest push in a very low moment: the financial crisis of 2008. In early December of that year, Obama, barely four weeks after his election, pitched an ambitious economic recovery plan. “We will make sure that every doctor’s office and hospital in this country is using cutting-edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes and help save billions of dollars each year,” he said in a radio address.

The idea had already been a fashionable one in Washington. Former House Speaker Newt Gingrich was fond of saying it was easier to track a FedEx package than one’s medical records. Obama’s predecessor, President George W. Bush, had also pursued the idea of wiring up the country’s health system. He didn’t commit much money, but Bush did create an agency to do the job: the Office of the National Coordinator (ONC).

In the depths of recession, the EHR conceit looked like a shovel-ready project that only the paper lobby could hate. In February 2009, legislators passed the HITECH Act, which carved out a hefty chunk of the massive stimulus package for health information technology. The goal was not just to get hospitals and doctors to buy EHRs, but rather to get them using them in a way that would drive better care. 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. Vendors, for their part, had to develop systems that met the government’s requirements.

Vice President Joe Biden watches President Barack Obama sign the American Recovery and Reinvestment Act in February 2009, which included a stimulus for electronic health records.(Jim Watson/AFP/Getty Images)

They didn’t have much time, though. 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. Everyone had big ideas for the EHRs. The FDA wanted the systems to track unique device identifiers for medical implants, the Centers for Disease Control and Prevention wanted them to support disease surveillance, CMS wanted them to include quality metrics and so on. “We had all the right ideas that were discussed and hashed out by the committee,” said Mostashari, “but they were all of the right ideas.”

Not everyone agreed, though, that they were the right ideas. 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.

The EHR vendor community, then a scrappy $2 billion industry, griped at the litany of requirements but stood to gain so much from the government’s $36 billion injection that it jumped in line. As Rusty Frantz, CEO of EHR vendor NextGen Healthcare, put it: “The industry was like, ‘I’ve got this check dangling in front of me, and I have to check these boxes to get there, and so I’m going to do that.’”

Halamka, who was an enthusiastic backer of the initiative in both the Bush and Obama administrations, blames the pressure for a speedy launch as much as the excessive wish list. “To go from a regulation to a highly usable product that is in the hands of doctors in 18 months, that’s too fast,” he said. “It’s like asking nine women to have a baby in a month.”

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. 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.

Dr. Bob Kocher, a physician and star investor with venture capital firm Venrock, who served in the Obama administration from 2009 to 2011 as a health and economic policy adviser, not only defends the rollout then but also disputes the notion that the government initiative has been a failure at all. “EHRs have totally lived up to the hype and expectations,” he said, emphasizing that they also serve as a technology foundation to support innovation on everything from patients accessing their medical records on a smartphone to AI-driven medical sleuthing. Others note the systems’ value in aggregating medical data in ways that were never possible with paper — helping, for example, to figure out that contaminated water was poisoning children in Flint, Mich.

But Rusty Frantz heard a far different message about EHRs — and, more important, it was coming from his own customers.

The Stanford-trained engineer, who in 2015 became CEO of NextGen, a $500-million-a-year EHR heavyweight in the physician-office market, learned the hard way about how his product was being viewed. As he stood at the podium at his first meeting with thousands of NextGen customers at Las Vegas’ Mandalay Bay Resort, just four months after getting the job, he told KHN and Fortune, “People were lining up at the microphones to yell at us: ‘We weren’t delivering stable software! The executive team was inaccessible! The service experience was terrible!’ ” (He now refers to the event as “Festivus: the airing of the grievances.”)

Frantz had bounced around the health care industry for much of his career, and from the nearby perch of a medical device company, he watched the EHR incentive bonanza with a mix of envy and slack-jawed awe. “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. “The software got slammed in, and the software wasn’t implemented in a way that supported care,” he said. “It was installed in a way that supported stimulus. This company, we were complicit in it, too.”

Even that may be a generous description. KHN and Fortune found a trail of lawsuits against the company, stretching from White Sulphur Springs, Mont., to Neillsville, Wis. Mary Rutan Hospital in Bellefontaine, Ohio, sued NextGen (formerly called Quality Systems) in federal court in 2013, arguing that it experienced hundreds of problems with the “materially defective” software the company had installed in 2011.

A consultant hired by the hospital to evaluate the NextGen system, whose 60-page report was submitted to the court, identified “many functional defects” that he said rendered the software “unfit for its intended purpose.” Some patient information was not accurately recorded, which had the potential, the consultant wrote, “to create major patient care risk which could lead to, at a minimum, inconvenience, and at worst, malpractice or even death.” Glitches at Mary Rutan included incidents in which the software would apparently change a patient’s gender at random or lose a doctor’s observations after an exam, the consultant reported. The company, he found, sometimes took months to address issues: One IT ticket, which related to a physician’s notes inexplicably deleting themselves, reportedly took 10 months to resolve. (The consultant also noted that similar problems appeared to be occurring at as many as a dozen other hospitals that had installed NextGen software.)

The Ohio hospital, which paid more than $1.5 million for its EHR system, claimed breach of contract. 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.

At the time, as it has been since then, NextGen’s software was certified by the government as meeting the requirements of the stimulus program. By 2016, NextGen had more than 19,000 customers who had received federal subsidies.

(Nicolas Rapp/Fortune)

NextGen was subpoenaed by the Department of Justice in December 2017, months after becoming the subject of a federal investigation led by the District of Vermont. Frantz tells KHN and Fortune that NextGen is cooperating with the investigation. “This company was not dishonest, but it was not effective four years ago,” he said. Frantz also emphasized that NextGen has “rapidly evolved” during his tenure, earning five industry awards since 2017, and that customers have “responded very positively.”

Glen Tullman, who until 2012 led Allscripts, another leading EHR vendor that benefited royally from the stimulus and that has been sued by numerous unhappy customers, admitted that the industry’s race to market took priority over all else.

“It was a big distraction. That was an unintended consequence of that,” Tullman said. “All the companies were saying, This is a one-time opportunity to expand our share, focus everything there, and then we’ll go back and fix it.” The Justice Department has opened a civil investigation into the company, Securities and Exchange Commission filings show. 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.

Much of the marketing mayhem occurred because federal officials imposed few controls over firms scrambling to cash in on the stimulus. It was a gold rush — and any system, it seemed, could be marketed as “federally approved.” Doctors could shop for bargain-price software packages at Costco and Walmart’s Sam’s Club — where eClinicalWorks sold a “turnkey” system for $11,925 — and cash in on the government’s adoption incentives.

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. Following the same playbook used by pharmaceutical companies, EHR sellers courted doctors at fancy dinners in ritzy hotels. One enterprising software firm advertised a “cash for clunkers” deal that paid $3,000 to doctors willing to trade in their current records system for a new one. Athenahealth held “invitation only” dinners at luxury hotels to advise doctors, among other things, how to use the stimulus to get paid more and capture available incentives. 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.”)

EHRs were supposed to reduce health care costs, at least in part by preventing duplicative tests. But as the federal government opened the stimulus tap, many raised doubts about the promised savings. Advocates bandied about a figure of $80 billion in cost savings even as congressional auditors were debunking it. While the jury’s still out, there’s growing suspicion the digital revolution may potentially raise health care costs by encouraging overbilling and new strains of fraud and abuse.

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.”

There’s also growing evidence that some doctors and health systems may have overstated their use of the new technology to secure stimulus funds, a potentially enormous fraud against Medicare and Medicaid that likely will take many years to unravel. In June 2017, the HHS inspector general estimated that Medicare officials made more than $729 million in subsidy payments to hospitals and doctors that didn’t deserve them.

Individual states, which administer the Medicaid portion of the program, haven’t fared much better. Audits have uncovered overpayments in 14 of 17 state programs reviewed, totaling more than $66 million, according to inspector general reports.

Last month, Sen. Chuck Grassley, an Iowa Republican who chairs the Senate Finance Committee, sharply criticized CMS for recovering only a tiny fraction of these bogus payments, or what he termed a “spit in the ocean.”

EHR vendors have also been accused of egregious and patient-endangering acts of fraud as they raced to cash in on the stimulus money grab. 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. In February, that company settled with the government for just over $57 million without denying or admitting wrongdoing. “These are cases of corporate greed, companies that prioritized profits over everything else,” said Christina Nolan, the U.S. attorney for the District of Vermont, whose office led the cases. (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.”)

Tower Of Babel

In early 2017, Seema Verma, then the country’s newly appointed CMS administrator, went on a listening tour. 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. “Physician burnout is real,” she told KHN and Fortune. 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.

What she heard then became suddenly personal one summer day in 2017, when her husband, himself a physician, collapsed in the airport on his way home to Indianapolis after a family vacation. For a frantic few hours, the CMS administrator fielded phone calls from first responders and physicians — Did she know his medical history? Did she have information that could save his life? — and made calls to his doctors in Indiana, scrambling to piece together his record, which should have been there in one piece. Her husband survived the episode, but it laid bare the dysfunction and danger inherent in the existing health information ecosystem.

Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, is taking on health “information blockers,” gag clauses and more.(T.J. Kirkpatrick for Fortune)

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.

What the framers of that vision didn’t count on were the business incentives working against it. A free exchange of information means that patients can be treated anywhere. And though they may not admit it, many health providers are loath to lose their patients to a competing doctor’s office or hospital. There’s a term for that lost revenue: “leakage.” And keeping a tight hold on patients’ medical records is one way to prevent it.

There’s a ton of proprietary value in that data, said Blumenthal, who now heads the Commonwealth Fund, a philanthropy that does health research. Asking hospitals to give it up is “like asking Amazon to share their data with Walmart,” 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. “We had an expression: They had to operate before they could interoperate,” he said.

In the absence of true incentives for systems to communicate, the industry limped along; some providers wired up directly to other select providers or through regional exchanges, but the efforts were spotty. A Cerner-backed interoperability network called CommonWell formed in 2013, but some companies, including dominant Epic, didn’t join. (“Initially, Epic was neither invited nor allowed to join,” said Sumit Rana, senior vice president of R&D at Epic. Jitin Asnaani, executive director of CommonWell countered, “We made repeated invitations to every major EHR … and numerous public and private invitations to Epic.”)

Epic then supported a separate effort to do much the same.

Last spring, Verma attempted to kick-start the sharing effort and later pledged a war on “information blocking,” threatening penalties for bad actors. She has promised to reduce the documentation burden on physicians and end the gag clauses that protect the EHR industry. Regarding the first effort at least, “there was consensus that this needed to happen and that it would take the government to push this forward,” she said. 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.

When it comes to patients, though, the real sharing too often stops. Despite federal requirements that providers give patients their medical records in a timely fashion, in their chosen format and at low cost (the government recommends a flat fee of $6.50 or less), patients struggle mightily to get them. 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. Fewer than half would share records via email. One hospital charged more than $500 to release them.

Sometimes the mere effort to access records leads to court. Jennifer De Angelis, a Tulsa attorney, has frequently sparred with hospitals over releasing her clients’ records. She said they either attempt to charge huge sums for them or force her to obtain a court order before releasing them. De Angelis added that she sometimes suspects the records have been overwritten to cover up medical mistakes.

Consider the case of 5-year-old Uriah R. Roach, who fractured and cut his finger on Oct. 2, 2014, when it was accidentally slammed in a door at school. Five days later, an operation to repair the damage went awry, and he suffered permanent brain damage, apparently owing to an anesthesia problem. The Epic electronic medical file had been accessed more than 76,000 times during the 22 days the boy was in the hospital, and a lawsuit brought by his parents contended that numerous entries had been “corrected, altered, modified and possibly deleted after an unexpected outcome during the induction of anesthesia.” The hospital denied wrongdoing. The case settled in November 2016, and the terms are confidential.

More than a dozen other attorneys interviewed cited similar problems, especially with gaining access to computerized “audit trails.” In several cases, court records show, government lawyers resisted turning over electronic files from federally run hospitals. That happened to Russell Uselton, an Oklahoma lawyer who represented a pregnant teen admitted to the Choctaw Nation Health Care Center in Talihina, Okla. Shelby Carshall, 18, was more than 40 weeks pregnant at the time. 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. 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. Though the federal government requires hospitals to produce electronic health records to patients and their families, Uselton had to obtain a court order to get the baby’s complete medical files. Government lawyers denied any negligence in the case, which is pending.

“They try to hide anything from you that they can hide from you,” said Uselton. “They make it extremely difficult to get records, so expensive and hard that most lawyers can’t take it on,” he said.

Nor, it seems, can high-ranking federal officials. 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. Said Verma, “We left that hospital and we still don’t have his information today.” That was nearly two years ago.

Well-Known Transgender Surgeon Resigns Following Furor Over Instagram Pictures Of Patients’ Genitals

Dr. Christopher Salgado, 50, worked at the L.G.B.T.Q. Center for Wellness, Gender and Sexual Health at the University of Miami Health System. “The purpose really was to be educational with it, but it went awry,” he said. However, critics were not only upset about the pictures but the captions that appeared to be mocking, as well.

Well-Known Transgender Surgeon Resigns Following Furor Over Instagram Pictures Of Patients’ Genitals

Dr. Christopher Salgado, 50, worked at the L.G.B.T.Q. Center for Wellness, Gender and Sexual Health at the University of Miami Health System. “The purpose really was to be educational with it, but it went awry,” he said. However, critics were not only upset about the pictures but the captions that appeared to be mocking, as well.

Nursing Home Fines Drop As Trump Administration Heeds Industry Complaints

The Trump administration’s decision to alter the way it punishes nursing homes has resulted in lower fines against many facilities found to have endangered or injured residents.

The average fine dropped to $28,405 under the current administration, down from $41,260 in 2016, President Barack Obama’s final year in office, federal records show.

The decrease in fines is one of the starkest examples of how the Trump administration is rolling back Obama’s aggressive regulation of health care services in response to industry prodding.

Encouraged by the nursing home industry, the Trump administration switched from fining nursing homes for each day they were out of compliance — as the Obama administration typically did — to issuing a single fine for two-thirds of infractions, the records show.

That reduces the penalties, giving nursing homes less incentive to fix faulty and dangerous practices before someone gets hurt.

“It’s not changing behavior [at nursing homes] in the way that we want,” said Dr. Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health. “For a small nursing home it could be real money, but for bigger ones it’s more likely a rounding error.”

Since Trump took office, the administration has heeded multiple nursing home complaints about zealous oversight. It granted facilities an 18-month moratorium from being penalized for violating eight new health and safety rules. It also revoked an Obama-era rule barring homes from pre-emptively requiring residents to submit to arbitration to settle disputes rather than go to court.

The slide in fines occurred even as the Centers for Medicare & Medicaid Services issued financial penalties 28 percent more frequently than it did under Obama. That’s due to a policy begun near the end of Obama’s term that required regulators to punish a facility every time a resident was harmed, instead of leaving it to their discretion.

While that policy increased the number of smaller fines, larger fines became less common. The total amount collected under Trump fell by 10 percent compared with the total in Obama’s final year, from $127 million under Obama to $114 million under Trump. (KHN compared penalties during 2016, Obama’s last year in office, with penalties under Trump from April 2017 through March 2018, the most recent month for which federal officials say data is reliably complete.)

(Story continues below.)

CMS said it has revised multiple rules governing fines under both administrations to make its punishments fairer, more consistent and better tailored to prod homes to improve care. “We are continuing to analyze the impact of these combined events to determine if other actions are necessary,” CMS said in a statement.

The move is broadly consistent with the Trump administration’s other industry-friendly policies in the health care sector. For instance, the administration has expanded the role of short-term insurance policies that don’t cover all types of services, given states more leeway to change their Medicaid programs and urged Congress to allow physicians to open their own hospitals.

Beth Martino, a spokeswoman for the American Health Care Association, a nursing home trade group, said the federal government has “returned to a method of applying fines in a way that incentivizes solving problems” rather than penalizing “facilities that are trying to do the right thing.”

Penalty guidelines were toughened in 2014, when the Obama administration instructed officials to favor daily fines. By 2016, those were used in two-thirds of cases. Those fines averaged $61,000.

When Trump took over, the nursing home industry complained that fines had spun “out of control” and become disproportionate to the deficiencies. “We have seen a dramatic increase in [fines] being retroactively issued and used as a punishment,” Mark Parkinson, president of the nursing home group, wrote in March 2017.

CMS agreed that daily fines sometimes resulted in punishments that were determined by the random timing of an inspection rather than the severity of the infraction. If inspectors visited a home in April, for instance, and discovered an improper practice had started in February, the accumulated daily fines would be twice as much as if the inspectors had come in March.

But switching to a preference for per-instance fines means much lower penalties, since fines are capped at $21,393 whether they are levied per instance or per day. Homes that pay without contesting the fine receive a 35 percent discount, meaning they currently pay at most $13,905.

Those maximums apply even to homes found to have committed the most serious level of violations, which are known as immediate jeopardy because the home’s practices place residents at imminent risk of harm. For instance, a Mississippi nursing home was fined $13,627 after it ran out of medications because it had been relying on a pharmacy 373 miles away, in Atlanta.  CMS also reduced $54,600 in daily fines to a single fine of $20,965 for a New Mexico home where workers hadn’t been properly disinfecting equipment to prevent infectious diseases from spreading.

On average, per-instance fines under Trump were below $9,000, records show.

“These are multimillion businesses — $9,000 is nothing,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, a nonprofit in Washington.

Big daily fines, averaging $68,080, are still issued when a home hasn’t corrected a violation after being cited. But even in those cases, CMS officials are allowed to make exceptions and issue a single fine if the home has no history of substantial violations.

The agency cautioned that comparisons of average fines is misleading because the overall number of inspections resulting in fines increased under Trump, from 3.5 percent in 2016 to 4.7 percent. The circumstances now warranting fines that weren’t issued before tend to draw penalties on the lower side.

However, KHN found that financial penalties for immediate jeopardies were issued in fewer cases under Trump. And when they were issued, the fines averaged 18 percent less than they did in 2016.

The frequency of immediate-jeopardy fines may further decrease. CMS told inspectors in June that they were no longer required to fine facilities unless immediate-jeopardy violations resulted in “serious injury, harm, impairment or death.” Regulators still must take some action, but that could be ordering the home to arrange training from an outside group or mandating specific changes to the way the home operates.

Barbara Gay, vice president of public policy communications at LeadingAge — an association of nonprofit organizations that provide elder services, including nursing homes — said that, under Trump, nursing homes “don’t feel they’ve been given a reprieve.”

But consumer advocates say penalties have reverted to levels too low to be effective. “Fines need to be large enough to change facility behavior,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, a nonprofit based in Washington. “When that’s not the case and the fine is inconsequential, care generally doesn’t improve.”

This story is part of a partnership that includes NPR and Kaiser Health News.

Report That Finds Sharp Increase In Commercial Health Care Prices Highlights Geographical Differences In Costs

“That fact that you could be paying 2.5 times more for the same healthcare services in San Jose than in Baltimore suggests there is a lot of variation in prices across the country,” said Bill Johnson, lead author of the report. Meanwhile, Humana launches a bundled-payment model for some Medicare Advantage members.

Insurance Giant UnitedHealthcare Will Require All New Employer-Sponsored Health Plans To Pass Drug Discounts To Consumers

Pharmacy benefit managers typically negotiate rebates from pharmaceutical companies to help offset the high initial prices set for many drugs. But those discounts rarely flow directly to the people filling prescriptions. The rebate system has come under intense scrutiny as of late as lawmakers take aim at high drug prices and pharma companies point the blame elsewhere. Meanwhile, the Senate Finance Committee plans to call executives from five pharmacy benefit managers–the middlemen who operate within the rebate system–to testify in front of Congress next month.

New Health Plans Expose The Insured To More Risk

One health plan from a well-known insurer promises lower premiums but warns that consumers may need to file their own claims and negotiate over charges from hospitals and doctors. Another does away with annual deductibles but requires policyholders to pay extra if they need certain surgeries and procedures.

Both are among the latest efforts in a seemingly endless quest by employers, consumers and insurers for the holy grail: less expensive coverage.

Premiums are 15 to 30 percent lower than conventional offerings, but the plans put a larger burden on consumers to be savvy shoppers. Even with those concerns, the offerings tap into a common underlying frustration.

“Traditional health plans have not been able to stem high cost increases, so people are tearing down the model and trying something different,” said Jeff Levin-Scherz, health management practice leader for benefit consultants Willis Towers Watson.

New types of insurance plans are sprouting up as employers face rising health care costs and individuals who buy their own coverage without an Affordable Care Act subsidy struggle to pay premiums. That has led some people to experiment with new ways to pay their medical expenses, such as short-term policies or alternatives like Christian sharing ministries, which are not insurance at all, but rather cooperatives where members pay one another’s bills.

Now some insurers — such as Blue Cross Blue Shield of North Carolina and a Minnesota startup called Bind Benefits, which is partnering with UnitedHealth Group — are coming up with their own novel offerings.

Insurers say the two new types of plans meet the ACA’s rules, although they interpret those rules in new ways. For example, the new policies avoid the federal law’s rule limiting consumers’ annual in-network limit on out-of-pocket costs: one by having no network and the other by calling additional charges premiums, which don’t count toward the out-of-pocket maximum.

But each plan could leave patients with huge costs in a system where it is extremely difficult for a patient to be a smart shopper — in part, because they have little negotiating power against big hospital systems and partly because illness is often urgent and unpredicted.

If the plans prompt doctors and hospitals to lower prices, “then that is worth taking a closer look,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But if it’s simply another flavor of shifting more risk to employees, I don’t think in the long term that’s going to bend the cost curve.”

Balancing Freedom, Control And Responsibility

The North Carolina Blue Cross Blue Shield “My Choice” policies aim to change the way doctors and hospitals are paid by limiting reimbursement for services to 40 percent above what Medicare would pay. The plan has no network of doctors and hospitals.

This approach “puts you in control to see the doctor you want,” the insurer says on its website. The plan is available to individuals who buy their own insurance and small businesses with one to 50 employees, aiming particularly at those who cannot afford ACA plans, said Austin Vevurka, a spokesman for the insurer. The policies are not sold on the ACA’s insurance marketplace, but can be purchased off-exchange from brokers.

With that freedom, however, consumers also have the responsibility to shop around for providers who will accept that amount. Those who don’t shop, or can’t because it’s an emergency, may get “balance-billed” by providers unsatisfied with the flat amount the plan pays.

“There’s an incentive to comparison shop, to find a provider who accepts the benefit,” said Vevurka.

The cost of balance bills could range widely, but could be thousands of dollars in the case of hospital care. Consumer exposure to balance bills is not capped by the ACA for out-of-network care.

“There are a lot of people for whom a plan like this would present financial risk,” said Levin-Scherz.

In theory, though, paying 40 percent above Medicare rates could help drive down costs over time if enough providers accept those payments. That’s because hospitals currently get about double Medicare rates through their negotiations with insurers.

“It’s a bold move,” said Mark Hall, director of the Health Law and Policy Program at Wake Forest University in North Carolina. Still, he said, it’s “not an optimal way” because patients generally don’t want to negotiate with their doctor on prices.

“But it’s an innovative way to put matters into the hands of patients as consumers,” said Hall. “Let them deal directly with providers who insist on charging more than 140 percent of Medicare.”

Blue Cross spokesman Vevurka said My Choice has telephone advisers to help patients find providers and offer tips on how to negotiate a balance bill. He would not disclose enrollment numbers for My Choice, which launched Jan. 1, nor would he say how many providers have indicated they will accept the payments.

Still, the idea — based on what is sometimes called “reference pricing” or “Medicare plus” — is gaining attention.

North Carolina’s state treasurer, for example, hopes to put state workers into such a pricing plan by next year, offering to pay 177 percent of Medicare. The plan has ignited a firestorm from hospitals.

Montana recently got its hospitals to agree to such a plan for state workers, paying 234 percent of Medicare on average.

Partly because of concerns about balance billing, employers aren’t rushing to buy into Medicare-plus pricing just yet, said Jeff Long, a health care actuary at Lockton Companies, a benefit consultancy.

Wider adoption, however, could spell its end.

Hospitals might agree to participate in a few such programs, but “if there’s more take-up on this, I see hospitals possibly starting to fight back,” Long said.

What About The Bind?

Minnesota startup Bind Benefits eliminates annual deductibles in its “on-demand” plans sold to employers who are opting to self-insure their workers’ health costs. Rather than deductibles, patients pay flat-dollar copayments for a core set of medical services, from doctor visits to prescription drugs.

In some ways, it’s simpler: no need to spend through the deductible before coverage kicks in or wonder what 20 percent of the cost of a doctor visit or surgery would be.

But not everything is included.

Patients who discover during the year that they need any of about 30 common procedures outlined in the plan, including several types of back surgery, knee arthroscopy or coronary artery bypass, must “add in” coverage, spread out over time in deductions from their paychecks.

“People are used to that concept, to buy what they need,” said Bind’s CEO, Tony Miller. “When I need more, I buy more.”

According to a company spokeswoman, the add-in costs vary by market, procedure and provider. Less than 7 percent of members should need add-in services in any given year, Bind estimates.

On the lower end, the cost for tonsillectomy and adenoidectomy ranges from $900 to $3,000, while lumbar spine fusion could range from $5,000 to $10,000.

To set those additional premiums, Bind analyzes how much doctors and facilities are paid, along with some quality measures from several sources, including UnitedHealth. The add-in premiums paid by patients then vary depending on whether they choose lower-cost providers or more expensive ones.

The ACA’s out-of-pocket maximums — $7,900 for an individual or $15,800 for a family — don’t include premium costs.

The Cumberland School District in Wisconsin switched from a traditional plan, which it purchased from an insurer for about $1.7 million last year, to Bind. Six months in, Superintendent Barry Rose said, it is working well.

Right off the bat, he said, the district saved about $200,000. More savings could come over the year if workers choose lower-cost alternatives for the “add-in” services.

“They can become better consumers because they can see exactly what they’re paying for care,” Rose said.

Levin-Scherz at Willis Towers said the idea behind Bind is intriguing but raises some issues for employers.

What happens, he asked, if a worker has an add-in surgery, owes several thousand dollars, then changes jobs before paying all the premiums for that add-in coverage? “Will the employee be sent a bill after leaving?” he said.

Hospitals, Health Industry Question Trump Administration’s Legal Authority To Require Price Transparency

The Trump administration is considering requiring hospitals and insurers to reveal the true costs of medical services, which have always been tightly held, confidential secrets by the parties involved. The industry says the administration lacks the authority to mandate such disclosures, while also pointing out that they wouldn’t do much to help consumers.

Trump’s Budget Offers $291M To Fight HIV In U.S. But Trims Overseas Efforts

The Trump administration took another step toward fulfilling its goal of ending the HIV epidemic in the United States Monday by requesting $291 million for its initiative in the White House’s annual budget.

But within the budget, the administration also proposed actions that could undermine efforts to control the virus’s spread, HIV experts and advocates said, including carving out funds from programs that aim to eradicate HIV in other parts of the world. Among those moves was a $1.35 billion cut in the President’s Emergency Plan for AIDS Relief (PEPFAR), according to an analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

That widely touted program, begun by President George W. Bush, provides antiretroviral medication and other services to patients in more than 50 countries. Last year, 14 million people around the world relied on the program for HIV medication.

Greg Millett, vice president and director of public policy at the HIV research foundation amfAR, described the administration’s budget as “schizophrenic.”

“There’s just so many opposites within this budget of things that are truly helpful and useful,” he said. “And then, they are counterbalanced by things that just erase that goodwill.”

The budget proposal is for the fiscal year beginning Oct. 1. Congress is not obligated to fulfill any of the requests in the budget proposal. The administration has asked for similar cuts to global HIV initiatives in the past without success.

The  allocation to combat HIV in the U.S. would be split between multiple programs. The Centers for Disease Control and Prevention would receive $140 million to work with state and local health departments to reduce new infections. Another share — approximately $120 million — would be directed to the Ryan White HIV/AIDS Program, which provides HIV-related medical care, support services and medications to patients.

President Donald Trump pledged in his State of the Union speech last month to eradicate the transmission of HIV in the United States in the next decade.

Jennifer Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation, said these funds “are actual real increases to those programs if they should go through.”

However, the budget also seeks to change funding for Medicaid — the federal-state partnership that provides health insurance for the poor and indigent — from unlimited federal matching to a block grant. It would also give states more flexibility to change Medicaid eligibility rules and shift certain costs toward beneficiaries. Advocates say those changes could directly impact access to services for HIV patients because Medicaid is the largest source of coverage for them.

In addition, the budget proposes cuts to the Housing Opportunities for Persons with AIDS program, which provides housing for those with HIV/AIDS.

HIV advocates also highlighted their concerns about the cut to global programs. Nearly 37 million people around the world lived with HIV or AIDS in 2017, according to UNAIDS. Roughly one-quarter of them did not know they were infected with the virus.

Countries receiving aid from these programs are unlikely to be able to continue these programs on their own, experts said.

The move to divest from overseas efforts and focus on domestic issues aligns with the Trump administration’s “America First” doctrine, said William McColl, vice president for policy and advocacy at AIDS United, an HIV advocacy organization.

But ending U.S. efforts undercuts the United States’ place as a global leader in combating the virus, he said.

The change also overlooks the fact that the virus will continue to circulate without regard to national borders.

“I hesitate to give anybody ideas, but unless you put a bubble over the United States, this is not going to really solve this issue,” McColl said.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Headline writers across the world (read: yours truly) breathed a sigh of relief this week when the venture formally known as “the health initiative founded by Amazon, Berkshire Hathaway and JPMorgan Chase” finally picked a name. After more than a year of tight-lipped secrecy, they settled on “Haven.” What do you guys think? I’m just thankful it’s short.

On to what you may have missed this week!

FDA Commissioner Scott Gottlieb sent shock waves through Washington and the industry when he announced he’ll be retiring at the end of the month. Gottlieb was a standout in the anti-regulatory, pro-business Trump administration as one of the most activist commissioners in recent years. Over the past two years, he has launched what could be termed a crusade against teen vaping — his most recent action coming just the day before the announcement, when he called out Walgreens and gas stations for selling tobacco products to minors — and cracked down on “miracle cures” and unregulated stem cell clinics and supplements, among other initiatives. Public health advocates are fretting that with him gone, some of the progress they’ve seen will be chipped away.

The departure is also a blow to the administration in that Gottlieb is a highly liked health official who worked well with Congress, winning over even Democratic lawmakers on Capitol Hill. Behind the scenes, he was known as someone who was “accessible,” would field lawmakers’ questions and was actively working on things that would make Congress happy. “I’ve never seen an administration official, Republican or Democrat, that has worked with the Hill so well on a bipartisan basis,” a senior congressional aide told Stat.

That’s not to say he didn’t have his critics. A decision on approving a powerful opioid late last year, in particular, drew fire from many advocates.

Gottlieb said his decision to leave was based on the fact that he missed spending time with his family, and White House officials confirmed that President Donald Trump did not seek the resignation.

Now the big question is: Who is going to replace him?

Stat: With Gottlieb’s Resignation, the Trump Administration Loses Its Backroom Whisperer on Capitol Hill

Politico: ‘Something Very Rare’: FDA’s Gottlieb Aggressively Tackled Difficult Issues

Stat: The Likely, Possible, and Longshot Contenders to Replace Gottlieb at FDA


As expected, legal challenges to the administration’s changes to the family planning rules came not in a trickle but a flood. California Attorney General Xavier Becerra, in his 47th lawsuit against the administration, said the rules restricting abortion referrals were like something out of 1920 and not 2019. Apart from California’s case, 20 states and D.C. announced they will be filing suits. Then came the announcement that Planned Parenthood Federation of America and the American Medical Association will also challenge the restrictions, deeming the changes a “domestic gag rule” and an overreach from the administration.

The New York Times: California Sues Trump Administration to Block Restrictions to Family Planning Program

The Washington Post: Planned Parenthood, American Medical Association Sue Trump Administration Over Abortion ‘Gag Rule’


Facing increasingly intense outrage over insulin prices, Eli Lilly has decided to offer an authorized generic version of its drug for half the cost. Stories of people dying after they rationed newly pricey insulin have been circulating with ever-increasing frequency, and lawmakers have made it their priority to specifically rout out answers about insulin price hikes. In that context, Eli Lilly’s move here seems more damage control than charitable, but it also puts them in good company with drugmakers who have been hotfooting it to avoid whatever worse would come out of Congress if they don’t make some changes.

Stat: Lilly Will Sell a Half-Price Version of Its Insulin. Will It Appease Critics?


Former Colorado Gov. John Hickenlooper officially threw his hat into the narrowing 2020 field this week. Hickenlooper seems to gravitate more toward the moderate wing of the Democratic Party, saying he supports universal health care in principle but refusing to get behind a “Medicare-for-all” plan. His evolution on gun control (as a governor who oversaw a mass shooting in the state where Columbine occurred) is also worth checking out.

The New York Times: John Hickenlooper on the Issues


There has always been a gap swallowing people who make too much for health law subsidies or Medicaid but not enough to comfortably afford insurance through the exchanges. A new county-by-county analysis looks at just how tough it is for the people who fall into the holes created by the ACA. A particularly striking figure? In almost all of Nebraska, a 60-year-old with a $50,000 income would pay from 30 to 50 percent of that income in premiums for the least expensive ACA health plan.

The Washington Post: ACA Premiums Rising Beyond Reach of Older, Middle-Class Consumers

Meanwhile, the Trump administration is interested in bolstering interstate insurance sales despite there being little appetite for it in the past and experts saying it wouldn’t lower premiums. In fact, the practice is already allowed under the health law, and no one does it because insurers think it’s just not worth it.

The Wall Street Journal: Trump Administration Looks to Jump Start Interstate Health-Insurance Sales


A teenager who got vaccinated against his mother’s wishes was the star witness at a hearing this week sparked in part by the measles outbreak. Ethan Lindenberger, a high school senior, hoisted the blame for his mother’s deeply rooted beliefs squarely on Facebook’s shoulders.

The anti-vaccination movement has long flourished on Facebook, partly because of the site’s search results and “suggested groups” feature. On Thursday, the company announced it has developed a policy to try to curb that culture of misinformation on vaccines, saying it will rank pages and groups that spread that kind of information lower and will keep them out of recommendations or predictions in search.

The Washington Post: Ethan Lindenberger: Facebook’s Anti-Vax Problem Intensified in Congressional Testimony

The New York Times: Facebook Announces Plan to Curb Vaccine Misinformation


After 12 long years, scientists finally announced that a second patient appears to have been cured of HIV. While the news was well-welcomed around the world — “This will inspire people that cure is not a dream,” said Dr. Annemarie Wensing, a virologist — there are some practical obstacles to consider. For example, bone marrow transplants (which is how both patients were cured) are extremely risky, especially since there are drugs that exist that can control HIV fairly well.

The New York Times: H.I.V. Is Reported Cured in a Second Patient, a Milestone in the Global AIDS Epidemic


In a scathing ruling that could have wide-reaching ramifications for the insurance industry, a judge blasted UnitedHealth Group for policies that he says were aimed at effectively discriminating against patients with mental health and substance abuse disorders to save money. The decision is part of a larger debate over parity in relation to coverage for mental health services versus other illnesses like diabetes. Insurance companies have been getting around parity requirements with internal rules, but advocates are viewing the judge’s ruling as a warning shot that those loopholes will no longer be tolerated.

The New York Times: Mental Health Treatment Denied to Customers by Giant Insurer’s Policies, Judge Rules

The FDA this week approved a cousin of party drug “Special K” to help people with severe cases of depression, marking a shift away from traditional antidepressant medications. While many said the news would give hope to desperate patients, others are worried about the potential for abuse.

The New York Times: Fast-Acting Depression Drug, Newly Approved, Could Help Millions


Honorable mention for International Women’s Day: A veritable “tsunami wave of women veterans” over the past several years is forcing the VA to step up in terms of meeting female-specific health care needs. Among basic issues are seeing to it that doctors are trained to deal with gynecological matters and ensuring that VA facilities have child care services available when female veterans come in for appointments.

The Wall Street Journal: As More Military Women Seek Health Care, VA Pursues Improvements


In the miscellaneous file for the week:

• Nearly 600,000 children have dropped off of states’ Medicaid and CHIP rolls over a one-year span. While states rush to assure anyone asking that it’s because the economy is improving, public health experts are alarmed at the disturbing trend.

Stateline: Child Enrollment in Public Health Programs Fell by 600K Last Year

• In a “craning your neck at the car wreck” sort of way, this profile on disgraced pharma bro Martin Shkreli is a wild read. Through the help of a contraband smartphone, Shkreli is, from his prison cell, still pulling the strings at his old company, schmoozing up his prison friends “Krispy” and “D-Block,” and planning his big comeback.

The Wall Street Journal: Martin Shkreli Steers His Old Company From Prison — With Contraband Cellphone

• Last year, doctors burst onto the gun-debate scene through the help of a viral tweet that directed them to “stay in their lane.” But a new analysis provides an interesting look at which lawmakers are getting the most money from physician-related PACs. (Hint: It’s overwhelming ones who are against tighter gun regulations.)

The Wall Street Journal: Doctors’ PACs Favored Candidates Opposing Gun Background Checks

• In slightly terrifying news, research that was halted over concerns it could create deadly flu viruses that could be used by terrorists was just given the green light again —without any explanation as to why. *Gulp*

The New York Times: Studies of Deadly Flu Virus, Once Banned, Are Set to Resume

• Everyone is expecting a big settlement in the sweeping opioid case against Purdue Pharma. But what happens if the opioid maker declares bankruptcy first?

Stat: If Purdue Pharma Declares Bankruptcy, What Happens to the Opioid Cases?

• Luke Perry’s early death from a stroke this week has many middle-aged Americans worried.

The New York Times: Here’s How Strokes Happen When You’re As Young As Luke Perry

• Drug companies and doctors are in a dirty war over fetal transplants. It may seem click-baity at first, but the issue is highly revealing of how the health industry works when it comes to something that could make people lots of money.

The New York Times: Drug Companies and Doctors Battle Over the Future of Fecal Transplants


That’s it from me! Have a great weekend!

Military Doctors In Crosshairs Of A Budget Battle

The U.S. military is devising major reductions in its medical corps, unnerving the system’s advocates who fear the cuts will hobble the armed forces’ ability to adequately care for health problems of military personnel at home and abroad.

The move inside the military coincides with efforts by the Trump administration to privatize care for veterans. The Department of Veterans Affairs last month proposed rules that would allow veterans to use private hospitals and clinics if government primary care facilities are not nearby or if they have to wait too long for an appointment.

Shrinking the medical corps within the armed forces is proving more contentious and complex. In 2017, a Republican-controlled Congress mandated changes in what a Senate Armed Services Committee report described as “an under-performing, disjointed health system” with “bloated medical headquarters staffs” and “inevitable turf wars.” The directive sought a greater emphasis for military doctors on combat-related needs while transferring other care to civilian providers.

Details of reductions have yet to be finalized, a military spokeswoman said. But within the system and among alumni, trepidation has increased since Military.com, an online military and veterans organization, reported in January that the Department of Defense had drafted proposals to convert more than 17,000 medical positions into fighting and support positions — a 13 percent reduction in medical personnel.

“That would be a drastic first cut,” said Dr. David Lane, a retired rear admiral and former director of the Walter Reed National Military Medical Center in Bethesda, Md.

At most risk in the current planning are positions that aren’t considered essential to troops overseas, such as training spots for new doctors and jobs that can be outsourced to private physicians and hospitals — obstetricians and primary care doctors, for example. The reductions may also limit the military’s medical humanitarian assistance and relief for foreign natural disasters and disease outbreaks.

Even in war zones, Lane warned, it would be a mistake to downplay the importance of contributions by doctors who do not specialize in trauma. In the 1991 invasion of Kuwait, for instance, cases of diseases and non-battle injuries rather than combat injuries created the most medical work, he said.

Doctors who train in the military’s highly regarded medical school — who have committed to serve in the armed forces after training— and those who do military residencies comprise much of the staff that serve troops overseas. A major deployment could leave the military flat-footed, said Dr. John Prescott, a former Army physician.

“The majority of folks in the military don’t stay in for their whole career, they stay in for a few years,” Prescott said. “I’m concerned there will be a very small cohort that will be available for deployment in the future.”

The military health system is responsible for more the 1.4 million active-duty and 331,000 reserve personnel, with 54 hospitals and 377 military clinics around the world. Split between the Navy, Army and Air Force, each with its own doctors and hospitals, the service has been targeted for years for overhaul to reduce redundancies and save costs.

The department has already started moving administrative functions under one bureaucracy, called the Defense Health Agency, which is slated to take over the service branch hospitals in 2021.

The budget for the next fiscal year is still being developed and final decisions have not yet been made, a Department of Defense spokeswoman, Lt. Col. Carla Gleason, said in an email. “Any reforms that do result will be driven by the Department’s efforts to ensure our medical personnel are ready to provide battlefield care in support of our forces, and to provide the outstanding medical benefits that Service members, retirees and their families deserve,” she said.

For years, critics of the broad role of the military health services have argued that many medical corps’ services — such as maternity care and pediatrics on bases — could be provided more effectively by civilian doctors and hospitals.

But Lane said there is too much focus on the high-profile trauma cases on the battlefield “that at the end of the day are a small portion” of medical care. “When we’re trying to put things back together that got broken during a war,” he said, “that’s what you need the most of — pediatricians, public health doctors, primary care doctors.”

Some studies commissioned by the department have concluded private hospitals could deliver less costly care, in part because doctors at hospitals take care of more patients. But the Congressional Budget Office said savings were not at all certain and that military hospitals might be less expensive if the government arranged for greater use of them.

Brad Carson and Morgan Plummer, who held senior jobs in the Department of Defense during President Barack Obama’s administration, argued in a 2016 essay that the military isn’t the best training for surgeons because it doesn’t provide them with a sufficient number of cases to develop expertise.

The military health system “has too much infrastructure, the wrong mix of providers, and predominantly serves the needs of beneficiaries who could easily have their health care needs satisfied by civilian providers at far less cost and with equal or better quality,” they wrote.

The government this year is spending $50 billion on the military health system, including Tricare insurance for more than 9 million active-duty service members, veterans, families and survivors, according to Congress’ budget office. That is roughly a tenth of the military budget. The CBO projected costs are on track to increase to $63 billion in 2033.

Defenders of the system reject the idea that non-wartime jobs can be eliminated without it hurting that core mission.

“Military health care providers between deployments maintain their clinical skills by treating service members and millions of beneficiaries,” Dr. Arthur Kellermann, dean of the school of medicine at the Uniformed Services University in Bethesda, wrote in a 2017 Health Affairs article. “Military hospitals provide valuable platforms for teaching the next generation of uniformed health care professionals and standby capacity for combat casualties.”

Prescott, the former Army doctor, said that the military may have trouble turning to civilian doctors in some regions given physician shortages, which he said the military cuts would exacerbate.

“Most hospitals are already pretty full, most health care providers are pretty busy,” said Prescott, now chief academic officer at the Association of American Medical Colleges.

Doctor shortages would increase if the military cut the slots it now has to train doctors, because there wouldn’t be new civilian residencies created to compensate. “Those positions basically disappear,” he said.

Kathryn Beasley, a retired Navy captain who is director of government relations for health affairs at the Military Officers Association of America, said she was also concerned with unforeseen consequences of dramatic cuts.

“Everything’s tied together, there’s a lot of interdependencies in these things,” she said. “You pull a string on one and you might feel it in an area you don’t expect.”