What Looks Like Overcharging By Your Hospital Might Not Be
Despite concerns first raised a few years ago, hospitals do not seem to be abusing their electronic data systems to generate bigger bills and boost their income — at least according to authors of a large study released Tuesday. Other leaders in the field say the jury's still out.
The concern over possible misuse of records grabbed headlines in 2012 after an investigation by the Center for Public Integrity and the New York Times found that some hospitals using electronic records were billing Medicare for significantly more than hospitals that still used paper records.
After the stories appeared, the Departments of Justice and Health and Human Services sent hospitals a strongly worded letter warning them against misusing the ease of electronic forms to pad their bills.
"When I read those articles I thought, 'That's interesting, I'm not surprised to hear that people are using tools to sort of maximize revenue,' " says Dr. Ashish Jha, a researcher at the Harvard School of Public Health.
But a colleague, Julia Adler-Milstein at the University of Michigan, was skeptical, Jha says.
She figured hospitals had already maximized the money they could make from billing, Jha says. "The chances that electronic records are somehow going to magically make that even more financially lucrative? She just didn't buy it."
So Jha and Adler-Milstein designed a study to go deeper. They compared billing records from 393 hospitals that use electronic records with 782 hospitals still using paper records. They were careful to make sure the hospitals they compared matched each other in terms of size and their status as either a teaching hospital or a for-profit company.
"To my surprise, we found nothing," says Jha. "We found that electronic health records didn't really change billing practices at all."
He concludes the study with advice for policymakers: "This worry about excessive billing, the empirical evidence says this should not be a big focus of attention."
But the study misses an important point, says Dr. Donald Simborg, a pioneer in the field of electronic health records.
"They're looking in the wrong place," Simborg says, "I don't think anybody's done the study that needs to be done."
Simborg started designing computerized patient records in the 1960s. More recently, he's led a pair of government advisory panels on how to guard against fraud in digital health records.
Simborg says Jha and Adler-Milstein only looked at inpatient records — the files regarding patients who spent at least one night in a hospital. The real area of concern, he says, is in emergency departments and outpatient clinics, an increasing number of which are owned or run by hospitals.
"Hospitals already have software that helps them [maximize billing for inpatient stays]. They've been doing that for years," Simborg says. What's new is that doctors in emergency rooms and clinics are just now getting digital record-keeping tools, which sometimes lead them to overdocument.
Simborg says he's seen it happen when he was watching doctors use electronic records he designed.
"I would see that they were documenting things that I know they didn't do to the patient," Simborg says. "And these were not crooks; it's just kind of human nature about having a tool that's so easy to click a button that puts in a lot of default information when you're in a hurry — because physicians are always in a hurry."
Electronic records that automatically fill in standard protocols for certain kinds of visits (like a well-check for kids, or a Medicare annual physical) can help doctors be more efficient. But if doctors don't delete things they chose not to do during such a visit, they can end up generating a bill that's higher than warranted.
Simborg says some systems even suggest ways doctors can modify their patient visits to allow them to charge more.
To Simborg, the warning letter to hospitals from federal regulators was the wrong approach. He says government watchdogs should focus more attention on the software industry.
"They can develop the guidelines that would reduce the likelihood that an electronic record would be abused," Simborg says, like making it easier for auditors to follow a doctor's digital record-keeping trail. "That's different than threatening that they're going to be prosecuted if they do these things."
Chantal Worzala, the American Hospital Association's policy director, says her organization is concerned about "insuring we have vendors who are creating products that support compliance with best practice."
She says she's pleased that Jha's study shows that hospitals aren't using electronic records to generate bigger bills for inpatient stays, but she also points out that the tools are new and will require ongoing vigilance.
"We could all benefit from learning more about how electronic health records work," Worzala says.
This story is part of a reporting partnership between NPR and Kaiser Health News.
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This is ALL THINGS CONSIDERED from NPR News. I'm Melissa Block.
ROBERT SIEGEL, HOST:
And I'm Robert Siegel. As more hospitals adopt electronic patient records, there have been concerns that the technology could be used to pad bills and overcharge patients and Medicare. Well, a new study out today says that is not happening. At least one medical software pioneer warns the record still needs scrutiny going forward. Eric Whitney reports on the study and begins with a look at how these records work.
ERIC WHITNEY, BYLINE: In the emergency department at Swedish Medical Center in Denver, Doctor Gretchen Hinson has just seen a couple of patients and is now dictating their information to an assistant.
GRETCHEN HINSON: Go ahead and do 11 for post-concussion syndrome and then prescription for Percocet for discharge.
WHITNEY: This documentation is important so patients get good follow-up care and so the hospital can get paid. The information will get sent to specialists in the billing department who go through doctors notes carefully to make sure they itemize everything their doctors do, and don't miss out on payment. Companies that make medical record software sometimes advertise that their products can help capture more information and, therefore, bring in more money. A couple of years ago, the Center for Public Integrity and the New York Times published stories saying hospitals that had adopted electronic records were sending bigger bills than those using paper. That made sense to Doctor Ashish Jha, a researcher at the Harvard School of Public Health.
ASHISH JHA: When I read those articles, I thought, that's interesting. I'm not surprised to hear that people are using tools to sort of maximize revenue.
WHITNEY: That may not be a bad thing if computers really are just catching things that fell through the cracks before. But Jha was concerned that electronic records might tempt doctors to say they're doing more for patients than they actually are.
JHA: What I worry about - and I've seen this happen - is that there are these templates, and physicians press one button, and then the entire electronic record gets populated with a detailed physical exam.
WHITNEY: This is one example of a feature that's meant to save doctors time but could be abused, allowing doctors to pad their bills with the click of a mouse. After the articles by the New York Times and the Center for Public Integrity ran, the Department of Justice sent hospitals across the country a letter warning them not to over-document. Jha and a colleague at the University of Michigan designed a study to see how much that was happening.
JHA: To my surprise, we found nothing. We found that electronic health records didn't really change billing practices at all.
WHITNEY: The study looked at billing records from hospitals that had adopted electronic medical records and compared them to a group of hospitals that hadn't. They found that those with electronic records did not generate bigger bills than those still on paper. Jha says policymakers should take note.
JHA: This worry about excessive billing - I understand where it comes from, but the empirical evidence says this should not be a big focus of attention.
WHITNEY: Totally the wrong conclusion, says Doctor Donald Simborg.
DONALD SIMBORG: They're looking in the wrong place.
WHITNEY: Simborg started designing electronic medical records back in the 1960s. More recently, the government recruited him to lead a pair of expert panels on how they might be used for fraud. He says Jha's study only looked at patients who stayed in hospitals overnight - not at those in emergency departments or hospitals' outpatient clinics. Those are the places the New York Times and Center for Public Integrity focused on, and Simborg would like to see researchers follow up on that.
SIMBORG: I don't think anybody's done the study that needs to be done.
WHITNEY: While Simborg doesn't think anyone really knows whether electronic records are being used inappropriately in clinics and ER's, he thinks regulators need to spend more energy policing the software industry.
SIMBORG: They can develop the guidelines that would reduce the likelihood that an electronic record would be abused. That's different than threatening them that they're going to be prosecuted if they do these things.
WHITNEY: The study of how hospitals use electronic records to generate bills is in today's edition of the journal "Health Affairs." The American Hospital Association says it proves their members are using their new electronic tools appropriately, but a spokesperson says the association agrees that software companies need to be watched to make sure their tools don't create pitfalls for doctors. For NPR News, I'm Eric Whitney.
SIEGEL: And that story is part of a reporting partnership of NPR and Kaiser Health News. Transcript provided by NPR, Copyright NPR.