Pluralistic: Epic Systems, a lethal health record monopolist (02 Oct 2024)


Today's links



A crowded field hospital. In the foreground are massed bundles of vivid green US $100 bills; atop them stands a robed skeleton, drinking from a blood filled goblet; blood stains the skeleton's robe. In the background is a row of giant mainframes.

Epic Systems, a lethal health record monopolist (permalink)

Epic Systems makes the dominant electronic health record (EHR) system in America; if you're a doctor, chances are you are required to use it, and for every hour a doctor spends with a patient, they have to spend two hours doing clinically useless bureaucratic data-entry on an Epic EHR.

How could a product so manifestly unfit for purpose be the absolute market leader? Simple: as Robert Kuttner describes in an excellent feature in The American Prospect, Epic may be a clinical disaster, but it's a profit-generating miracle:

https://prospect.org/health/2024-10-01-epic-dystopia/

At the core of Epic's value proposition is "upcoding," a form of billing fraud that is beloved of hospital administrators, including the "nonprofit" hospitals that generate vast fortunes that are somehow not characterized as profits. Here's a particularly egregious form of upcoding: back in 2020, the Poudre Valley Hospital in Ft Collins, CO locked all its doors except the ER entrance. Every patient entering the hospital, including those receiving absolutely routine care, was therefore processed as an "emergency."

In April 2020, Caitlin Wells Salerno – a pregnant biologist – drove to Poudre Valley with normal labor pains. She walked herself up to obstetrics, declining the offer of a wheelchair, stopping only to snap a cheeky selfie. Nevertheless, the hospital recorded her normal, uncomplicated birth as a Level 5 emergency – comparable to a major heart-attack – and whacked her with a $2755 bill for emergency care:

https://pluralistic.net/2021/10/27/crossing-a-line/#zero-fucks-given

Upcoding has its origins in the Reagan revolution, when the market-worshipping cultists he'd put in charge of health care created the "Prospective Payment System," which paid a lump sum for care. The idea was to incentivize hospitals to provide efficient care, since they could keep the difference between whatever they spent getting you better and the set PPS amount that Medicare would reimburse them. Hospitals responded by inventing upcoding: a patient with controlled, long-term coronary disease who showed up with a broken leg would get coded for the coronary condition and the cast, and the hospital would pocket both lump sums:

https://pluralistic.net/2024/06/13/a-punch-in-the-guts/#hayek-pilled

The reason hospital administrators love Epic, and pay gigantic sums for systemwide software licenses, is directly connected to the two hours that doctors spent filling in Epic forms for every hour they spend treating patients. Epic collects all that extra information in order to identify potential sources of plausible upcodes, which allows hospitals to bill patients, insurers, and Medicare through the nose for routine care. Epic can automatically recode "diabetes with no complications" from a Hierarchical Condition Category code 19 (worth $894.40) as "diabetes with kidney failure," code 18 and 136, which gooses the reimbursement to $1273.60.

Epic snitches on doctors to their bosses, giving them a dashboard to track doctors' compliance with upcoding suggestions. One of Kuttner's doctor sources says her supervisor contacts her with questions like, "That appointment was a 2. Don’t you think it might be a 3?"

Robert Kuttner is the perfect journalist to unravel the Epic scam. As a journalist who wrote for The New England Journal of Medicine, he's got an insider's knowledge of the health industry, and plenty of sources among health professionals. As he tells it, Epic is a cultlike, insular company that employs 12.500 people in its hometown of Verona, WI.

The EHR industry's origins start with a GW Bush-era law called the HITECH Act, which was later folded into Obama's Recovery Act in 2009. Obama provided $27b to hospitals that installed EHR systems. These systems had to more than track patient outcomes – they also provided the data for pay-for-performance incentives. EHRs were already trying to do something very complicated – track health outcomes – but now they were also meant to underpin a cockamamie "incentives" program that was supposed to provide a carrot to the health industry so it would stop killing people and ripping off Medicare. EHRs devolved into obscenely complex spaghetti systems that doctors and nurses loathed on sight.

But there was one group that loved EHRs: hospital administrators and the private companies offering Medicare Advantage plans (which also benefited from upcoding patients in order to soak Uncle Sucker):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/

The spread of EHRs neatly tracks with a spike in upcharging: "from 2014 through 2019, the number of hospital stays billed at the highest severity level increased almost 20 percent…the number of stays billed at each of the other severity levels decreased":

https://oig.hhs.gov/oei/reports/OEI-02-18-00380.pdf

The purpose of a system is what it does. Epic's industry-dominating EHR is great at price-gouging, but it sucks as a clinical tool – it takes 18 keystrokes just to enter a prescription:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2729481

Doctors need to see patients, but their bosses demand that they satisfy Epic's endless red tape. Doctors now routinely stay late after work and show up hours early, just to do paperwork. It's not enough. According to another one of Kuttner's sources, doctors routinely copy-and-paste earlier entries into the current one, a practice that generates rampant errors. Some just make up random numbers to fulfill Epic's nonsensical requirements: the same source told Kuttner that when prompted to enter a pain score for his TB patients, he just enters "zero."

Don't worry, Epic has a solution: AI. They've rolled out an "ambient listening" tool that attempts to transcribe everything the doctor and patient say during an exam and then bash it into a visit report. Not only is this prone to the customary mistakes that make AI unsuited to high-stakes, error-sensitive applications, it also represents a profound misunderstanding of the purpose of clinical notes.

The very exercise of organizing your thoughts and reflections about an event – such as a medical exam – into a coherent report makes you apply rigor and perspective to events that otherwise arrive as a series of fleeting impressions and reactions. That's why blogging is such an effective practice:

https://pluralistic.net/2021/05/09/the-memex-method/

The answer to doctors not having time to reflect and organize good notes is to give them more time – not more AI. As another doctor told Kuttner: "Ambient listening is a solution to a self-created problem of requiring too much data entry by clinicians."

EHRs are one of those especially hellish public-private partnerships. Health care doctrine from Reagan to Obama insisted that the system just needed to be exposed to market forces and incentives. EHRs are designed to allow hospitals to win as many of these incentives as possible. Epic's clinical care modules do this by bombarding doctors with low-quality diagnostic suggestions with "little to do with a patient’s actual condition and risks," leading to "alert fatigue," so doctors miss the important alerts in the storm of nonsense elbow-jostling:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5058605/

Clinicians who actually want to improve the quality of care in their facilities end up recording data manually and keying it into spreadsheets, because they can't get Epic to give them the data they need. Meanwhile, an army of high-priced consultants stand ready to give clinicians advise on getting Epic to do what they need, but can't seem to deliver.

Ironically, one of the benefits that Epic touts is its interoperability: hospitals that buy Epic systems can interconnect those with other Epic systems, and there's a large ecosystem of aftermarket add-ons that work with Epic. But Epic is a product, not a protocol, so its much-touted interop exists entirely on its terms, and at its sufferance. If Epic chooses, a doctor using its products can send files to a doctor using a rival product. But Epic can also veto that activity – and its veto extends to deciding whether a hospital can export their patient records to a competing service and get off Epic altogether.

One major selling point for Epic is its capacity to export "anonymized" data for medical research. Very large patient data-sets like Epic's are reasonably believed to contain many potential medical insights, so medical researchers are very excited at the prospect of interrogating that data.

But Epic's approach – anonymizing files containing the most sensitive information imaginable, about millions of people, and then releasing them to third parties – is a nightmare. "De-identified" data-sets are notoriously vulnerable to "re-identification" and the threat of re-identification only increases every time there's another release or breach, which can used to reveal the identities of people in anonymized records. For example, if you have a database of all the prescribing at a given hospital – a numeric identifier representing the patient, and the time and date when they saw a doctor and got a scrip. At any time in the future, a big location-data breach – say, from Uber or a transit system – can show you which people went back and forth to the hospital at the times that line up with those doctor's appointments, unmasking the person who got abortion meds, cancer meds, psychiatric meds or other sensitive prescriptions.

The fact that anonymized data can – will! – be re-identified doesn't mean we have to give up on the prospect of gleaning insight from medical records. In the UK, the eminent doctor Ben Goldacre and colleagues built an incredible effective, privacy-preserving "trusted research environment" (TRE) to operate on millions of NHS records across a decentralized system of hospitals and trusts without ever moving the data off their own servers:

https://pluralistic.net/2024/03/08/the-fire-of-orodruin/#are-we-the-baddies

The TRE is an open source, transparent server that accepts complex research questions in the form of database queries. These queries are posted to a public server for peer-review and revision, and when they're ready, the TRE sends them to each of the databases where the records are held. Those databases transmit responses to the TRE, which then publishes them. This has been unimaginably successful: the prototype of the TRE launched during the lockdown generated sixty papers in Nature in a matter of months.

Monopolies are inefficient, and Epic's outmoded and dangerous approach to research, along with the roadblocks it puts in the way of clinical excellence, epitomizes the problems with monopoly. America's health care industry is a dumpster fire from top to bottom – from Medicare Advantage to hospital cartels – and allowing Epic to dominate the EHR market has somehow, incredibly, made that system even worse.

Naturally, Kuttner finishes out his article with some antitrust analysis, sketching out how the Sherman Act could be brought to bear on Epic. Something has to be done. Epic's software is one of the many reasons that MDs are leaving the medical profession in droves.

Epic epitomizes the long-standing class war between doctors who want to take care of their patients and hospital executives who want to make a buck off of those patients.

(Image: Flying Logos, CC BY-SA 4.0, modified)


Hey look at this (permalink)



A Wayback Machine banner.

This day in history (permalink)

#20yrsago George Soros blogs https://web.archive.org/web/20041009162245/http://georgesoros.com/index.cfm?Fuseaction=Home

#15yrsago Zombies Calling: snappy popcult zombie comic in the Scott Pilgrim mold https://memex.craphound.com/2009/10/02/zombies-calling-snappy-popcult-zombie-comic-in-the-scott-pilgrim-mold/

#10yrsago Keurig sued for anti-competitive K-cup tactics https://www.cbc.ca/news/business/keurig-coffee-sued-for-600m-by-ontario-based-club-coffee-1.2783633

#10yrsago Directors’ commentary for “In Real Life” https://web.archive.org/web/20160331041746/http://www.forbiddenplanet.co.uk/blog/2014/directors-commentary-cory-doctorow-jen-wang-talk-in-real-life/

#10yrsago David Cameron raps the Tories’ nasty party manifesto https://www.youtube.com/watch?v=0YBumQHPAeU

#10yrsago Hong Kong and America: two systems, one corruption https://web.archive.org/web/20141006033919/http://www.lessig.org/2014/10/we-should-be-protesting-too/

#10yrsago World Intellectual Property Organization in shambolic chaos https://www.keionline.org/22621

#10yrsago Why the UK middle class should be rioting in the streets https://www.telegraph.co.uk/men/thinking-man/11109845/Why-arent-the-British-middle-classes-staging-a-revolution.html

#10yrsago Human beings are the gut flora of immortal, transhuman corporations https://memex.craphound.com/2014/10/02/human-beings-are-the-gut-flora-of-immortal-transhuman-corporations/

#10yrsago Daughter of Hong Kong leader thanks “taxpayers” for diamonds on Facebook https://timesofindia.indiatimes.com/world/china/Hong-Kong-leaders-daughter-creates-controversy-with-Facebook-post/articleshow/44115995.cms

#10yrsago Nobody wants to host the 2022 Olympics https://sports.yahoo.com/why-no-one-wants-to-host-the-2022-olympics-225450509.html?soc_src=mediacontentstory

#5yrsago IRS admits it audits poor people because auditing rich people is too expensive https://www.propublica.org/article/irs-sorry-but-its-just-easier-and-cheaper-to-audit-the-poor#168476

#5yrsago Elizabeth Warren proposes an “excessive lobbying tax” that would fund independent Congressional experts and public participation in policy https://medium.com/@teamwarren/excessive-lobbying-tax-fca7cc86a7e5

#5yrsago Apple bans an app because Hong Kong protesters might use it to avoid the murderous, out of control police https://memex.craphound.com/2019/10/02/apple-bans-an-app-because-hong-kong-protesters-might-use-it-to-avoid-the-murderous-out-of-control-police/

#5yrsago The complicated, nuanced story of how racialized French people fought to save their local McDonald’s https://www.npr.org/2019/09/05/758048712/libert-galit-and-french-fries


Upcoming appearances (permalink)

A photo of me onstage, giving a speech, holding a mic.



A screenshot of me at my desk, doing a livecast.

Recent appearances (permalink)



A grid of my books with Will Stahle covers..

Latest books (permalink)



A cardboard book box with the Macmillan logo.

Upcoming books (permalink)

  • Picks and Shovels: a sequel to "Red Team Blues," about the heroic era of the PC, Tor Books, February 2025

  • Unauthorized Bread: a middle-grades graphic novel adapted from my novella about refugees, toasters and DRM, FirstSecond, 2025



Colophon (permalink)

Today's top sources:

Currently writing:

  • Enshittification: a nonfiction book about platform decay for Farrar, Straus, Giroux. Today's progress: 834 words (57028 words total).

  • A Little Brother short story about DIY insulin PLANNING

  • Picks and Shovels, a Martin Hench noir thriller about the heroic era of the PC. FORTHCOMING TOR BOOKS JAN 2025

Latest podcast: Vigilant (a Little Brother story) https://craphound.com/littlebrother/2024/09/29/vigilant-a-little-brother-story/


This work – excluding any serialized fiction – is licensed under a Creative Commons Attribution 4.0 license. That means you can use it any way you like, including commercially, provided that you attribute it to me, Cory Doctorow, and include a link to pluralistic.net.

https://creativecommons.org/licenses/by/4.0/

Quotations and images are not included in this license; they are included either under a limitation or exception to copyright, or on the basis of a separate license. Please exercise caution.


How to get Pluralistic:

Blog (no ads, tracking, or data-collection):

Pluralistic.net

Newsletter (no ads, tracking, or data-collection):

https://pluralistic.net/plura-list

Mastodon (no ads, tracking, or data-collection):

https://mamot.fr/@pluralistic

Medium (no ads, paywalled):

https://doctorow.medium.com/

Twitter (mass-scale, unrestricted, third-party surveillance and advertising):

https://twitter.com/doctorow

Tumblr (mass-scale, unrestricted, third-party surveillance and advertising):

https://mostlysignssomeportents.tumblr.com/tagged/pluralistic

"When life gives you SARS, you make sarsaparilla" -Joey "Accordion Guy" DeVilla